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Nasogastric tube insertion
Assessment
Nasogastric tube insertion
can be used for up to six months. These tubes have a guide wire to assist insertion that is removed once the tube is in place. Both types of tubes are radio-opaque and have measurement markers to aid insertion and assist the management of the tube following insertion. Before inserting the tube it should be measured. The tip of the tube is held at the tip of the patient’s xiphisternum to the ear and to the tip of the patient’s nose, taking note of the centimetre markers in order to establish the length to which the tube should be passed. Most adult patients measure at approximately 54 centimetres (see Figures 1 and 2).
Joanne Willcox
This article outlines the safe placement and management of a nasogastric tube, adhering to national best practice and guidance from the National Patient Safety Agency (NPSA). Please note that this article only focuses on adult patients. Clinical indications for a nasogastric tube include: • drainage of the stomach contents, including air • to allow access to the stomach bypassing the oral route, in order to administer fluids, drugs and nutrients. Contraindications for a nasogastric tube include: • patients with maxillofacial disorders or injury • patients diagnosed with oesophageal tumours or trauma • patients post-laryngectomy • patients with oropharyngeal tumours or surgery • confirmed or suspected skull fractures or unstable cervical spinal injuries above C4 • ingestion of corrosive products • patients with clotting disorders. Patients with any of the above conditions should be referred to specialist teams such as the nutrition team when considering placing a nasogastric tube. If the patient is on medications that will affect the pH of the gastric aspirate, such as proton pump inhibitors, with the exception of ranitidine, then an alternative investigation such as a radiograph should be used to confirm tube placement. No more than three attempts should be made to insert the tube, and if the patient shows signs of respiratory distress the procedure should be abandoned.3
Pre-insertion preparation The patient’s verbal consent should be sought prior to the procedure, with explanation of the risks and benefits; once consent is obtained this should be documented in the medical notes. A history should be taken of any nasal fractures or polyps which may affect the insertion of the tube. An assessment of the patient’s ability to swallow will determine if sips of water can be used to aid the tube insertion. Mouthwash can be used for those patients who are unable to swallow. The patient should be sat upright and a ‘stop’ signal should be agreed between the practitioner and the patient in order to reduce distress when the tube is inserted. Often a brief pause indicated by the ‘stop’ signal can reduce anxiety and increase the chances of a successful and less traumatic procedure.1 Equipment required includes: • nasogastric tube – feeding or drainage • 50 ml catheter tip syringe • drainage bag or spigot • pH paper (with 0.5 increments. A pH of 6.0 or more may indicate bronchial or intestinal placement)
Measurement of tube
Tube selection Nasogastric tubes that are inserted in order to drain the stomach of air or gastric contents are usually single port and are made of polyvinylchloride (PVC). PVC corrodes after ten days and can splinter if not replaced, causing oesophageal and nasal irritation. Fine-bore tubes with a French gauge of 6 can adequately be used to administer nutrients, drugs and fluids.5 An 8 fr can be considered if the patient is receiving a feed containing fibre. Finebore tubes are made from polyurethane, which is flexible and
b
c
a
Joanne Willcox BSc(hons) Nursing is a Registered Nurse and a Senior Clinical Skills Facilitator at University Hospitals of Leicester, UK. She graduated at De Montfort University, Leicester and her focus is the undergraduate medical school curriculum. Conflicts of interest: none declared.
THE FOUNDATION YEARS 5S
University Hospitals of Leicester. Policy for the insertion and post-insertion care of a nasogastric tube in adults, children and infants, 2005
Figure 1
13
© 2008 Elsevier Ltd. All rights reserved.
Assessment
Flowchart for the safe insertion and management of nasogastric tubes Check guidewire is mobile within the tube. Insert tube as per “Procedure for the insertion of a nasogastric tube for the adult patient” (Appendix Two). Guidewire may be removed after insertion if free running (n.b. do not instil water at this point)
Using a 50 ml sterile catheter tip syringe, syringe 30 ml AIR into stomach and aspirate gastric contents slowly
No aspirate. Check the tube length
Yes 3–5 ml aspirate
Refer to Appendix Three of this policy Test with pH paper Check all ports on NG tube sealed and airtight No aspirate
If swallow intact and pt not NBM, ask the patient to drink pineapple or blackcurrant Fortijuice or pure orange juice
pH above 6
If swallow intact and pt not NBM, ask the patient to drink pineapple or blackcurrant Fortijuice
Consider retrying after 30 minutes (once only)
pH 5.5 or below
No aspirate pH above 6 Check tube length. Consider advancing to 60 cms at nostril, withdrawing slowly to 50 cms, aspirating at 1 cm increments until aspirate gained
No aspirate
Chest X-ray: Consultant, Registrar or Radiology report review of chest X-ray Documentation in medical notes to include positon of tube and if safe to use for feeding.
Flush the tube with air as this may move the tube away from the stomach wall. Re-aspirate
Position of tip of NG tube is therefore confirmed in stomach
Flush tube with sterile water (in UIL) / cooled boiled water (in community) and remove guidewire if present
Consider removing and re-passing tube or X-ray No aspirate No aspirate
Document in notes and on NG insertion sticker (see Section 6)
Retry drawing back after 3–5 minutes
Commence feeding
Reposition patient to left side
No aspirate
NBM, nil by mouth; NG, nasogastric University Hospitals of Leicester. Policy for the insertion and post-insertion care of a nasogastric tube in adults, children and infants, 2005
Figure 2
THE FOUNDATION YEARS 5S
14
© 2008 Elsevier Ltd. All rights reserved.
Assessment
• apron and gloves • glass of water and straw if the patient is able to swallow • micropore tape to secure the tube to the patient’s nostril (check allergies).
• Drugs such as metoclopromide will increase gastric emptying, making it difficult to obtain an aspirate. An X-ray should be used to determine the position of the tube in the case of no aspirate. An X-ray is only indicated if a gastric aspirate is unobtainable or the pH result is 6 or above and the patient is unable to swallow an acidic drink to alter the pH. An X-ray must be reviewed by a suitably qualified clinician and the nasogastric tube is not to be used for drugs, fluid or nutrients until it has been reviewed. Please note that the X-ray results are only valid at the time it is taken. • Once the tube’s position has been confirmed, remove the guide wire (if still present; occasionally it is advisable to leave the guide wire in place to aid re-alignment if obtaining aspirate is difficult) gently so not to misplace the tube and flush with 10 ml of sterile water to unblock the tube of any gastric aspirate and activate the water-soluble lubricant that coats the lumen of the tube.5 If the guide wire is difficult to remove, the tube may have curled in the oesophagus; pull back the tube by 20 cms and re-attempt to pass the tube. • Secure the tube to the nose and in the case of a feeding tube to the cheek with hypoallergenic tape. Cleaning the area with an alcohol swab can aid with adhesion of the tape. • Attach bile bag or spigot (if required). • Ensure patient’s comfort. • Wash hands and document in the notes, using the accompanying sticker that manufacturers provide with the tubes, paying particular attention to the measurement marker of the tube and a witnessed pH result dated and timed. ◆
Tube placement • Wash hands, apply alcohol rub and put on an apron and gloves prior to assembling your equipment. • If using a fine-bore tube with a guide wire, ensure that the guide wire is moving freely within the tube and there are no kinks; this will assist removal of the guide wire once the tube is inserted.2 • Sit the patient upright, ensuring the head is not tilted backwards; this will ensure that the epiglottis is not obstructing the oesophagus. • Measure the tube (see above) and assess the patient’s ability to swallow. • At this point you should wash your hands and apply alcohol rub in order to minimize cross-infection. • Lubricate the tip of the tube with sterile water to assist inser tion. Aqueous jelly such as KY is alkaline and will therefore affect the pH result. • Slide the tip of the tube in a backwards motion into the chosen nostril and encourage the patient to swallow. The swallowing reflex ensures that the glottis closes, enabling the tube to pass into the oesophagus, reducing the risk of bronchial intubation.4 If any resistance is felt, alter direction or attempt the other nostril. • As the tube passes into the nasopharynx, encourage the patient to tilt their chin forward and swallow a mouthful of water (if appropriate), drinking through a straw. • Continue to advance the tube until the pre-measured marker has been reached. Stop and remove the tube if the patient shows signs of respiratory distress and seek medical support. • Ensure all other ports are closed and attach a 50 ml catheter tip syringe (only catheter tip syringes and enteral syringes should be used). Using gentle suction withdraw an aspirate sample using the 50 ml catheter tip syringe. Apply the aspirate to the pH paper to confirm that it is gastric aspirate. • A pH result of less than 5.5 indicates that the tube is in the stomach, or less than 5.0 if using 1.0 pH increment paper. Note drugs that the patient may be taking that can affect the pH result. If an aspirate is unobtainable and the patient is able to swallow, give them an acidic drink such as pineapple Fortijuice orally and retry after ten minutes.
THE FOUNDATION YEARS 5S
References 1 Dean HR. A blend of comforting strategies and a form of team comforting were used during nasogastric tube insertion. Evidence Based Nursing 1999; 2(4): 134. 2 Mensforth A, Nightingale JMD. Insertion and care of enteral feeding tubes. In: Nightingale JMD, ed. Intestinal Failure. London: Greenwich Medical Media, 2001. 3 National Patient Safety Agency (NPSA). How to confirm the correct position of nasogastric feeding tubes in infants, children and adults. http://www.npsa.nhs.uk/health/display?contentId=3525, 2005. 4 Pritchard AP, Mallett J. The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 5th edn. London: Blackwell Scientific Press, 2000. 5 Rollins H. A nose for trouble. Nursing Times 1997; 93(49): 66–67.
15
© 2008 Elsevier Ltd. All rights reserved.
Nasogastric tube insertion
can be used for up to six months. These tubes have a guide wire to assist insertion that is removed once the tube is in place. Both types of tubes are radio-opaque and have measurement markers to aid insertion and assist the management of the tube following insertion. Before inserting the tube it should be measured. The tip of the tube is held at the tip of the patient’s xiphisternum to the ear and to the tip of the patient’s nose, taking note of the centimetre markers in order to establish the length to which the tube should be passed. Most adult patients measure at approximately 54 centimetres (see Figures 1 and 2).
Joanne Willcox
This article outlines the safe placement and management of a nasogastric tube, adhering to national best practice and guidance from the National Patient Safety Agency (NPSA). Please note that this article only focuses on adult patients. Clinical indications for a nasogastric tube include: • drainage of the stomach contents, including air • to allow access to the stomach bypassing the oral route, in order to administer fluids, drugs and nutrients. Contraindications for a nasogastric tube include: • patients with maxillofacial disorders or injury • patients diagnosed with oesophageal tumours or trauma • patients post-laryngectomy • patients with oropharyngeal tumours or surgery • confirmed or suspected skull fractures or unstable cervical spinal injuries above C4 • ingestion of corrosive products • patients with clotting disorders. Patients with any of the above conditions should be referred to specialist teams such as the nutrition team when considering placing a nasogastric tube. If the patient is on medications that will affect the pH of the gastric aspirate, such as proton pump inhibitors, with the exception of ranitidine, then an alternative investigation such as a radiograph should be used to confirm tube placement. No more than three attempts should be made to insert the tube, and if the patient shows signs of respiratory distress the procedure should be abandoned.3
Pre-insertion preparation The patient’s verbal consent should be sought prior to the procedure, with explanation of the risks and benefits; once consent is obtained this should be documented in the medical notes. A history should be taken of any nasal fractures or polyps which may affect the insertion of the tube. An assessment of the patient’s ability to swallow will determine if sips of water can be used to aid the tube insertion. Mouthwash can be used for those patients who are unable to swallow. The patient should be sat upright and a ‘stop’ signal should be agreed between the practitioner and the patient in order to reduce distress when the tube is inserted. Often a brief pause indicated by the ‘stop’ signal can reduce anxiety and increase the chances of a successful and less traumatic procedure.1 Equipment required includes: • nasogastric tube – feeding or drainage • 50 ml catheter tip syringe • drainage bag or spigot • pH paper (with 0.5 increments. A pH of 6.0 or more may indicate bronchial or intestinal placement)
Measurement of tube
Tube selection Nasogastric tubes that are inserted in order to drain the stomach of air or gastric contents are usually single port and are made of polyvinylchloride (PVC). PVC corrodes after ten days and can splinter if not replaced, causing oesophageal and nasal irritation. Fine-bore tubes with a French gauge of 6 can adequately be used to administer nutrients, drugs and fluids.5 An 8 fr can be considered if the patient is receiving a feed containing fibre. Finebore tubes are made from polyurethane, which is flexible and
b
c
a
Joanne Willcox BSc(hons) Nursing is a Registered Nurse and a Senior Clinical Skills Facilitator at University Hospitals of Leicester, UK. She graduated at De Montfort University, Leicester and her focus is the undergraduate medical school curriculum. Conflicts of interest: none declared.
THE FOUNDATION YEARS 5S
University Hospitals of Leicester. Policy for the insertion and post-insertion care of a nasogastric tube in adults, children and infants, 2005
Figure 1
13
© 2008 Elsevier Ltd. All rights reserved.
Assessment
Flowchart for the safe insertion and management of nasogastric tubes Check guidewire is mobile within the tube. Insert tube as per “Procedure for the insertion of a nasogastric tube for the adult patient” (Appendix Two). Guidewire may be removed after insertion if free running (n.b. do not instil water at this point)
Using a 50 ml sterile catheter tip syringe, syringe 30 ml AIR into stomach and aspirate gastric contents slowly
No aspirate. Check the tube length
Yes 3–5 ml aspirate
Refer to Appendix Three of this policy Test with pH paper Check all ports on NG tube sealed and airtight No aspirate
If swallow intact and pt not NBM, ask the patient to drink pineapple or blackcurrant Fortijuice or pure orange juice
pH above 6
If swallow intact and pt not NBM, ask the patient to drink pineapple or blackcurrant Fortijuice
Consider retrying after 30 minutes (once only)
pH 5.5 or below
No aspirate pH above 6 Check tube length. Consider advancing to 60 cms at nostril, withdrawing slowly to 50 cms, aspirating at 1 cm increments until aspirate gained
No aspirate
Chest X-ray: Consultant, Registrar or Radiology report review of chest X-ray Documentation in medical notes to include positon of tube and if safe to use for feeding.
Flush the tube with air as this may move the tube away from the stomach wall. Re-aspirate
Position of tip of NG tube is therefore confirmed in stomach
Flush tube with sterile water (in UIL) / cooled boiled water (in community) and remove guidewire if present
Consider removing and re-passing tube or X-ray No aspirate No aspirate
Document in notes and on NG insertion sticker (see Section 6)
Retry drawing back after 3–5 minutes
Commence feeding
Reposition patient to left side
No aspirate
NBM, nil by mouth; NG, nasogastric University Hospitals of Leicester. Policy for the insertion and post-insertion care of a nasogastric tube in adults, children and infants, 2005
Figure 2
THE FOUNDATION YEARS 5S
14
© 2008 Elsevier Ltd. All rights reserved.
Assessment
• apron and gloves • glass of water and straw if the patient is able to swallow • micropore tape to secure the tube to the patient’s nostril (check allergies).
• Drugs such as metoclopromide will increase gastric emptying, making it difficult to obtain an aspirate. An X-ray should be used to determine the position of the tube in the case of no aspirate. An X-ray is only indicated if a gastric aspirate is unobtainable or the pH result is 6 or above and the patient is unable to swallow an acidic drink to alter the pH. An X-ray must be reviewed by a suitably qualified clinician and the nasogastric tube is not to be used for drugs, fluid or nutrients until it has been reviewed. Please note that the X-ray results are only valid at the time it is taken. • Once the tube’s position has been confirmed, remove the guide wire (if still present; occasionally it is advisable to leave the guide wire in place to aid re-alignment if obtaining aspirate is difficult) gently so not to misplace the tube and flush with 10 ml of sterile water to unblock the tube of any gastric aspirate and activate the water-soluble lubricant that coats the lumen of the tube.5 If the guide wire is difficult to remove, the tube may have curled in the oesophagus; pull back the tube by 20 cms and re-attempt to pass the tube. • Secure the tube to the nose and in the case of a feeding tube to the cheek with hypoallergenic tape. Cleaning the area with an alcohol swab can aid with adhesion of the tape. • Attach bile bag or spigot (if required). • Ensure patient’s comfort. • Wash hands and document in the notes, using the accompanying sticker that manufacturers provide with the tubes, paying particular attention to the measurement marker of the tube and a witnessed pH result dated and timed. ◆
Tube placement • Wash hands, apply alcohol rub and put on an apron and gloves prior to assembling your equipment. • If using a fine-bore tube with a guide wire, ensure that the guide wire is moving freely within the tube and there are no kinks; this will assist removal of the guide wire once the tube is inserted.2 • Sit the patient upright, ensuring the head is not tilted backwards; this will ensure that the epiglottis is not obstructing the oesophagus. • Measure the tube (see above) and assess the patient’s ability to swallow. • At this point you should wash your hands and apply alcohol rub in order to minimize cross-infection. • Lubricate the tip of the tube with sterile water to assist inser tion. Aqueous jelly such as KY is alkaline and will therefore affect the pH result. • Slide the tip of the tube in a backwards motion into the chosen nostril and encourage the patient to swallow. The swallowing reflex ensures that the glottis closes, enabling the tube to pass into the oesophagus, reducing the risk of bronchial intubation.4 If any resistance is felt, alter direction or attempt the other nostril. • As the tube passes into the nasopharynx, encourage the patient to tilt their chin forward and swallow a mouthful of water (if appropriate), drinking through a straw. • Continue to advance the tube until the pre-measured marker has been reached. Stop and remove the tube if the patient shows signs of respiratory distress and seek medical support. • Ensure all other ports are closed and attach a 50 ml catheter tip syringe (only catheter tip syringes and enteral syringes should be used). Using gentle suction withdraw an aspirate sample using the 50 ml catheter tip syringe. Apply the aspirate to the pH paper to confirm that it is gastric aspirate. • A pH result of less than 5.5 indicates that the tube is in the stomach, or less than 5.0 if using 1.0 pH increment paper. Note drugs that the patient may be taking that can affect the pH result. If an aspirate is unobtainable and the patient is able to swallow, give them an acidic drink such as pineapple Fortijuice orally and retry after ten minutes.
THE FOUNDATION YEARS 5S
References 1 Dean HR. A blend of comforting strategies and a form of team comforting were used during nasogastric tube insertion. Evidence Based Nursing 1999; 2(4): 134. 2 Mensforth A, Nightingale JMD. Insertion and care of enteral feeding tubes. In: Nightingale JMD, ed. Intestinal Failure. London: Greenwich Medical Media, 2001. 3 National Patient Safety Agency (NPSA). How to confirm the correct position of nasogastric feeding tubes in infants, children and adults. http://www.npsa.nhs.uk/health/display?contentId=3525, 2005. 4 Pritchard AP, Mallett J. The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 5th edn. London: Blackwell Scientific Press, 2000. 5 Rollins H. A nose for trouble. Nursing Times 1997; 93(49): 66–67.
15
© 2008 Elsevier Ltd. All rights reserved.