Care of Nasogastric (Decompression) Tubes

Who may insert a NG tube

-Physicians, advanced practice providers, and RNs -physicians order is required to place

Preparing the tube for placement

-apply water soluble lubricant to last 2-3 inches of NG tube

Fluroscopy placement of NG tubes

-appropriate if patient is lethargic, diminished gag reflex, uncooperative, combative, esophageal varices, history of upper GI or ENT/neck surgery

Bedside placement of NG tubes

-appropriate if the patient is awake, alert, able to reliably follow directions, and are cooperative

How do you verify tube placement is in the stomach?

-aspiration of gastric contents -inject 30 mLs of air using 60 mL syringe and withdraw gastric contents -test pH of aspirate (gastric content pH <5) -radiographic confirmation (abdominal x-ray)

Assessment of an NG tube

-assess every 4 hours for proper placement of the tube, tube patency, and output (quantity and quality) -monitor the nasal skin around the tube for irritation -use a device that secures the tube to the nose to prevent accidental removal -assess for peristalsis by auscultating for bowel sounds with the suction disconnected -aspirate contents with 30 mL of normal saline every 4 hours or as requested by the health care provider

Preparing supplies for NG placement

-determine type and size of NG tube needed -enteral feeding requires smaller, more flexible tub #8-12 -gastric decompression or lavage requires larger, less flexible tubs #14-18 -select the smallest size tube for therapeutic purpose

Review the following with the patient before inserting the NG tube

-indication for placement -procedure -anticipated outcomes after placement (i.e. deliver nutrition, decompress stomach, GI rest) -how to care for NG tube, securement, side effects -any concerns, anxiety -indications for removal -removal procedure

Salem sump tube

-inserted through the nose and placed in the stomach -attached to low continuous suction -this tube has a vent that prevents the stomach mucosa from being pulled away during suctioning

Assessment prior to inserting a NG tube

-inspect nares and pharynx (history of broken dose, deviated septum) -offer hygiene (blow nose) -occlude one nare at a time to determine which side is largest and most patent -ask about prior experience with NG tube or if has a preference for placement

What is the most common suction setting?

-low intermittent suction

What angle should the head of the bed be at for NG tube?

-maintain head of bed at 30 degrees to prevent enteral nutrition aspiration if receiving nutrition

Placement of NG tubes

-may be inserted intraoperatively/during procedure, at bedside, or under fluroscopy

How do you determine the length of NG tube to be inserted?

-measure tube length from tip of nose to lower earlobe tragus, and then on to the xyphoid process -mark tube with tape and/or marker once tube insertion length determine

What position should the patient be in when inserting a NG tube?

-position patient in high fowler's position -must be at a 45 degree angle at minimum

Gastric lavage

-requires the insertion of a large-bore NGT with instillation of a room-temperature solution in volumes of 200 to 300 mL -no evidence that sterile saline or sterile water is better than tap water for this procedure -the solution and the blood are repeatedly withdrawn until returns are clear or light pink -instruct patient to lie on left side

How do you secure a NG tube?

-secure tube to nose -tape with split ends or securement device -do not secure tube so that it maintains direct contact/pressure with side of nare -add a tape tab to exposed tubing and secure the tab to the patient's gown with safety pin

Levin tube

-single lumen nasogastric tube -used to remove gastric contents via intermittent suction or to provide tube feedings -does not have a vent and therefore should only be connected to low intermittent suction -they are used much less often than Salem sump pumps

The nurse inserts a nasogastric tube to determine

-the presence or absence of blood in the stomach -assess the rate of bleeding -prevent gastric dilation -administer lavage

Supplies for medication administration with NG tubes

-verify if meds can be crushed -pill crusher -60 mL catheter tip syringe -Chux or towel -8-10 ounces room temperature water -tape -sethescope

Supplies needed for NG tube placement

-water soluble lubricant -clean gloves -pH test strips for gastric content aspirate testing -emesis basin -Catheter-tip 60 mL syringe -Securement device or prepared tape -safety pin -suction canister, head, and tubing -towel -glass of water with staw

Reasons for a NG tube

1. gastric decompression (abdomen often distended, vomiting, pain) 2. gastrointestinal rest (bowel resection, post-operative) 3. Monitor bleeding (upper GI) 4. Post-operative healing promotion (bariatric surgery, gastrectomy, esophageal resection) 5. Gastric lavage (stomach pumping in overdoses, poison) 6. Enteral nutrition

NG insertion

1. instruct patient you are about to begin (some feel discomfort and may gag) 2. hold NG tube so curve follows anatomical curve of nasopharyngeal cavity 3. have patient tilt nose slightly upward 4. slowly guide the tip into the nare, with a slight downward angle 5. once tube reaches the oropharynx, instruct patient to flex head toward chest and begin swallowing water 6. continue to advance tube toward stomach until desired length is inserted 7. note presence of immediate gastric contents being expelled form tube (bowel obstruction) 8. secure tube to patients nare and gown 9. connect to suction if ordered 10. document placement

Medication administration steps with NG tube

1. position patient in semi-fowlers 2. administer one medication at a time, finely crush tablet/capsule and dilute medication with 5-10 mL of water, mix until dissolved 3. verify NG tube patency and aspirate contents 4. administer each medication using this sequence, flush NG tube with 30 mL of water, administer crushed/liquid medication, flush NG tube with 5 mL water 5. flush with 30-50 mL of water after final medication 6. Clamp NG following administration for 30-60 minutes; return to suction

Removal of a NG tube

1. provide order needed to remove NG tube 2. explain procedure 3. place towel across chest 4. place patient in semi-fowlers 5. don clean gloves 6. remove suction 7. unpin exposed tube from gown and remove securement device from nose 8. instruct patient to hold their breath and swiftly withdraw tube in one motion (5-10 seconds) 9. inspect tube to see its intact and provide oral care and nasal care 10. document removal

After a partial gastrectomy is performed, a client is returned form the postanesthesia care unit to the surgical unit with an IV solution infusing and a nasogastric tube in place. The nurse identifies that there is no nasogastric drainage for 30 minutes. There is an order for instillation of the nasogastric tube prn. The nurse should instill A. 30 mL of normal saline and continue the suction B. 20 mL of air and clamp off the suction for 1 hour C. 50 mL of saline and increase the pressure of the suction D. 15 mL of distilled water and disconnect the suction for 30 minutes

A. 30 mL of normal saline and continue the suction

A client is admitted to the surgical unit from the postanesthesia care unit with a Salem sump nasogastric tube that is to be attached to wall suction. Which nursing action should the nurse implement when caring for this client? A. Use normal saline to irrigate the tube B. Employ sterile technique when irrigating the tube C. Withdraw the tube quickly when decompression is terminated D. Allow the client to have small sips of ice water unless nauseated

A. Use normal saline to irrigate the tube

The client has a nasogastric (NG) tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate and depth has decreased. What is the nurse's best response? A. "It's common for clients with uncomfortable equipment, such as NG tubes to have a lower rate of breathing." B. "The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism." C. "Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps correct the problem." D. "The client is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis."

B. "The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism."

Two hours after a subtotal gastrectomy, the nurse identifies that the drainage from the client's nasogastric tube is bright red. What should the nurse do first? A. Notify the health care provider B. Clamp the nasogastric tube for one hour C. Determine that this is an expected finding D. Irrigate the nasogastric tube with iced saline

C. Determine that this is an expected finding

A client is to have gastric gavage. In which position should the nurse place the client when the nasogastric tube is being inserted? A. Supine B. Mid-fowler C. High-fowler D. Trendleneburg

C. High-fowler