Module 9 - NG Tubes

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a nasogastric (NG) tube?

"Tell me if you see any vomit in the patient's mouth during oral care." Rationale: Responsibility for this aspect of care related to NG tube management may be delegated to NAP. Responsibility for aspirating 5 mL to 10 mL of stomach contents before flushing the tube and checking to see if the NG tubing has advanced are not aspects of NG tube management that can be delegated to NAP. NAP would not be aware of what an NG-type complaint is.

Which patient does not have a medical condition that contraindicates placement of a nasogastric tube?

A 28-year-old patient who fractured a femur after heavy drinking. Rationale: Neither the patient's broken femur nor the patient's alcohol consumption would contraindicate placement of a nasogastric tube. A 73-year-old patient on anticoagulation therapy would be at high risk for bleeding, which is a contraindication for tube feeding. A 54-year-old patient with facial trauma is a contraindication for a nasogastric tube. A 67-year-old patient with unexplained nosebleeds would contraindicate placement of a nasogastric tube.

What will the nurse need before removing a patient's nasogastric tube?

A health care provider's order Rationale: The nasogastric tube may be removed only with a health care provider's order. Hypoactivity of bowel sounds is not the best indicator for removal of a nasogastric tube. A feeding tube may not be removed without a health care provider's order. Absence of pain is not an indicator for removal of a nasogastric tube. A feeding tube may not be removed without a health care provider's order. Although flatus production indicates a functioning digestive system, a nasogastric tube may not be removed without a health care provider's order.

When checking gastric aspirate from an NG tube, the nurse assesses a pH of 7. What would the nurse do next?

Anticipate a chest x-ray Rationale: Normal gastric pH is 5 or less. A pH greater than 7 could mean that the tube is in the small intestine or lung. The nurse must act on this finding and anticipate a chest x-ray. Doing nothing, advancing or pulling back the tube is not correct.

What would the nurse do before providing the patient with a scheduled intermittent feeding through a nasogastric (NG) tube?

Check NG tube placement. Rationale: The nurse must check NG tube placement before providing a scheduled tube feeding. Listening to bowel or lung sounds would not give the nurse any information about NG tube position. Turning the patient onto his or her left side would not give the nurse any information about NG tube position.

How could the nurse assess the patency of a nasogastric (NG) tube being used for enteral nutrition?

Check the gastric residual volume. Rationale: The nurse would check gastric residual volume. Doing so could determine the patency of the feeding tube. Elevating the head of the bed does not address the patency of the NG tube. Intravenous infusion sets should not be used to infuse tube feedings. Monitoring the patient's intake in 8 hours does not address the patency of the NG tube.

Why does the nurse elevate the head of the bed to 30 degrees for a patient receiving an intermittent tube feeding?

Elevating the head of the bed reduces the risk for aspiration. Rationale: Elevating the head of the bed reduces the risk for aspiration. Digestion is not affected when the head of the bed is elevated. Reducing acid reflux is not the reason for elevating the head of the bed. Nutrient absorption is unaffected by elevating the head of the bed.

What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube?

Examine each naris for patency and skin breakdown. Rationale: Examining each naris for patency and signs of skin breakdown will help the nurse determine which naris will accommodate a nasogastric tube with less discomfort. Although the high-Fowler's position is recommended for insertion of a nasogastric tube, the position itself will not reduce discomfort. Anesthetizing the throat would hinder the patient's ability to swallow safely during insertion of the nasogastric tube. Sipping water will not reduce the patient's discomfort.

What would the nurse do if material aspirated from a patient's nasogastric tube resembled coffee grounds in color and texture?

Notify the health care provider. Rationale: Coffee-grounds aspirate indicates bleeding. The health care provider should be notified.

What would the nurse do if he or she were not able to insert a nasogastric tube in either of a patient's nares?

Notify the physician that the attempts were unsuccessful. Rationale: The nurse would notify the physician because he or she will need to attempt to insert the tube or determine another treatment option. Attempting to insert a tube again may harm the patient. Although documentation is necessary, it does not address the patient's need for a nasogastric tube. Delaying an attempt at inserting the nasogastric tube makes success no more likely and risks harming the patient.

After unsuccessfully attempting to flush a nasogastric (NG) tube with water, what is the most appropriate action for the nurse to take?

Obtain a product designed to unclog NG tubes. Rationale: If the feeding tube becomes clogged, the nurse should obtain and use an unclogging product for feeding tubes. Ginger ale and other sodas can increase the risk of clogging. Flushing with juice can increase the risk of clogging. Never force-flush a feeding tube. Doing so could rupture the tube and harm the patient.

What is the proper response to the nurse's observation that the patient's closed-system enteral feeding has 150 mL of formula remaining and that the infusion order rate is for 50 mL/hr?

Plan to check the feeding for completion within the next 3 hours. Rationale: Because the ordered dose is 50 mL/hr, checking for completion within 3 hours is the right choice. Recalculating the present drip factor for accuracy does not address the issue of time needed to infuse the feeding. The closed-system feeding has a 24-hour delivery timeframe. Terminating delivery is inappropriate because the tube feeding still has 3 hours to infuse. Because the formula still has 3 hours to infuse, there is no need to contact the pharmacy.

Which intervention might the nurse delegate to nursing assistive personnel (NAP) when inserting a nasogastric tube?

Positioning the patient in a high-Fowler's position Rationale: Positioning the patient is within NAP scope of practice. NAPs are not permitted to assess bowel sounds. It is not within NAP scope of practice to determine any portion of the patient's medical history. Patient education may not be delegated to NAP.

How might the nurse minimize the patient's anxiety when removing a nasogastric tube?

Provide reassurance of what will happen during the procedure and talk the patient through the process. Rationale: Letting the patient know what to expect during an intervention usually reduces anxiety. Administration of antianxiety medication is not necessary to remove a nasogastric tube. Removal of a nasogastric tube does not require emotional support. Although this advice is not inappropriate, providing verbal reassurance related to something the patient has already experienced is more effective.

What patient care might the nurse delegate to nursing assistive personnel (NAP) when a patient's nasogastric tube is removed?

Providing the patient with mouth care Rationale: The skill of mouth care may be delegated to NAP. The skill of assessing for distention may not be delegated to NAP. Documentation of the nasogastric tube removal is a skill that may not be delegated to NAP. Assessment of bowel sounds is a skill that may not be delegated to NAP.

What would the nurse use to irrigate a patient's nasogastric tube after providing medications?

Purified water Rationale: Of the options suggested here, water is the most effective agent for preventing tube clogging. Coffee, tea, and apple juice increase the likelihood of tube clogging. Purified water (sterile for irrigation) or saline is preferred for use as a diluent or flush solution over other fluids (including tap water).

Which nursing action is appropriate when feeding gastric residual is 50 mL?

Return it to the stomach via the feeding tube. Rationale: If the volume of the residual stomach contents is less than 250 mL, it can be returned to the stomach via the feeding tube. This small amount of gastric aspirate can be returned to the stomach. It does not need to go down the commode or be discarded as liquid biohazard.

Why does the nurse clamp the nasogastric tube before removing it from a patient?

To keep any fluid from flowing out Rationale: Clamping the tube keeps any residual fluid in the tube from flowing out. Clamping the tube does not suppress the cough reflex, hinder the gag reflex or prevent the transmission of microorganisms.

What would minimize the nurse's risk for contamination during the removal of a nasogastric tube?

Wearing treatment gloves Rationale: Wearing gloves will protect the nurse from contamination. Giving the patient an emesis basin would not minimize the risk for contamination. Placing a towel would minimize the patient's risk for contamination during the removal of a nasogastric tube; it would not minimize the nurse's risk. Tissues are not used during the removal of a nasogastric tube. A patient might use tissues to blow his or her nose after the tube is removed.

What would the nurse do if he or she encountered resistance when inserting a nasogastric tube?

Withdraw the tube to the nasopharynx Rationale: If the patient starts to cough, experiences a drop in oxygen saturation, or shows other signs of respiratory distress, withdraw the tube into the posterior nasopharynx until normal breathing resumes. Do not force the tube or push it against resistance. Coughing will not help remove the source of resistance; rather, it is an indication that the tube is misplaced. If the tube meets resistance, neither swallowing nor hyperextending the neck will help to advance it.