NASOGASTRIC TUBE NASOGASTRIC TUBE INSERTION and INSERTION and

FEEDINGFEEDING

HARLEY L. DELA CRUZ RN MANHARLEY L. DELA CRUZ RN MAN

InstructorInstructor20122012

PLS READ FIRST CHAPTER 36 PLS READ FIRST CHAPTER 36 BRUNNER AND SUDDARTHS TEXT BRUNNER AND SUDDARTHS TEXT BOOK MS NURSING 7BOOK MS NURSING 7THTH EDITION EDITION

NASOGASTRIC TUBENASOGASTRIC TUBEThe nasogastric (NG) tube is passed through the nose, past the throat and into the stomach. This type of tube permits the patient to receive nutrition through a tube feeding using the stomach as a natural reservoir for food. Another purpose of a NG tube may be to decompress or to drain unwanted fluid and air from the stomach. This application would be used, for example, to allow the intestinal tract to rest and promote healing after bowel surgery. The NG tube can also be used to monitor bleeding in the gastrointestinal (GI) tract, to remove un-desirable substances (lavage) such as poisons, or to help treat an intestinal obstruction.

NASOGASTRIC TUBENASOGASTRIC TUBE

TYPES OF PROCEDURESTYPES OF PROCEDURES

GASTRIC GAVAGEGASTRIC GAVAGE

GASTRIC LAVAGEGASTRIC LAVAGE

IndicationsIndications

Diagnostic Diagnostic – Evaluation of upper gastrointestinal (GI) Evaluation of upper gastrointestinal (GI)

bleed (ie, presence, volume) bleed (ie, presence, volume) – Aspiration of gastric fluid content Aspiration of gastric fluid content – Identification of the esophagus and Identification of the esophagus and

stomach on a chest radiographstomach on a chest radiograph– Administration of radiographic contrast Administration of radiographic contrast

to the GI tract to the GI tract

IndicationsIndications

TherapeuticTherapeutic– Gastric decompression, including maintenance Gastric decompression, including maintenance

of a decompressed state after of a decompressed state after endotracheal intubation, often via the , often via the oropharynx oropharynx

– Relief of symptoms and bowel rest in the setting Relief of symptoms and bowel rest in the setting of small-bowel obstructionof small-bowel obstruction

– Aspiration of gastric content from recent Aspiration of gastric content from recent ingestion of toxic material ingestion of toxic material

– Administration of medication Administration of medication – Feeding Feeding – Bowel irrigationBowel irrigation

ContraindicationsContraindications

Absolute contraindications Absolute contraindications – Severe midface trauma Severe midface trauma – Recent nasal surgeryRecent nasal surgery

Relative contraindications Relative contraindications – Coagulation abnormality Coagulation abnormality – Esophageal varices or stricture Esophageal varices or stricture – Recent banding or cautery of Recent banding or cautery of

esophageal varices esophageal varices – Alkaline ingestionAlkaline ingestion

EQUIPMENTSEQUIPMENTS

EQUIPMENTSEQUIPMENTS Nasogastric (polyurethane) tube of Nasogastric (polyurethane) tube of

appropriate size (8–18 French)appropriate size (8–18 French) StethoscopeStethoscope Small basin filled with ice or warm water Small basin filled with ice or warm water

(optional)(optional) Water-soluble lubricantWater-soluble lubricant Normal saline solution (for irrigation only)Normal saline solution (for irrigation only) Tongue bladeTongue blade Asepto bulb syringe or Toomey syringe (20–50 Asepto bulb syringe or Toomey syringe (20–50

mL)mL) FlashlightFlashlight Nonallergenic tape (1″wide)Nonallergenic tape (1″wide) TissuesTissues

EQUIPMENTSEQUIPMENTS TissuesTissues Glass of water with strawGlass of water with straw Topical anesthetic (lidocaine spray or gel) Topical anesthetic (lidocaine spray or gel)

(optional)(optional) ClampClamp Suction apparatus (if ordered)Suction apparatus (if ordered) Bath towel or disposable padBath towel or disposable pad Emesis basinEmesis basin Safety pin and rubber bandSafety pin and rubber band Nonsterile disposable glovesNonsterile disposable gloves Tincture of benzoin or skin adhesiveTincture of benzoin or skin adhesive pH paperpH paper

TYPES OF NASOGASTRIC TYPES OF NASOGASTRIC TUBESTUBES

The Levin Tube -The Levin Tube -is a one-lumen nasogastric is a one-lumen nasogastric tube tube

TYPES OF NASOGASTRIC TYPES OF NASOGASTRIC TUBESTUBES

The Salem-Sump Tube.The Salem-Sump Tube.

This tube is a two-lumen This tube is a two-lumen piece of equipment.piece of equipment.

It has a drainage lumen and a It has a drainage lumen and a smaller secondary tube smaller secondary tube that is open to the that is open to the atmosphere. atmosphere.

TYPES OF NASOGASTRIC TYPES OF NASOGASTRIC TUBESTUBES

The Miller-Abbott Tube.The Miller-Abbott Tube.

This tube is also a two-lumen This tube is also a two-lumen nasogastric tube. nasogastric tube.

There is a rubber balloon at There is a rubber balloon at the tip of one tube; the the tip of one tube; the other tube has holes near other tube has holes near its tip. its tip.

TYPES OF NASOGASTRIC TYPES OF NASOGASTRIC TUBESTUBES

The Cantor Tube -The Cantor Tube - has one lumen and a bag has one lumen and a bag on the end. on the end.

Sengstaken-Blakemore TubeSengstaken-Blakemore Tube

SIZESSIZES

Adult - 16-18FAdult - 16-18F

Pediatric - In pediatric patients, the Pediatric - In pediatric patients, the correct tube size varies with the correct tube size varies with the patient’s age. patient’s age.

Size FG-8 FG-10 FG-12 FG-14 FG-16 FG-18 FG-20

Colour Code Blue Black White Green Orange Red Yellow

Infection ControlInfection Control

Hand WashingHand Washing Wear a set of glovesWear a set of gloves Wearing face and eye protectionWearing face and eye protection Wear disposable apron. Wear disposable apron.

AssessmentAssessment Assess the patency of the patient’s nares by asking Assess the patency of the patient’s nares by asking

the patient to occlude one nostril and breathe the patient to occlude one nostril and breathe normally through the other. Select the nostril through normally through the other. Select the nostril through which air passes more easily. Also, assess the which air passes more easily. Also, assess the patient’s history for any recent facial trauma, polyps, patient’s history for any recent facial trauma, polyps, blockages, or surgeries. Patients with facial fractures blockages, or surgeries. Patients with facial fractures or facial surgeries present a higher risk for or facial surgeries present a higher risk for misplacement into the brain. Many institutions require misplacement into the brain. Many institutions require a physician to place NG tubes in these patients. a physician to place NG tubes in these patients. Inspect the abdomen for distention and firmness; Inspect the abdomen for distention and firmness; auscultate for bowel sounds or peristalsis and palpate auscultate for bowel sounds or peristalsis and palpate the abdomen for distention and tenderness. If the the abdomen for distention and tenderness. If the abdomen is distended, consider measuring the abdomen is distended, consider measuring the abdominal girth at the umbilicus to establish a abdominal girth at the umbilicus to establish a baseline.baseline.

Possible nursing diagnoses may Possible nursing diagnoses may include:include:

Imbalanced Nutrition, Less than Body Imbalanced Nutrition, Less than Body RequirementsRequirements

Risk for AspirationRisk for Aspiration Impaired SwallowingImpaired Swallowing Acute PainAcute Pain Deficient KnowledgeDeficient Knowledge Risk for Disturbance in Body ImageRisk for Disturbance in Body Image NauseaNausea

NURSING RESPONSIBILITYNURSING RESPONSIBILITY

Inserting and removing the tubeInserting and removing the tube Assessing correct placementAssessing correct placement Securing the tubeSecuring the tube Meeting patient comfort needsMeeting patient comfort needs Monitoring patient responses Monitoring patient responses

IMPLEMENTATIONIMPLEMENTATION

Verify for physician order.Verify for physician order. Identify Client & Introduce yourselfIdentify Client & Introduce yourself Explain the procedureExplain the procedure Assemble the Materials neededAssemble the Materials needed

IMPLEMENTATIONIMPLEMENTATION

Explain the procedure, benefits, risks, Explain the procedure, benefits, risks, complications, and alternatives to complications, and alternatives to the patient or the patient's the patient or the patient's representative. representative.

Examine the patient’s nostril for septal Examine the patient’s nostril for septal deviation. To determine which nostril deviation. To determine which nostril is more patent, ask the patient to is more patent, ask the patient to occlude each nostril and breathe occlude each nostril and breathe through the other. through the other.

POSITIONPOSITION Position the patient in a High Fowler’s Position the patient in a High Fowler’s

position.position.

AdultAdult

– – Measure from Measure from the tip of the the tip of the nose, around the nose, around the ear, and down to ear, and down to the xyphoid the xyphoid process.process.

MEASUREMENTMEASUREMENT

InfantInfant

– – Measure from Measure from the tip of the the tip of the nose, around the nose, around the ear and down to ear and down to the umbilicus. the umbilicus.

MEASUREMENTMEASUREMENT

INSERTIONINSERTION

Lubricate the distal end of the TubeLubricate the distal end of the Tube

INSERTIONINSERTION After selecting the appropriate nostril, After selecting the appropriate nostril,

ask patient to slightly hyperextend ask patient to slightly hyperextend head back against the pillow. Gently head back against the pillow. Gently insert the tube into the nostril while insert the tube into the nostril while directing the tube upward and directing the tube upward and backward along the floor of the backward along the floor of the nose .Patient may gag when tube nose .Patient may gag when tube reaches pharynx. Provide tissues for reaches pharynx. Provide tissues for tearing or watering of eyes. Offer tearing or watering of eyes. Offer comfort and reassurance to the patient.comfort and reassurance to the patient.

INSERTIONINSERTION When pharynx is reached, instruct patient to When pharynx is reached, instruct patient to

touch chin to chest. Encourage patient to sip touch chin to chest. Encourage patient to sip water through a straw or swallow even if no water through a straw or swallow even if no fluids are permitted. Advance tube in downward fluids are permitted. Advance tube in downward and backward direction when patient swallows. and backward direction when patient swallows. Stop when patient breathes. If gagging and Stop when patient breathes. If gagging and coughing persist, stop advancing the tube and coughing persist, stop advancing the tube and check placement of tube with tongue blade and check placement of tube with tongue blade and flashlight. If tube is curled, straighten the tube flashlight. If tube is curled, straighten the tube and attempt to advance again. Keep advancing and attempt to advance again. Keep advancing tube until pen marking is reached. Do not use tube until pen marking is reached. Do not use force. Rotate tube if it meets resistance.force. Rotate tube if it meets resistance.

INSERTIONINSERTION

Instruct the Patient to drink while Instruct the Patient to drink while the tube is insertedthe tube is inserted

INSERTIONINSERTION

Discontinue procedure and Discontinue procedure and remove tube if there are signs of remove tube if there are signs of distress, such as gasping, distress, such as gasping, coughing, cyanosis, and inability coughing, cyanosis, and inability to speak or hum.to speak or hum.

CHECKING FOR PLACEMENTCHECKING FOR PLACEMENT While keeping one hand on tube or While keeping one hand on tube or

temporarily securing with tape, determine temporarily securing with tape, determine that tube is in patient’s stomach: that tube is in patient’s stomach:

a. Attach syringe to end of tube and aspirate a. Attach syringe to end of tube and aspirate a small amount of stomach a small amount of stomach contents.contents.

Visualize aspirated contents, checking for color Visualize aspirated contents, checking for color and consistency.and consistency.

The tube is in the stomach if its contents The tube is in the stomach if its contents can be aspirated:pH of aspirate can then can be aspirated:pH of aspirate can then be tested to determine gastric placement. be tested to determine gastric placement. If unable to obtain specimen, reposition If unable to obtain specimen, reposition the patient and flush the tube with 30 mL the patient and flush the tube with 30 mL of air. This action may be necessary of air. This action may be necessary several times. Current literature several times. Current literature recommends that the nurse ensures recommends that the nurse ensures proper placement of the NG tube by proper placement of the NG tube by relying on multiple methods and not on relying on multiple methods and not on one method alone.one method alone.

Visualize aspirated contents, checking for Visualize aspirated contents, checking for color and consistency.color and consistency.

Gastric fluid can be green with particles, off Gastric fluid can be green with particles, off white, or brown if old blood is present. white, or brown if old blood is present.

Intestinal aspirate tends to look clear or straw-Intestinal aspirate tends to look clear or straw-colored to a deep golden-yellow color. colored to a deep golden-yellow color.

Also, intestinal aspirate may be greenish-Also, intestinal aspirate may be greenish-brown if stained with bile. brown if stained with bile.

Respiratory or tracheobronchial fluid is usually Respiratory or tracheobronchial fluid is usually off-white to tan and may be tinged with off-white to tan and may be tinged with mucus. mucus.

A small amount of blood-tinged fluid may be A small amount of blood-tinged fluid may be seen immediately after NG insertion.seen immediately after NG insertion.

b. Auscultation of air b. Auscultation of air insufflated through insufflated through the tubethe tube

CHECKING FOR PLACEMENTCHECKING FOR PLACEMENT

c. Immersion of the c. Immersion of the Proximal end of in a Proximal end of in a glass of water.glass of water.

d. Aspiration of fluid from the tube, d. Aspiration of fluid from the tube, with pH testing of the aspirate. with pH testing of the aspirate. pH pH << 5 – GIT 5 – GIT

pH pH >> 6 - Respiratory 6 - Respiratory

CHECKING FOR PLACEMENTCHECKING FOR PLACEMENT

Current research demonstrates that Current research demonstrates that the use of pH is predictive of correct the use of pH is predictive of correct placement. The pH of gastric placement. The pH of gastric contents is acidic (less than 5.5). If contents is acidic (less than 5.5). If patient is taking an acid-inhibiting patient is taking an acid-inhibiting agent, the range may be 4.0 to 6.0. agent, the range may be 4.0 to 6.0. The pH of intestinal fluid is 7.0 or The pH of intestinal fluid is 7.0 or higher.higher. The pH of respiratory fluid The pH of respiratory fluid is 6.0 or higheris 6.0 or higher. This method will . This method will not effectively differentiate between not effectively differentiate between intestinal fluid and pleural fluid.intestinal fluid and pleural fluid.

e. Chest X-raye. Chest X-ray

CHECKING FOR PLACEMENTCHECKING FOR PLACEMENT

f. NG OPTIMIZERf. NG OPTIMIZER

SECURE THE TUBESECURE THE TUBE Anchor the tube securely to the nose and Anchor the tube securely to the nose and

cheek - keeping it out of the patients field cheek - keeping it out of the patients field of vision. of vision.

SECURE THE TUBESECURE THE TUBE Apply tincture of benzoin or other skin Apply tincture of benzoin or other skin

adhesive to tip of nose and allow to dry. adhesive to tip of nose and allow to dry. Secure tube with tape to patient’s nose:Secure tube with tape to patient’s nose:

a. Cut a 4″ piece of tape and split bottom 2″ or a. Cut a 4″ piece of tape and split bottom 2″ or use packaged nose tape for NG tubes.use packaged nose tape for NG tubes.

b. Place unsplit end over bridge of patient’s b. Place unsplit end over bridge of patient’s nose.nose.

c. Wrap split ends under tubing and up and c. Wrap split ends under tubing and up and over onto nose.over onto nose. Be careful not to pull tube Be careful not to pull tube too tightly against nose.too tightly against nose.

Clamp tube and cap or attach tube to Clamp tube and cap or attach tube to suction according to the physician’s suction according to the physician’s orders. orders.

Secure tube to patient’s gown by using Secure tube to patient’s gown by using rubber band or tape and safety pin. For rubber band or tape and safety pin. For additional support, tube can be taped additional support, tube can be taped onto patient’s cheek using a piece of onto patient’s cheek using a piece of tape. tape. If double-lumen tube (eg, Salem If double-lumen tube (eg, Salem sump) is used, secure vent above sump) is used, secure vent above stomach level. stomach level. Attach at shoulder level.Attach at shoulder level.

Assist with or provide oral hygiene at Assist with or provide oral hygiene at every 2- to 4-hour interval. Lubricate the every 2- to 4-hour interval. Lubricate the lips generously and clean nares and lips generously and clean nares and lubricate as needed. Offer analgesic lubricate as needed. Offer analgesic throat lozenges or anesthetic spray for throat lozenges or anesthetic spray for throat irritation if needed. throat irritation if needed.

Remove all equipment, lower the bed, Remove all equipment, lower the bed, and make the patient comfortable. and make the patient comfortable. Remove gloves and perform hand Remove gloves and perform hand hygiene.hygiene.

Unexpected Situations and Unexpected Situations and Associated InterventionsAssociated Interventions

As tube is passing through pharynx, As tube is passing through pharynx, patient begins to retch and gag: patient begins to retch and gag: This This is common during placement of an NG is common during placement of an NG tube. Ask the patient if he/she wants the tube. Ask the patient if he/she wants the nurse to stop the procedure, allowing the nurse to stop the procedure, allowing the patient to gain composure from the patient to gain composure from the gagging episode. Continue to advance gagging episode. Continue to advance tube if the patient relates that he/she tube if the patient relates that he/she agrees. Have the emesis basin nearby agrees. Have the emesis basin nearby incase patient begins to vomit.incase patient begins to vomit.

Unexpected Situations and Unexpected Situations and Associated InterventionsAssociated Interventions

The nurse is unable to pass the The nurse is unable to pass the tube after trying a second time tube after trying a second time down the one nostril: down the one nostril: If the If the patient’s condition permits, inspect patient’s condition permits, inspect the other nostril and attempt to pass the other nostril and attempt to pass the nasogastric tube down this the nasogastric tube down this nostril. If unable to pass down this nostril. If unable to pass down this nostril, consult another health nostril, consult another health professional.professional.

Unexpected Situations and Unexpected Situations and Associated InterventionsAssociated Interventions

As tube is passing through pharynx, As tube is passing through pharynx, patient begins to cough and shows signs patient begins to cough and shows signs of respiratory distress: of respiratory distress: Stop advancing Stop advancing the tube! the tube! The tube is most likely entering the The tube is most likely entering the trachea. Pull tube back into nasal area. Support trachea. Pull tube back into nasal area. Support patient as he/she regains normal breathing patient as he/she regains normal breathing ability and composure. If patient feels that ability and composure. If patient feels that he/she can tolerate another attempt, ask he/she can tolerate another attempt, ask patient to keep chin on chest and swallow as patient to keep chin on chest and swallow as tube is advanced to help prevent the tube from tube is advanced to help prevent the tube from entering thetrachea. Begin to advance tube, entering thetrachea. Begin to advance tube, watching for any signs of respiratory distress.watching for any signs of respiratory distress.

Unexpected Situations and Unexpected Situations and Associated InterventionsAssociated Interventions

No gastric contents can be No gastric contents can be aspirated: aspirated: If patient is comatose, If patient is comatose, check oral cavity. If tube is in gastric check oral cavity. If tube is in gastric area, small air boluses may need to area, small air boluses may need to be given until gastric contents can be be given until gastric contents can be aspirated.aspirated.

Special Nursing ConsiderationsSpecial Nursing Considerations Measure tube from tip of nose to ear Measure tube from tip of nose to ear

lobe and from ear lobe to xiphoid lobe and from ear lobe to xiphoid process. Add 8″to 10″for intestinal process. Add 8″to 10″for intestinal placement. Mark tubing at desired placement. Mark tubing at desired point.point.

Place patient on his or her right side. Place patient on his or her right side. Nasointestinal tube is usually placed in Nasointestinal tube is usually placed in the stomach and allowed to advance the stomach and allowed to advance through peristalsis through the pyloric through peristalsis through the pyloric sphincter (may take up to 24 hours).sphincter (may take up to 24 hours).

Special Nursing ConsiderationsSpecial Nursing Considerations

Administer medications to enhance Administer medications to enhance GI motility, such as metoclopramide GI motility, such as metoclopramide (Reglan), if ordered.(Reglan), if ordered.

Test pH of aspirate when tube has Test pH of aspirate when tube has advanced to marked point to confirm advanced to marked point to confirm placement in intestine. Confirm placement in intestine. Confirm position by radiograph. Secure with position by radiograph. Secure with tape once placement is confirmed.tape once placement is confirmed.

COMPLICATIONSCOMPLICATIONS

Minor complicationsMinor complications

- Nose Bleeds,Sinusitis, and sore throat- Nose Bleeds,Sinusitis, and sore throat

More significant complicationsMore significant complications

- Erosion of the nose where the tube is - Erosion of the nose where the tube is anchored, esophageal perforation, anchored, esophageal perforation, pulmonary aspiration, a collapsed lung, or pulmonary aspiration, a collapsed lung, or intracranial placement of the tube.intracranial placement of the tube.

DOCUMENTATIONDOCUMENTATION

Date and time of procedureDate and time of procedure Indication for insertionIndication for insertion Type of tube usedType of tube used Distance tube inserted (if appropriate)Distance tube inserted (if appropriate) The nature of the aspirateThe nature of the aspirate Methods used to check location of the tube Methods used to check location of the tube

insertioninsertion Any procedural comments Any procedural comments

ADMINISTERING A TUBE FEEDINGADMINISTERING A TUBE FEEDING Feeding can be provided on an intermittent or Feeding can be provided on an intermittent or

continuous basis. If the order calls for continuous basis. If the order calls for continuous feeding, an external feeding pump continuous feeding, an external feeding pump is needed to regulate the flow of formula. is needed to regulate the flow of formula. Intermittent feedings are delivered at regular Intermittent feedings are delivered at regular intervals, using gravity for instillation or a intervals, using gravity for instillation or a feeding pump to administer the formula over a feeding pump to administer the formula over a set period of time. Intermittent feedings might set period of time. Intermittent feedings might also be given as a bolus, using a syringe to also be given as a bolus, using a syringe to instill the formula quickly in one large amount.instill the formula quickly in one large amount.

Goal: Goal: The patient will receive the tube feeding The patient will receive the tube feeding without complaints of nausea or episodes of without complaints of nausea or episodes of vomiting.vomiting.

Transabdominal tube feeding Transabdominal tube feeding and careand care

A percutaneous endoscopic A percutaneous endoscopic gastrostomy (PEG) or (PEJ) gastrostomy (PEG) or (PEJ) jejunostomy tube can be inserted jejunostomy tube can be inserted endoscopically without the need for endoscopically without the need for laparotomy or general anesthesia. laparotomy or general anesthesia. Used for nutrition, drainage, and Used for nutrition, drainage, and decompression. decompression. 

Contraindications to endoscopic Contraindications to endoscopic placementplacement

ObstructionObstruction Previous gastric surgery Previous gastric surgery  Morbid obesityMorbid obesity AscitesAscites

Gastrostomy Feeding TubeGastrostomy Feeding Tube

Jejunostomy Feeding TubeJejunostomy Feeding Tube

Gastrojejunostomy Feeding TubeGastrojejunostomy Feeding Tube

Nursing careNursing care

Equipment: Equipment: NGT FeedingNGT Feeding  o Feeding formula Feeding formula 

120 ml of water120 ml of water4” x 4” gauze pads4” x 4” gauze padsSoap, mouthwash, toothpaste, or mild salt solution Soap, mouthwash, toothpaste, or mild salt solution Skin protectant / 4” x 4” gauze pads Skin protectant / 4” x 4” gauze pads Hypoallergenic tapeHypoallergenic tapeGravity – drip administration bagsGravity – drip administration bagsGloves /Alcohol preps /Disposable pad or towelGloves /Alcohol preps /Disposable pad or towel

Asepto or Toomey syringeAsepto or Toomey syringe

Enteral feeding pump (if ordered)Enteral feeding pump (if ordered)

Rubber band /Clamp (Hoffman or butterfly)Rubber band /Clamp (Hoffman or butterfly)

IV poleIV pole

pH paperpH paper

Preparation of EquipmentPreparation of Equipment Always check the expiration date on commercially Always check the expiration date on commercially

prepared feeding formulas.prepared feeding formulas.If the formula has been prepared by the dietitian or If the formula has been prepared by the dietitian or pharmacist, check the preparation time and date.pharmacist, check the preparation time and date.Discard any opened formula that’s more than 1 day Discard any opened formula that’s more than 1 day old.old.Commercially – prepared administration sets and Commercially – prepared administration sets and enteral pumps allow continuous formula enteral pumps allow continuous formula administration.administration.

ASSESSMENTASSESSMENT Assess abdomen by inspecting for presence of Assess abdomen by inspecting for presence of

distention, auscultating for bowel sounds, and palpating distention, auscultating for bowel sounds, and palpating the abdomen for firmness or tenderness. If the the abdomen for firmness or tenderness. If the abdomen is distended, consider measuring the abdomen is distended, consider measuring the abdominal girth at the umbilicus. If the patient reports abdominal girth at the umbilicus. If the patient reports any tenderness or nausea, exhibits any rigidity or any tenderness or nausea, exhibits any rigidity or firmness of the abdomen, and if there is an absence of firmness of the abdomen, and if there is an absence of bowel sounds, confer with physician before bowel sounds, confer with physician before administering the tube feeding. Assess for patient administering the tube feeding. Assess for patient and/or family understanding if appropriate for the and/or family understanding if appropriate for the rationale for the tube feeding and address any rationale for the tube feeding and address any questions or concerns expressed by the patient and questions or concerns expressed by the patient and family members. Consult physician if need for further family members. Consult physician if need for further explanation.explanation.

NURSING DIAGNOSISNURSING DIAGNOSIS Imbalanced Nutrition, Less than Body Imbalanced Nutrition, Less than Body

RequirementsRequirements Risk for Aspiration Risk for Aspiration Deficient KnowledgeDeficient Knowledge Risk for Impaired Social InteractionRisk for Impaired Social Interaction Risk for Alteration in NutritionRisk for Alteration in Nutrition Risk for Body Image Disturbance.Risk for Body Image Disturbance.

IMPLEMENTATIONIMPLEMENTATION1. Identify the patient.1. Identify the patient.

2. Explain the procedure to the patient and 2. Explain the procedure to the patient and why this intervention is needed. Raise the why this intervention is needed. Raise the bed. Pull the patient’s bedside curtain. bed. Pull the patient’s bedside curtain. Perform key abdominal assessments as Perform key abdominal assessments as described above.described above.

3. Assemble equipment. Check amount, 3. Assemble equipment. Check amount, concentration, type, and frequency of tube concentration, type, and frequency of tube feeding on patient’s chart. Check expiration feeding on patient’s chart. Check expiration date of formula.date of formula.

4. Perform hand hygiene. Put on No gloves.4. Perform hand hygiene. Put on No gloves.

5. 5. Position patient with head of bed elevated at Position patient with head of bed elevated at least 30 to 45 degrees or as near normal least 30 to 45 degrees or as near normal position for eating as possible.position for eating as possible.

6. Unpin tube from patient’s gown. 6. Unpin tube from patient’s gown. Check to see that Check to see that the NG tube is properly located in the stomach, the NG tube is properly located in the stomach, by first instilling air, then aspirate for gastric by first instilling air, then aspirate for gastric contents. contents. At times, due to the tendency of small-At times, due to the tendency of small-bore tubes to collapse upon aspiration, several bore tubes to collapse upon aspiration, several attempts may be necessary to aspirate gastric attempts may be necessary to aspirate gastric contents. After repeated instillations of 30 mL of air, contents. After repeated instillations of 30 mL of air, accompanied by repositioning the patient, if unable accompanied by repositioning the patient, if unable to aspirate gastric contents, the tube placement to aspirate gastric contents, the tube placement should be checked by radiograph verified by should be checked by radiograph verified by physician’s order. Check the pHphysician’s order. Check the pH

7. After multiple steps have been taken to ensure that 7. After multiple steps have been taken to ensure that the feeding tube is located in the stomach or small the feeding tube is located in the stomach or small intestine, intestine, aspirate all gastric contents with a aspirate all gastric contents with a syringe and measure to check for the residual syringe and measure to check for the residual amount of feeding in the stomach.amount of feeding in the stomach. Flush tube Flush tube with 30 mL of water for irrigation. Proceed with with 30 mL of water for irrigation. Proceed with feeding if amount of residual does not exceed agency feeding if amount of residual does not exceed agency policy or physician’s guideline. Disconnect syringe policy or physician’s guideline. Disconnect syringe from tubing and cap end of tubing while preparing from tubing and cap end of tubing while preparing the formula feeding equipment. Remove gloves.the formula feeding equipment. Remove gloves.

8. Put on gloves before preparing, assembling and 8. Put on gloves before preparing, assembling and handling any part of the feeding system.handling any part of the feeding system.

9. Administer feeding. 9. Administer feeding.

When Using a Feeding BagWhen Using a Feeding Bag (Open(Open System)System)

a. Hang bag on IV pole and adjust to about 12″ a. Hang bag on IV pole and adjust to about 12″ above the stomach. Clamp tubing.above the stomach. Clamp tubing.

b. Check the expiration date of the formula. b. Check the expiration date of the formula. Cleanse top of feeding container with a Cleanse top of feeding container with a disinfectant before opening it. disinfectant before opening it. Pour formula Pour formula into feeding bag and allow solution to into feeding bag and allow solution to run through tubing. run through tubing. Close clamp.Close clamp.

c. Attach feeding setup to feeding tube, open c. Attach feeding setup to feeding tube, open clamp, and regulate drip according to clamp, and regulate drip according to physician’s order, or allow feeding to run in physician’s order, or allow feeding to run in over 30 minutes.over 30 minutes.

d. d. Add 30 to 60 mL (1–2 oz) of water for Add 30 to 60 mL (1–2 oz) of water for irrigation to feeding bag when feeding irrigation to feeding bag when feeding is almost completed and allow it to run is almost completed and allow it to run through the tube.through the tube.

e. Clamp tubing immediately after water has e. Clamp tubing immediately after water has been instilled. Disconnect from feeding tube. been instilled. Disconnect from feeding tube. Clamp tube and cover end with cap.Clamp tube and cover end with cap.

When Using a Large Syringe (Open When Using a Large Syringe (Open System)System)

a. Remove plunger from 30- or 60-mL syringe.a. Remove plunger from 30- or 60-mL syringe.

b. Attach syringe to feeding tube, pour b. Attach syringe to feeding tube, pour premeasured amount of tube feeding into premeasured amount of tube feeding into syringe, open clamp, and allow food to enter syringe, open clamp, and allow food to enter tube. tube. Regulate rate, fast or slow, by Regulate rate, fast or slow, by height of the syringe. Do not push height of the syringe. Do not push formula with syringe plunger.formula with syringe plunger.

c. c. Add 30 to 60 mL (1–2 oz) of water for Add 30 to 60 mL (1–2 oz) of water for irrigation to syringe when feeding is irrigation to syringe when feeding is almost completed, and allow it to run almost completed, and allow it to run through the tube.through the tube.

d. When syringe has emptied, hold syringe d. When syringe has emptied, hold syringe high and disconnect from tube. Clamp tube high and disconnect from tube. Clamp tube and cover end with cap.and cover end with cap.

10. Observe the patient’s response during 10. Observe the patient’s response during and after tube feeding and assess the and after tube feeding and assess the abdomen at least once a shift.abdomen at least once a shift.

11. 11. Have patient remain in upright Have patient remain in upright position for at least 1 hour after position for at least 1 hour after feeding.feeding.

12. Wash and clean equipment or replace 12. Wash and clean equipment or replace according to agency policy. Remove gloves according to agency policy. Remove gloves and perform hand hygiene.and perform hand hygiene.

When the feeding finishes, flush the When the feeding finishes, flush the feeding tube with 30 to 60 ml of feeding tube with 30 to 60 ml of water to maintain patency and water to maintain patency and provide hydration.provide hydration.Cap the tube to prevent leakage.Cap the tube to prevent leakage.Rinse the feeding administration set Rinse the feeding administration set thoroughly with hot water to avoid thoroughly with hot water to avoid contaminating subsequent feedings. contaminating subsequent feedings. Allow it to dry between feedings.Allow it to dry between feedings.

DocumentationDocumentation Type of nasogastric tube or gastrostomy/jejunostomy Type of nasogastric tube or gastrostomy/jejunostomy

Record tube length in inches or centimeters Record tube length in inches or centimeters Document the aspiration of gastric contents and pH Document the aspiration of gastric contents and pH and bilirubin of the gastric contents when intermittent and bilirubin of the gastric contents when intermittent feeding is used. Note the components of the feeding is used. Note the components of the abdominal assessment, such as observation of the abdominal assessment, such as observation of the abdomen, presence of distention or firmness, and abdomen, presence of distention or firmness, and presence of bowel sounds. Include subjective data presence of bowel sounds. Include subjective data from the patient such as abdominal pain or nausea or from the patient such as abdominal pain or nausea or any other patient response. Record the amount of any other patient response. Record the amount of residual volume that was obtained. Document the residual volume that was obtained. Document the position of the patient, the type of feeding, and the position of the patient, the type of feeding, and the method and the amount of feeding. Include any method and the amount of feeding. Include any relevant patient teaching.relevant patient teaching.

Follow up phaseFollow up phase1.1. Assure the patient that most Assure the patient that most

discomfort he feels will lessen as he discomfort he feels will lessen as he gets used to the tube.gets used to the tube.

2.2. Irrigate the tube at regular intervals Irrigate the tube at regular intervals (every 2 hours unless otherwise (every 2 hours unless otherwise indicated) with small volumes of indicated) with small volumes of prescribed fluidprescribed fluid3434..

3.3. Cleanse nares and provide mouth Cleanse nares and provide mouth care every shiftcare every shift3535..

4. Apply petroleum jelly to nostrils as 4. Apply petroleum jelly to nostrils as needed, and assess for skin irritation or needed, and assess for skin irritation or breakdownbreakdown3636..

5. Keep head of bed elevated at least 30 5. Keep head of bed elevated at least 30 degreesdegrees3737..

6. Record the time, type, and size of tube 6. Record the time, type, and size of tube inserted. Document placement checks inserted. Document placement checks after each assessment, along with after each assessment, along with amount, color, consistency of drainageamount, color, consistency of drainage3838..

Unexpected Situations and Associated Unexpected Situations and Associated InterventionsInterventions

Tube is found not to be in stomach or Tube is found not to be in stomach or intestine: intestine: Tube must be in stomach before feed-ing. Tube must be in stomach before feed-ing. If tube is in esophagus, patient is at increased risk for If tube is in esophagus, patient is at increased risk for aspiration. aspiration.

When checking for residue, nurse aspirates a When checking for residue, nurse aspirates a large amount: large amount: Before discarding or replacing Before discarding or replacing residue, check with physician and agency policy. residue, check with physician and agency policy. Replacing a large amount may increase patient’s risk Replacing a large amount may increase patient’s risk for vomiting and aspiration, while discarding a large for vomiting and aspiration, while discarding a large amount may increase patient’s risk for metabolic amount may increase patient’s risk for metabolic alkalosis. At times, the physician will order the nurse alkalosis. At times, the physician will order the nurse to replace half of the residue and recheck in a set to replace half of the residue and recheck in a set amount of time.amount of time.

Patient complains of nausea after tube Patient complains of nausea after tube feeding: feeding: Ensure that head of bed remains Ensure that head of bed remains elevated and that suction equipment is at bedside. elevated and that suction equipment is at bedside. Check medication record to see if any antiemetics Check medication record to see if any antiemetics have been ordered for patient. Consider notifying have been ordered for patient. Consider notifying the physician for an order for an antiemetic.the physician for an order for an antiemetic.

When attempting to aspirate contents, nurse When attempting to aspirate contents, nurse notes that tube is clogged: notes that tube is clogged: Most obstructions Most obstructions are caused by coagulation of formula. Try using are caused by coagulation of formula. Try using warm water and gentle pressure to remove clog. warm water and gentle pressure to remove clog. Carbonated sodas, such as Coca Cola, and meat Carbonated sodas, such as Coca Cola, and meat tenderizers have not been shown effective in tenderizers have not been shown effective in removing clogs in feeding tubes. Never use a removing clogs in feeding tubes. Never use a stylet to unclog tubes. Tube may have to be stylet to unclog tubes. Tube may have to be replaced. To prevent clogs, ensure that adequate replaced. To prevent clogs, ensure that adequate flushing is completed after feedings.flushing is completed after feedings.

NGT RemovalNGT Removal

EquipmentsEquipments- Towel/ tissuesTowel/ tissues- Disposable glovesDisposable gloves- Mouth hygiene materialsMouth hygiene materials- 50-mL syringe (optional)50-mL syringe (optional)- GlovesGloves- StethoscopeStethoscope- Disposable plastic bagDisposable plastic bag- Normal saline solution for irrigation Normal saline solution for irrigation

(optional)(optional)- Emesis basinEmesis basin

Procedure: PreparationProcedure: Preparation

1.1. Make sure that gastric or small Make sure that gastric or small bowel drainage is not excessive in bowel drainage is not excessive in volume.volume.

2.2. Make sure, by auscultation, that Make sure, by auscultation, that audible peristalsis is present.audible peristalsis is present.

3.3. Determine whether the patient is Determine whether the patient is passing flatus; this indicates passing flatus; this indicates peristalsisperistalsis3939..

4. Verify the health care provider's 4. Verify the health care provider's order for removal.order for removal.

Performance phasePerformance phase

1.1. Place a towel across the patient's Place a towel across the patient's chest, and inform him that the tube chest, and inform him that the tube is to be withdrawnis to be withdrawn4040..

2.2. Apply disposable glovesApply disposable gloves4141..

3.3. Remove the tape from the patient's Remove the tape from the patient's nose.nose.

4.4. Instruct the patient to take a deep Instruct the patient to take a deep breath and hold itbreath and hold it4242..

5. Slowly, but evenly, withdraw tubing 5. Slowly, but evenly, withdraw tubing and cover it with a towel as it and cover it with a towel as it emergesemerges4343. (As the tube reaches the . (As the tube reaches the nasopharynx, you can pull quickly.)nasopharynx, you can pull quickly.)

6. Provide the patient with materials 6. Provide the patient with materials for oral care and lubricant for nasal for oral care and lubricant for nasal drynessdryness4444..

7. Dispose of equipment in appropriate 7. Dispose of equipment in appropriate receptacle.receptacle.

8. Document time of tube removal and 8. Document time of tube removal and the patient's reaction.the patient's reaction.

9. Document tube removal and color, 9. Document tube removal and color, consistency, and amount of drainage consistency, and amount of drainage in suction canister.in suction canister.

10. Continue to monitor the patient for 10. Continue to monitor the patient for signs of GI difficultiessigns of GI difficulties4545..

DocumentationDocumentationDocument assessment of the abdomen. If an Document assessment of the abdomen. If an

abdominal girth reading was obtained, record abdominal girth reading was obtained, record this measurement. Document the removal of this measurement. Document the removal of the nasogastric tube from the naris where it the nasogastric tube from the naris where it had been placed. Note if there is any irritation had been placed. Note if there is any irritation to the skin of the naris. Record the amount of to the skin of the naris. Record the amount of NG drainage in the suction container on the NG drainage in the suction container on the patient’s intake-and-output record as well as patient’s intake-and-output record as well as the color of the drainage. Record any the color of the drainage. Record any pertinent teaching, such as instruction to pertinent teaching, such as instruction to patient to notify nurse if he/she experiences patient to notify nurse if he/she experiences any nausea, abdominal pain, or bloating.any nausea, abdominal pain, or bloating.

Unexpected Situations and Associated Unexpected Situations and Associated InterventionsInterventions

Within 2 hours after NG tube removal, Within 2 hours after NG tube removal, patient’s abdomen is showing signs patient’s abdomen is showing signs of distentionof distention: Notify physician. Physician : Notify physician. Physician may order nurse to replace NG tube.may order nurse to replace NG tube.

Epistaxis occurs with removal of NG Epistaxis occurs with removal of NG tube: tube: Occlude both nares until bleeding Occlude both nares until bleeding has subsided. Ensure that patient is in has subsided. Ensure that patient is in upright position. Document epistaxis in upright position. Document epistaxis in patient’s medical record.patient’s medical record.

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HLDelacruz2012HLDelacruz2012