Inserting a Nasogastric Tube

 By inserting  nasogastric tube you are gaining access to the stomach and its contents.
There are many types of nasogastric tubes that comes in different sizes. Among the
most common are the Levin catheter, which is single lumen, small bore tube more
appropriate for administration of medication or nutrition,  invented by Abraham Louis
Levin, an American physician ( December 16, 1880- Sept 15, 1940.) The Levin tube is
also widely used  for duodenal drainage after surgery and management of trauma
patients. The Salem Sump catheter, is a large bore double lumen  tube that can be
used for feeding or administering medication, but their primary function is gastric
suctioning and decompression.
 Definition – A nasogastric tube is a flexible plastic tube inserted through the nostrils,
down the nasopharynx, and into the stomach or the upper portion of the small intestine.
Placement of NG tube is always confirmed by with an X ray prior to to use. ( Perry,
Potter & Ostendorf, 2014.)
PURPOSES:
To administer tube feedings and medications to clients unable to eat by mouth or
swallow a sufficient diet without aspirating food or fluids into the lungs
To establish a means for suctioning stomach contents to prevent gastric distention,
nausea, and vomiting
To remove stomach contents for laboratory analysis
To lavage (wash) the stomach in case of poisoning or overdose of medications
ASSESSMENT
Check for history of nasal surgery or deviated septum
Assess patency of nares
Determine presence of gag reflex
Assess mental status or ability to participate in the procedure
 PLANNING
Before inserting a nasogastric tube, determine the size of the tube to be inserted and
whether the
tube is to be attached to a suction
 Equipment
Large – or small-bore tube (nonlatex preferred ) 
Non allergenic adhesive tape, 2.5 cm (1 in.) wide
Clean gloves 
Water - soluble lubricant 
Facial tissues
Glass of water and drinking straw 
20 – 50 -ml syringe with an adapter  
Basin   
Ph test strip or meter 
Bilirubin dipstick
Stethoscope 
Disposable pad or towel 
Suction apparatus
Safety pin and elastic band       
C02 detector (optional)   
IMPLEMENTATION
Criteria             Rationale
Assist the client to a high Fowler’s
position if his or her health condition
permits, and support the head on a pillow.
Place a towel or disposable pad across
the chest.

Performance Identifying the patient ensures the right

1. Prior to performing the insertion patient receives the intervention and
introduce self and verify the client’s helps prevents errors.  (Lynn, 20015)  
identity using two patient's identifiers,(i.g., Explanation facilitates patient cooperation
name and date of birth.) Explain to the (Lynn, 2015)
client what you are going to do, why it is
necessary, and how he or she can
participate. The passage of a gastric tube
is unpleasant because the gag reflex is
activated during insertion. Establish a
method for the client to indicate distress
and a desire for you to pause the
insertion. Raising a finger or a hand is
often used for this.

2. Perform hand hygiene and observe Hand hygiene and PPE prevent the
other appropriate infection control spread of microorganisms ( Lynn, 2015) 
procedures (e.g., clean gloves).
3. Provide for client privacy Closing the door or pulling the curtain is
the client's right to privacy ( Carter, 2012 )
4. Assess the client’s nares
·      Apply clean gloves
·      Ask the client to hyperextend the
head, and using a flashlight, observe the
intactness of the tissues of the nostrils,
including any irritations or abrasions.
·      Examine the nares for any
obstructions or deformities by asking the
client to breathe through one nostril while
occluding the other.
·      Select the nostril that has the greater
airflow.

5. Prepare the tube -

If a small bore-tube is being used, ensure  
stylet or guidewire is secured in position. - An improperly positioned stylet or 
  guidewire  can traumatize the
  nasopharynx, esophagus and stomach.
If a large bore- tube (e.g Salem sump  
tube) is being used, place the tube in a  
basin of warm water, while preparing the  
client -This allows the tubing to become more
pliable and flexible. However, if the
softened tube becomes difficult to control,
it may be helpful to place the distal end in
a basin of ice water to help it hold its
shape.

6. Determine how far to insert the tube. -This length approximates the distance
Use the tube to mark off the distance from the nares to the stomach. This
from the tip of the client’s nose to the tip distance varies among individuals.
of the earlobe to the tip of the xiphoid
Mark this length with adhesive tape if the
tube does not have markings
7. Insert the tube
Lubricate the tip of the tube well with -A water-soluble lubricant dissolves if the
water soluble lubricant or water to ease tube accidentally enters the lungs. An oil-
insertion. In some agencies, topical based lubricant, such as petroleum jelly,
lidocaine anesthetic is used on the tube will not dissolve and could cause
or in the client’s nose to numb the area. respiratory complications if it enters the
  lungs.
Insert the tube, with its natural curve  
toward client, into the selected nostril. -Hyperextension of the neck reduces the
Ask the client to hyperextend the neck , curvature of the nasopharyngeal junction.
and gently advance the tube toward the  
nasopharynx -Directing the tube along the floor avoids
  the projections (turbinate) along the
Direct the tube along the floor of the lateral wall.
nostril and toward the ear on that side  
  -Tears are a natural body response.
Slight pressure and a twisting motion are Provide the client with tissues as needed.
sometimes required to pass the tube into  
the nasopharynx and some client’s eyes -The tube should never be forced against
may water at this point. resistance because of the danger if injury
   
If the tube meets resistance, withdraw it -Tilting the head forward facilitates
relubricate it, and insert it in the other passage of the tube into the posterior
nostril pharynx and esophagus rather than into
  the larynx; swallowing move the epiglottis
Once the tube reaches the oropharynx over the opening to the larynx.
(throat), the client will feel the tube in the  
throat and may gag and retch. Ask the  
client to tilt the head forward, and  
encourage the client to tilt the head  
forward, and encourage the client to drink  
and swallow  
If the client gags, stop passing the tube  
momentarily. Have the client rest, take a  
few breaths, and take sips of water to  
calm the gag reflex.  
In cooperation with the client pass the -The tube may be coiled in the throat, if
tube 5 to 10 cm (2 to 4 in.) with each so, withdraw it until it is straight, and try
swallow, until the indicated length is again to insert it.
inserted.
If the client continues to gag and the tube
does not advance with each swallow,
withdraw it slightly and inspect the throat
by looking through the mouth
If a CO2 detector is used, after the tube
has been advanced approximately 30 cm
(12in), draw air through the detector. Any
change in color of the color of the
detector indicates placement of the tube
in the respiratory tract (Meyer et al 2009),
Immediately withdraw the tube and
reinsert

8. Ascertain correct placement of the tube -Testing pH is a reliable way to determine

Aspirate stomach contents, and check the location of a feeding tube. Gastric
pH, which should be acidic contents are commonly pH 1 to 5; 6 or
Aspirate can also be tested for bilirubin. greater would indicate the contents are
Bilirubin levels in the lungs should be from lower in the intestinal tract or in the
almost zero, while levels in the stomach respiratory tract. Some researches
will be approximately 2.5mg/dl and in the suggest that a pH of greater than 4
intestine more than 10mg/dl should be followed by further confirmation
 Almost all nasogastric tubes are of tube location (Stock, Gilbertson, &
radiopaque, and position can be Babl, 2008
confirmed by x-ray. Check agency policy. -The stylet is sharp and could pierce the
If a small-bore tube is used, leave the tube and injure the client or cut off the
stylet or guidewire in place until correct tube end.
position is verified by x-ray. If the stylet  
has been removed, never reinsert it while -This method does not guarantee tube
the tube is in place position
 Place a stethoscope over a client’s
epigastrium and inject 10-30 ml of air into
the tube while listening for a whooshing
sound. Although still one of the methods
used, do not use this method as the
primary method for determining
placement of the feeding tube.
 If the signs indicate placement in the
lung, remove the tube and begin again
 If the signs do not indicate placement in
the lungs or stomach, advance the tube
5cm(2in), and repeat the tests

9. Secure the tube by taping it to the -Taping in this manner prevents the tube
bridge of the client’s nose. from pressing against and irritating the
If the client has oily skin, wipe the nose edge of the nostril
first with alcohol to defat skin
 Cut 7.5cm (3in) of tape, and split it
lengthwise at one end, leaving 2.5-cm 
(1in) tab in the end
 Place the tape over the bridge of the
client’s nose, and bring the split ends
under the tubing and back up over the
nose. Ensure that the tube is centrally
located prior to securing with tape to
maximize air flow and prevent irritation to
the side of nares.  

10. Once correct position  has been

determined, attach the tube to a suction
source of feeding apparatus as ordered ,
or clamp the end of the tubing.
11. Secure the tube to the client’s gown -The tube is attached to prevent it from
 Loop an elastic band around the end of dangling and pulling
the tubing, and attach the elastic band to  
the gown with a safety pin or -This prevents gastric contents from
Attach a piece of adhesive tape to the flowing into the vent lumen 
tube, and pin the tape to the gown.
If a Salem pump is used, attach the anti-
reflux valve to the vent port (if used) and
position the port above the client’s waist
Remove and discard gloves. Perform
hand hygiene

12. Document relevant information; The

insertion of the tube the means by which
correct placement was determined and
client responses (e.g. discomfort or
abdominal distention)
13. Establish a plan for providing daily
nasogastric tube care
Inspect the nostril for discharge and
irritation
Clean the nostril and tube with
moistened, cotton-tipped applicators
Apply a water-soluble lubricant to the
nostril if it appears dry or encrusted
Change the adhesive tape as required
Give frequent mouth care. Due to the
presence of the tube, the client may
breathe through the mouth

14. If suction is applied ensure the

patency of both the nasogastric and
suction tubes is maintained
 Irrigations of the tube may be required at
regular intervals. In some agencies,
irrigations must be ordered by the primary
care provider. Prior to each irrigation,
 recheck tube placement
If a Salem sump tube is used, follow
agency policies for irrigating the vent
lumen with air to maintain patency of the
suctioning lumen. Often, a sucking sound
can be heard from the vent port if it is
patent.
Keep accurate records of the client’s fluid
intake and output, and record the amount
and characteristics of the drainage

15. Document the type of the tube

inserted, date and time of tube insertion,
type of suction used, color and amount of
gastric contents, and the client’s
tolerance of the procedure
EVALUATION
Conduct appropriate  follow up, such as degree of client comfort, client tolerance of the
nasogastric tube, correct placement of nasogastric tube in stomach, client
understanding of restrictions, color and amount of gastric contents if attached to
suction , or stomach contents aspirated.