Nasogastric Tube Insertion and Care and Review of Enteral Tubes

Nasogastric Tube Insertion & Care and Review of Enteral Tubes You will be divided into 4 groups & complete each section of this self-directed learning guide. Nasogastric Tube Insertion ½ of your group will perform NG tube insertion on “Woody” our NG tube simulator and tape in place. ½ of your group will complete the following desk activity (see Skill 42-6, p. 1153-1155). Preparation? ●​ Understand the patient's condition and the purpose of the tube placement. ●​ Review the physician's orders ●​ Obtain the patient's medical history, and assess for any contraindications like recent nasal/facial trauma or surgery. ○​ A history of nasal fractures or trauma may have caused a deviated nasal septum, narrowing the nasal passages and making NG tube insertion more difficult or impossible through that nostril. Basilar skull fractures increase the risk of inadvertently inserting the tube into the cranial vault instead of the esophagus. ○​ If the patient has a severely deviated septum, it may be necessary to use the contralateral nostril for insertion or consider an alternative route like orogastric intubation. Any recent nasal surgery or active nosebleeds would also contraindicate nasal intubation. ●​ Ensure the patient is NPO (nothing by mouth) as instructed. ●​ Explain the procedure thoroughly to the patient, addressing any concerns, and obtain verbal consent. ●​ Gather all necessary supplies and equipment. Equipment/Supplie s? How do you position the patient? ●​ The patient should be positioned in a semi-fowler's or high fowler's position. This involves raising the head of the bed to around 30-60 degrees. NG tube (appropriate size) Water-soluble lubricant Emesis basin Stethoscope pH strips or paper 60mL catheter tip syringe Nose clip or tape to secure tube Cup of water (to help patient swallow during insertion) Gloves Towel or pad to place under patient's head Oral hygiene equipment 1 ●​ The semi-upright position facilitates easier passage of the NG tube down the esophagus and into the stomach. It also allows the patient to swallow more comfortably during tube advancement. ●​ A small pillow or towel roll can be placed under the patient's shoulders to maintain proper head and neck alignment. The patient's head should be in a neutral, midline position without excessive flexion or extension. ●​ For a comatose patient requiring nasogastric (NG) tube insertion, proper positioning is crucial to facilitate safe passage and prevent complications. ○​ The patient should be placed in a semi-fowler's or high fowler's position, with the head of the bed raised 30-60 degrees. ○​ If the patient cannot be positioned upright due to their condition, the head should be kept in a neutral, midline position without excessive flexion or extension. ○​ An assistant may need to gently hold the patient's head in place during the procedure. Proper positioning helps align the airway and esophagus, allowing smoother NG tube advancement while reducing the risk of misplacement or aspiration. What instructions do you give the patient? ●​ Remain in a semi-fowler's or high fowler's position throughout the procedure ●​ Take small sips of water when instructed to help with swallowing the tube ●​ Try to remain calm and breathe normally during insertion ●​ Do not talk once the tube begins passing through your nose and throat ●​ Swallow as the tube advances to help guide it down the esophagus ●​ Indicate any discomfort, nausea, or difficulty breathing immediately ●​ Do not pull or dislodge the tube once it is secured in place How do you measure the distance of insertion? ●​ Have the patient flex their neck slightly and measure from the tip of the nose to the earlobe. ●​ Then measure from the earlobe to the xiphoid process (the bony prominence at the bottom of the sternum). ●​ Add these two measurements together to determine the approximate distance the NG tube needs to be inserted. List the steps for insertion. 1.​ 2.​ 3.​ 4.​ Explain the procedure and obtain informed consent from the patient. Gather necessary supplies Position the patient in a semi-fowler's or high fowler's position. Measure the approximate distance for insertion from the nose to the stomach. 5.​ Lubricate the NG tube with water-soluble lubricant. 2 6.​ Gently insert the NG tube through the selected nostril, advancing slowly as the patient swallows. 7.​ Confirm placement by aspirating gastric contents and checking the pH. 8.​ Secure the NG tube in place and connect it to intermittent suction or drainage bag. 9.​ Document the procedure, tube placement, and any patient reactions. 10.​Provide patient education on NG tube care and when to notify the nurse. How do you verify placement? (p. 1155 & see also Box 42-16 p. 1150-1151) 1.​ X-ray verification of NG tube placement involves taking an abdominal x-ray to visualize the path of the tube. The x-ray should show the NG tube following the esophageal course into the stomach. If the tip of the tube appears in the intestines or respiratory tract, it is misplaced. 2.​ Measuring the pH is another method to confirm gastric placement. After inserting the NG tube, attach a syringe and pull back to aspirate gastric contents. Test the pH using a pH strip or meter. A pH between 1-5.5 indicates gastric acid and proper stomach placement. A pH above 5.5 may signal respiratory or intestinal placement. -​ Describe anchoring the tube. Both x-ray and pH testing provide reliable confirmation that the NG tube is correctly positioned in the stomach before using it for feedings or medications. Proper verification prevents complications from tube misplacement. ●​ One method to secure an NG tube is to use medical tape across the bridge of the nose. First, place a small piece of tape or split gauze under the tube at the nostril exit to prevent skin irritation. ●​ Then, loop the tube over the patient's ear and use medical tape strips across the bridge of the nose to anchor it in place. ●​ Another option is to use a safety pin to secure the tube to the patient's gown or clothing. After looping the excess tubing over the ear, place a safety pin horizontally through the tube and pin it to the patient's clothing. This helps prevent dislodgement while allowing some mobility. Whichever method is used, be sure to monitor for skin integrity and reinforce or reposition the anchoring as needed. Nasogastric Tube Irrigation ½ of your group will perform NG tube irrigation on mannequin. ½ of your group will complete the following desk activity. Remember that NG tubes are used for decompression or for enteral feeds NG tubes for decompression provide the removal of secretions and gaseous substances from the GI tract to prevent and relieve abdominal distension. Two types of NG tubes for decompression: 3 1.​ Single bore (Levin tube) to intermittent suction 2.​ Salem Sump Tube with vent lumen to continuous suction [2 lumens, one for removal of gastric contents, the second lumen (blue pigtail) as an air vent] “Wash hands & apply clean gloves. Check tube placement.” Why do you need to check tube placement before irrigating? What is the pH of gastric fluid? What is the pH of intestinal or respiratory tract fluid? What observations do you make: 1.​ Of contents? 2.​ Of patient? ●​ It is crucial to check the NG tube placement before irrigating or instilling anything through it to ensure it is still properly positioned in the stomach. ●​ If the tube has become dislodged into the respiratory tract, irrigating could cause serious complications like aspiration pneumonia or respiratory distress. ●​ Verifying gastric placement by checking pH, auscultating, or x-ray helps prevent inadvertently administering substances into the lungs or other incorrect locations. Proper tube position must be confirmed before any use of the NG tube. ●​ The pH of normal gastric fluid is between 1-3.5, indicating high acidity from hydrochloric acid secretion. ●​ The pH of intestinal fluid is around 7-8, close to neutral. ●​ The pH of respiratory tract fluids is also around 7-8, close to neutral. ●​ A pH below 5.5 generally indicates gastric placement of an NG tube, while a pH above 5.5 suggests intestinal or respiratory placement. For NG tube irrigation, key observations include: ●​ Of contents: ○​ Amount and characteristics of return/residual after irrigation ○​ Presence of blood, bile, or undigested food in return ○​ Ability to flush the tube without resistance ●​ Of patient: ○​ Respiratory status for signs of aspiration ○​ Abdominal discomfort or distention ○​ Nausea or vomiting ○​ Skin integrity around nares and tube securement 4 Nasogastric Tube Removal ½ of your group will perform NG tube removal simulation and answer these questions: See the straw in glass of water on the table. What happens if you do not kink the straw when you remove it? ●​ If you do not kink or clamp the NG tube when removing it, air will be allowed to enter the stomach. This can cause gastric distention, discomfort, and potentially aspiration if stomach contents reflux up the tube. ●​ Kinking or clamping the tube prevents this air entry and keeps stomach contents contained until the tube is fully removed. ●​ Proper technique is important for patient safety and comfort during NG tube removal. What happens if you kink the straw before removing it? ●​ It will prevent air from entering the straw as you pull it out. This mimics the proper technique for removing an NG tube - kinking or clamping the tube before withdrawal prevents air from being drawn into the stomach, which could cause gastric distention, discomfort, or aspiration risk. Why do we kink or clamp the NG tube before removing? ●​ We kink or clamp the NG tube before removing it to prevent air from being drawn into the stomach as the tube is withdrawn. This avoids gastric distention, discomfort, and aspiration risk from stomach contents refluxing up the open tube. Kinking seals off the lumen and maintains a closed system until the tube is fully removed. Practice removing the NG tube on the simulated patient in the learning station. ½ of your group will complete the following desk activity: NG Removal Steps 1.​ Verify order 2.​ Assess bowel sounds 3.​ Explain procedure 4.​ Wash hands and apply clean disposable gloves 5.​ Turn off suction 6.​ Stand on R side of pt. if R-handed, on L side of pt. if L-handed 7.​ Position pt. in high Fowler’s position if possible 8.​ Remove tape from nose and unpin tube from gown 9.​ Place a towel across the pt.’s chest, give patient facial tissue 10.​Instruct pt. to take a deep breath and to exhale slowly. Clamp or kink the tubing and then pull the tube out steadily and smoothly into a towel held in your other hand. 11.​Document procedure 5 What would you do if bowel sounds were absent in step 2? ●​ If bowel sounds are absent during the assessment in step 2, I would not proceed with removing the NG tube. Absent bowel sounds could indicate an ileus or bowel obstruction, in which case removing the tube could lead to complications. ●​ I would notify the provider, document the finding, and follow any new orders regarding keeping the NG tube in place or obtaining further evaluation before removal. Patient safety is the top priority. What do you assess once the tube is removed? ●​ After removing the NG tube, I would assess the patient's nares and throat for any bleeding, irritation or trauma from the tube. I would also inspect the NG tube itself, noting the appearance and amount of any drainage present. Monitoring the patient's respiratory status, level of comfort, and any nausea or vomiting after tube removal is important as well. Providing oral care and ensuring the patient's safety and comfort are priorities post-removal What care do you give now? After removing the NG tube, I would provide the following care: ●​ Offer oral fluids and diet as tolerated, unless contraindicated ●​ Provide oral hygiene and suction if needed ●​ Monitor for nausea, vomiting, or respiratory distress ●​ Reassess bowel sounds ●​ Document removal time, tube characteristics, patient's tolerance ●​ Ensure patient comfort and safety ●​ The key priorities are maintaining hydration, monitoring for complications, promoting oral hygiene, and documenting thoroughly. Prompt intervention is needed for any adverse signs or symptoms. What do you document? When documenting NG tube removal, I would include: ●​ Date and time of removal ●​ Reason for removal (order, patient request, etc.) ●​ Pre-removal assessments (bowel sounds, abdominal exam) ●​ Characteristics of the removed tube (length, drainage amount/color) ●​ Patient's tolerance of the procedure ●​ Any complications during removal ●​ Post-removal status (respiratory, GI, comfort level) ●​ Interventions provided (oral care, diet, etc.) ●​ Name and credentials of nurse performing removal 6 Enteral tube feeding review In the fall we learned about enteral tube feeds given through Gastrostomy and Jejunostomy tubes. Today we are adding to this, looking at enteral feeds given through NG tubes. Your entire group will complete this exercise at the desk area. In order to better understand enteral tube feeds, you need to review the anatomy of the GI system. Label the diagram seen below (see p.1101, Figure 42:1). Refer to p. 1135 in your Potter and Perry text for the following questions. NG tubes are used when NG tubes are typically used when enteral feeds are to be administered enteral feeds are to be for less than 4-6 weeks. administered for less than how many weeks? Why are surgically or Surgically or endoscopically placed tubes like gastrostomy or jejunostomy endoscopically placed tubes are preferred for long-term feeding because they are more secure, 7 tubes preferred for long term feeding? have lower risks of dislodgement or aspiration, and are better tolerated by the patient. What is the indication for placement of an enteral tube beyond the stomach (Nasoenteric tube)? A nasoenteric tube is placed beyond the stomach, into the small intestine, when there is delayed gastric emptying, gastric outlet obstruction, severe reflux, or intolerance to gastric feedings. After insertion of an NG tube, how should placement be verified before the patient receives the first enteral feed? After NG tube insertion, placement should be verified by aspirating gastric contents and checking the pH (should be ≤5.5 for proper gastric placement) or by obtaining an abdominal X-ray before initiating feedings. See Skill 42-4 “Administering Enteral Feedings via Nasoenteric Tube” on p. 1142-1148 for the following questions. What position should the The textbook, the patient should be in a semi-Fowler's or high Fowler's patient be in? position with the head of the bed elevated 30-45 degrees during administration of enteral feedings via a nasoenteric tube. This positioning helps reduce the risk of aspiration. Review the procedure and summarize steps. 1.​ Verify physician order and gather supplies. 2.​ Explain procedure to patient and provide privacy. a.​ "For this feeding, I will be elevating the head of your bed to help prevent any complications. I'll first check to ensure the tube is properly positioned by aspirating a small amount of fluid and testing it. Then I will flush the tube with water to clear it. The feeding solution will run through the tube and into your intestine at a slow, controlled rate set by the pump. I'll be monitoring you closely throughout for any discomfort or issues. When finished, I'll flush the tube again and ensure you are positioned comfortably. Please let me know if you have any questions or concerns arise during the process." 3.​ Wash hands and apply clean gloves. 4.​ Position patient semi-Fowler's or high Fowler's. 5.​ Check tube placement by aspirating gastric contents and testing pH. 6.​ Flush tube with water before and after feeding or medication administration. 8 7.​ Connect feeding container tubing to nasoenteric tube using aseptic technique. 8.​ Set prescribed feeding rate and begin infusion. 9.​ Monitor patient frequently, checking residuals as ordered. 10.​When complete, flush tube again and secure it. 11.​Provide oral care and reposition patient for comfort. 12.​Document intake, output, residuals, and patient tolerance. How do you check for gastric residual (p 1143)? ●​ To check for gastric residual, stop the tube feeding and aspirate stomach contents using a syringe connected to the nasoenteric tube. ●​ Measure the volume aspirated. If it exceeds the amount delivered over the previous 2 hours for continuous feedings, or 50% of the previous bolus feeding, return the aspirate, hold the feeding, and notify the provider. Briefly explain the rationale for determining the gastric residual (p 1143). ●​ Checking gastric residual volumes before enteral feedings helps assess gastric emptying and tolerance. ●​ Excessive residuals may indicate delayed gastric emptying, intestinal obstruction, or feeding intolerance. This allows adjusting the feeding rate or holding feedings temporarily to prevent complications like aspiration, nausea, or vomiting. ●​ Start feeding at prescribed slow rate, usually 20-30 mL/hr initially ●​ Increase rate gradually as tolerated, e.g. 10-25 mL/hr every 4-8 hrs ●​ Monitor for signs of intolerance like abdominal discomfort, nausea, diarrhea ●​ Check gastric residuals periodically, hold feeding if excessive ●​ Flush tube with water before/after feeding and medication administration ●​ Keep head of bed elevated 30-45 degrees during feeding ●​ Rotate feeding bag regularly to prevent separation ●​ Discard unused portion after hang time expires ○​ Hang time refers to the maximum allowable time that an enteral feeding solution can remain hanging and be safely administered. Once the hang time is reached, any remaining feeding solution must be discarded due to risk of bacterial growth. Typical hang times are 4-8 hours for opened ready-to-hang containers at room temperature. Following proper hang time limits helps prevent feeding-related infections. Review section on initiating feeding and make point form notes (p. 1144-1145) 9 How often should the bag and tubing be changed (p. 1145)? List the 3 main unexpected outcomes and what you should do about them (p.1145). The feeding bag and tubing should be changed every 24 hours to prevent bacterial growth and maintain proper nutrition delivery. 1.​ Diarrhea - Slow the feeding rate, check for lactose intolerance, consider anti-diarrheal medication if persistent. 2.​ Nausea/Vomiting - Stop the feeding, check for residuals, restart at a lower rate when symptoms resolve. 3.​ Abdominal cramping/distention - Slow the rate, reposition the tube, provide anti-gas medication if needed. Review “Administering Enteral feeds via Gastrostomy or Jejunostomy tube” (Skill 42-5, p. 11146-1148). Administering enteral feeds via gastrostomy or jejunostomy tube involves the following steps: 1.​ Assemble all necessary supplies like the feeding bag, feeding solution, 60mL catheter tip syringe, water, and feeding pump if ordered. 2.​ Explain the procedure to the patient and provide privacy. 3.​ Perform hand hygiene and apply clean gloves. 4.​ Check for residual volume by aspirating gently with the 60mL syringe before initiating the feeding. 5.​ Flush the tube with 30-60mL of warm water before and after the feeding to maintain patency. 6.​ Connect the feeding bag tubing to the gastrostomy or jejunostomy tube, unclamp it, and adjust the pump rate as per the prescribed order. 7.​ Ensure the head of the bed is elevated 30-45 degrees during the feeding to prevent aspiration. 8.​ Monitor closely for any signs of intolerance like nausea, vomiting, abdominal pain or distention. 9.​ After completing the feeding, flush the tube again with 30-60mL of warm water and clamp it. 10.​Change the tubing set and feeding bag every 24 hours to prevent bacterial growth. 11.​Provide mouth care and reposition the patient for comfort after the procedure. Proper technique, monitoring for complications, and maintaining feeding tube patency are crucial for safe enteral nutrition administration.