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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)
    • 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
    • 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 → 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; then discard gloves and apron; wash hands; document procedure and pH of aspirate 
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