Nasogastric and Orogastric Tube Insertion, Care, and Removal

PROCEDURE

113 Nasogastric and Orogastric Tube Insertion, Care, and Removal

Carol McGinnis

PURPOSE: Nasogastric (NG) and orogastric (OG) tubes are inserted to facilitate gastric decompression and drainage. This may involve removal of air, retained food materials, secretions, or blood, as well as ingested drugs or toxins. These tubes are also used to deliver fluid and medication and sometimes enteral tube feeding via the gastric route on a short-term basis until a smaller feeding tube or percutaneous tube can be inserted. OG tubes might be inserted when nasal tubes are contraindicated or unable to be placed (e.g., basilar skull or nasal fracture) or sometimes preferentially, as in critical care settings. Consider that the OG tube position may be more difficult to maintain in a conscious, nonintubated patient who might be at risk for tube displacement secondary to tongue movement or difficulty securing the tube.

PREREQUISITE NURSING KNOWLEDGE

? Knowledge of the anatomy and physiology of the gastrointestinal (GI) tract is necessary.

? Knowledge about use and care of the variety of tubes that may be used in clinical practice can help guide practice. Knowing the intended use for the NG tube may help determine the best type and size of the tube.

? Knowledge of means to guide and comfort the patient during a potentially uncomfortable procedure is beneficial.13,18,20

? Critical thinking skills are important, especially in terms of determining and monitoring appropriate tube position and assessing that the tube is accomplishing its intended purpose.

? Knowledge of evidence-based measures to verify appropriate tube position is important.

? Knowledge of means to prevent or monitor for adverse effects that could be related to an NG tube, which may include sinus infection, tube misplacement and displacement, tube clogging, pressure ulcers related to tube securement, and patient discomfort.

EQUIPMENT

? NG tube, preferably with numeric markings to help identify depth of insertion and to determine whether the external tube amount has changed

? Water-soluble lubricant ? A 50- or 60-mL syringe with a tip that is appropriate for

the tube being inserted and that will meet standards to prevent administration into an inappropriate port.11 ? Small towel ? Clean gloves ? Stethoscope ? pH strips; follow institutional protocol for quality control and bedside testing

? Emesis bag or basin (keep discretely out of sight) and tissues for eye watering, etc.

? Tape and securement device of choice, which may include transparent dressing or nasal securement device

? Skin prep agent or agent to promote adherence to skin, such as tincture of benzoin; optional (e.g., if skin is oily)

? Indelible marker Additional equipment, to have available as needed, includes the following: ? Local anesthetic agent (e.g., lidocaine gel) per physician,

advanced practice nurse, or other healthcare professional order/institutional protocol. If using lidocaine gel administered via syringe, use tip that meets standards to prevent administration into an inappropriate port.11 ? Clean cup and supplies if specimens are to be obtained ? Ice chips or a cup of water with a straw if the patient is able to safely swallow fluid

PATIENT AND FAMILY EDUCATION

? Explain the purpose of the NG or OG tube and that efforts will be made to minimize discomfort and provide support. Some patients may appreciate that having an NG is less unpleasant than abdominal distention and vomiting. Rationale: Patient and family anxiety may be decreased.

? Explain what the patient might expect as well as the patient's role in assisting with the passage of the tube. Rationale: This information may decrease patient anxiety and help during the procedure.

PATIENT ASSESSMENT AND PREPARATION

Patient Assessment

? Obtain history, including recent facial or head injury with basilar skull fracture or transsphenoidal pituitary resection. Determine whether the patient has had prior

1011

1012 Unit IV Gastrointestinal System

nasal or upper GI surgery, esophageal stent, or anatomical anomalies (e.g., deviated nasal septum, esophageal diverticulae or varices, known hiatal hernia). Rationale: Contraindications to placing an NG tube include basilar skull fracture and may include nasal or pharyngeal, esophageal, or gastric injury or surgery. Other conditions may require special care or complicate placement. ? If the patient is susceptible to epistaxis or sinusitis, determine which naris is more susceptible. Inquire whether the patient has a preference for which naris should be used for NG intubation. Rationale: Preliminary assessment provides an alert to contraindications or potential issues that can be avoided or minimized related to tube placement. ? Assess the nares to determine patency by assessing air exchange and by visual inspection. Rationale: The naris with the best airflow may be easiest to access. ? Assess physical status before tube insertion, including assessing for abdominal distention, firmness, tenderness, tympany, and presence or absence, as well as quality, of bowel sounds. Rationale: This provides preliminary information that will be useful in monitoring patient status.

Patient Preparation

? Verify that the patient is the correct patient using two identifiers. Rationale: Before performing a procedure, the

nurse should ensure the correct identification of the patient for the intended intervention. ? Perform a preprocedure verification of patient need for the procedure, and so on, and a timeout, if nonemergent. Rationale: This ensures patient safety. ? Ensure that the patient understands what the procedure will involve and how the tube will be helpful. Rationale: Patient understanding can reduce anxiety and increase cooperation. ? Assess what helps the patient deal with stressful procedures and offer suggestions for dealing with temporary discomfort (e.g., related to tube insertion, such as distraction, focal point, washcloth or other item to squeeze, breathing techniques). If the patient is restless, having another person present for the patient to have a hand to hold may be helpful. Rationale: This maintains the patient's sense of self-control. ? If the patient may safely sip on water, he or she may find this to be helpful during the NG insertion, or it may be overwhelming; assess patient preference. Rationale: Following the swallow mechanism may facilitate tube insertion if it is not distracting.

Procedure for NG or OG Tube Insertion

Steps

Rationale

1. HH

2. Don PE as indicated. 3. Position the patient in Fowler's

or semi-Fowler's position, as possible, providing for patient comfort as well as easy access. If water is to be sipped during the procedure, the head of the bed needs to be appropriately elevated. 4. Discuss and provide comfort measures, including administration of lidocaine gel or other agent per physician, advanced practice nurse, or other healthcare professional order via the appropriate naris for NG insertion. If used, follow proper medication administration procedure. 5. Place a clean towel over the patient's upper chest area.

Patient and staff comfort, as possible, are important for any procedure. Provide for safety of patient swallow if there is to be sipping of water.

To reduce patient discomfort. Patients may be able to aid in selfcomforting means.

To provide a clean work surface and keep supplies as clean as possible.

6. Prepare supplies for easy access (e.g., on clean overbed table).

7. Perform HH again, and don clean gloves.

To aid in organization and avoid unnecessary delays in the procedure.

To aid in cleanliness of procedure.

Special Considerations

A calming nurse presence also provides comfort and a sense of security.

Although this is not a sterile procedure, optimal cleanliness is in the patient's best interest.

Repeat if interrupted for nonprocedural-related reasons.

113 Nasogastric and Orogastric Tube Insertion, Care, and Removal 1013

Procedure for NG or OG Tube Insertion--Continued

Steps

Rationale

8. Estimate the length of tube to be

inserted:

A. The traditional method of

measuring insertion distance

(from tip of nose to ear or

earlobe to xiphoid process or

NEX) may underestimate the

amount of tube needed to

access the gastric fluid pool.

Adding the amount of

1 2

the

distance from the tip of the

xiphoid process to the

umbilicus to this measurement

may help ensure that the tube

tip opening(s) reach the

gastric pool. This method has

been called NEMU for nose/

ear/midumbilicus.6?9,12,22

B. Identify the corresponding

number on the tube to be

inserted or, if without

numbers, mark the tube or

note identifier at the intended

exit point

9. Lubricate the end of the tube with

water-soluble lubricant.

10. Ensure that the head is in the

chin-tuck position if this is not

contraindicated.

To help determine the appropriate amount of tube insertion length.

To facilitate easier tube passage across potentially dry tissue.

Aids in accessing the GI tract versus the trachea.

11. For NG tube insertion: Insert the tube gently through the naris at an angle parallel to the floor of the nasal canal and then with a gentle downward motion as the tube advances through the nasal passage toward the distal pharynx. If resistance is felt, try gentle rotation of the tube tip until it advances beyond the nasal passage. If resistance continues, withdraw the tube and allow the patient to rest, relubricate the tube, and retry or insert the tube via the other naris. Do not force past resistance.

12. For NG tube insertion: If the patient agrees and is able to swallow safely, sipping on water may enhance NG insertion after the tube is in the oropharynx. If swallowing is not safe, the patient could try dry swallowing to facilitate tube insertion, if desired.

To best guide the tube through the opening in the naris toward the nasopharynx.

Tube may follow the swallow mechanism and aid insertion. However, this may be distracting to a patient who prefers to have the tube inserted quickly.

Special Considerations Anatomy differs from patient to

patient; know that there is no exact method to determine the best tube insertion length; correlate with clinical condition, aspirated returns, etc.

The chin-tuck position has been shown to be more successful in accessing the GI tract than the neutral head position.3,14

A slight chin-tuck position might be possible if a neck collar is being used.

This may be the most uncomfortable portion of the procedure for the patient. One naris may be more patent that the other.

Swallowing is not necessary for successful NG insertion, although it may be helpful.

Procedure continues on following page

1014 Unit IV Gastrointestinal System

Procedure for NG or OG Tube Insertion--Continued

Steps

Rationale

13. For OG tube insertion: Insert the tube via the oral cavity, guiding it downward toward the esophagus. If resistance is met, rotate the tube end to guide it toward the esophagus. Do not force the tube. If continued resistance is met, stop the procedure and investigate barriers to tube advancement.

14. Watch for patient cues (e.g., cough, discomfort) as the tube is advanced.

To guide the tube into the esophagus, then the stomach.

Patient discomfort could signal potential tube advancement via the respiratory tract or that the tube is kinked or curled in the nasopharyngeal or oral cavity.

15. Continue to advance the tube to the intended distance as previously determined. If there is any resistance, do not force the tube past resistance. If the tube is difficult to advance, pull it back to the naso- or oropharyngeal area and gently advance again. Insertion of a small amount of air via syringe can help assess for tube kinking. Gentle resistance may be felt when the tube has been inserted to the distal stomach.

16. Instill 20?30 mL of air into the tube with a large syringe while listening for the air bolus over the epigastric region.

Advance tube to the stomach with sliding motion through the esophagus. Forcing the tube can cause kinking or trauma.

Although this is unreliable in assessing tube placement alone, it can provide valuable information to add to other information regarding tube placement.

17. Once the tube has been inserted to the predetermined length, aspirate using a 60-mL syringe to assess for gastric content. The tube may need to be advanced or withdrawn slightly to best obtain gastric content, which may help determine best placement.

18. Observe the quantity, color, and quality of the aspirated returns and store in a clean container to assess pH when the tube has been secured.

Gastric returns can indicate that the hole(s) of the tube are in a pool of gastric fluid.

Can help differentiate between gastric fluid and returns from the upper small bowel.15,16 Also provides valuable clinical information (e.g., evidence of recent gastric bleeding or a large volume of dark fluid, which might predispose to reflux or emesis).

Special Considerations The tongue might provide a barrier to

tube insertion, and gentle guidance over and past it might be helpful.

Sense of gagging may not be unexpected, but do not advance the tube if the patient is coughing because tube is more likely to enter respiratory tract (pull back to nasopharyngeal area and readvance). Patient cues can be very helpful, although respiratory intubation can occur with no overt signs such as coughing.

Anatomical anomalies such as hiatal hernias may present challenges to NG insertion. Guide but never force tube insertion.

If air is difficult to hear, the tube may not be in the stomach. If the injected air is audible in the mouth area, the tube tip may have curled in the upper GI tract. If unable to instill air, the tube may be kinked.

May need to insert a small volume of air to clear the tube of thick secretions to facilitate aspiration of gastric returns.

Returns from the small bowel might be clear gold in color and perhaps thick and oily as opposed to typical gastric returns.16 Gastric decompression will be missed if the tube terminates in the upper small bowel.

113 Nasogastric and Orogastric Tube Insertion, Care, and Removal 1015

Procedure for NG or OG Tube Insertion--Continued

Steps

Rationale

19. Cleanse the area for tube securement. Use a skin prep agent as indicated. If using the split-tape method to secure the tube to the nasal area: A. Split the tape lengthwise, leaving 1?2 inches unsplit. B. Clean the top of the nose with alcohol or a skin prep agent and apply an adhesive or tacifier agent (e.g., tincture of benzoin) for adhesiveness as indicated. C. Secure the unsplit tape to the top of the nose and wrap the split ends around the tube in opposite directions, leaving a gap at the tip of the nose to avoid pressure on nasal tissue. Pull up on the tip of the naris during taping to prevent the tube from pressing against the external aspect of the nares Or Secure the tube using a nasal securement device, also avoiding pressure on any nasal tissue Or If the tube is relatively small and soft, it may be able to secure across the cheek using transparent dressing up to the naris, overlapping two dressings as needed. Secure to the neck area to reduce pressure on the cheek dressings--pinch the tape around the tube, then to the neck for additional security.

20. For OG tube securement, the tube might be secured to the endotracheal tube that is often present when this method is used. If the endotracheal tube is not present, secure the tube to the corresponding cheek and neck area, monitoring frequently for potential tube displacement.

21. Measure the amount of tube that is external (from the naris to the distal tube end) and/or note numerical marking of tube at exit and mark the tube where it exits the naris with an indelible marker.

Reduces potential for inadvertent tube misplacement.

Avoid pressure from the tube against nasal mucosa with tube securement. Ensure that there is space between the tube and internal or external aspects of the naris or skin; serious pressure ulcers can and do develop related to NG securement.

Using a skin prep agent may aid the adhesiveness of the tape or other dressing material.

The risk of displacement for an orally placed tube is increased when there is difficulty securing it.

Provides an objective measure to determine placement; marking aids in quickly determining tube misplacement.

Special Considerations If it is possible to adequately secure

the tube to the cheek and neck area, the patient may prefer this as opposed to having it hang from the nose.

Ongoing need for oral gastric access is often considered as endotracheal extubation is planned.

Document in a place that is visible for ongoing monitoring.

Procedure continues on following page

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