Nasogastric tube insertion

Introduction

• Wash hands; Introduce self; Patient’s name, DOB and wrist band; Explain procedure and obtain consent
  • Risks: sores around nose/tape, tube misplacement (into lungs), aspiration/pneumonia, discomfort/irritation
  • Contraindications: oesophageal varices, base of skull fracture, recent epistaxis, maxillofacial disorders
• Warn patient it will be uncomfortable and ask them to raise their hand if they want to stop
• Advise the patient they must swallow when asked

Preparation 

• Wash hands and put on apron
• Clean tray inside and out
• Gather equipment around tray (think through what you need in order)

• Wash hands
• Open packets and place neatly in tray, keeping items in plastic parts of packets (without touching the instruments themselves)
• Return to patient     

Procedure

Preparation

• Wash hands 
• Sit patient straight upright (head in normal position)
• Ask patient to blow their nose
• Measure from the patient’s tip of nose → ear lobe → xiphisternum in centimetres with the nasogastric tube (it has measurements on it). Then add 10cm and remember the total.
• Give patient cup of water with a straw

Insertion

• Wash hands
• Put on gloves
• Lubricate the tip of the tube
• Gently push the tube into the nostril aiming posteriorly as close to horizontal as possible
• The patient will gag when the tube reaches the back of their throat
• Ask them to swallow and then keep swallowing. Push the tube down fast when they are swallowing.
• Continue advancing the tube until the memorised measurement is reached
• Confirm correct placement (i.e. in the stomach, not the lungs) by one of two possible methods (in order of preference):
  • Aspirate gastric contents and drop onto pH paper (pH should be ≤5.5)
  • Order a chest x-ray, on which the NG tube must meet all four criteria to ensure it is safe to use:
    • Pass vertically down the oesophagus (must not follow the course of either of the main bronchi)
    • Clearly bisect the carina
    • Cross the diaphragm in the midline
    • Tip visible at least 10cm beyond the gastro-oesophageal junction below the left hemidiaphragm
• Remove tube guidewire – present in fine-bore feeding tubes only. NB: never try to replace guidewire after removing. 
• Tape tube down at nose and over ear
• Flush with saline

Other points

• Check the pH is ≤5.5 and flush the tube before every feed
• Daily care: check skin around tubing, clean around nose, flush tube
• Drugs are put down separately – you cannot give enteric coated/slow release drugs via NG
• To remove: Inject 10ml air down tube and gently remove

To complete

• Thank patient and restore clothing
• Discard waste and clean tray
• Discard gloves and apron
• Wash hands
• Document procedure and pH of aspirate