Nasogastric tube insertion

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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)

Equipment list

• Gloves
• Vomit bowl
• Cup of water with a straw (if patient is able/safe to swallow)
• Nasogastric tube
  • Fine-bore feeding tube (usually 6-8 French gauge): made of polyurethane (lasts 6-8 weeks), used for feeding
  • Wide-bore Ryle’s tube (usually 14-16 French gauge): made of polyvinyl chloride (lasts 7-10 days), used for drainage
• Lubrication jelly (water-soluble)
• 50ml syringe (to aspirate)
• 10ml syringe filled with normal saline (to flush)
• pH paper strip
• Tape (to stick down)

• 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 → bottom of Xiphisternum (NEX) in centimetres with the nasogastric tube (it has measurements on it) – remember this measurement
• Give patient cup of water with a straw

Insertion

• Wash hands
• Put on gloves
• Lubricate the tip and first 10-15cma 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 gently and steadily 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

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

To complete

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