NASOGASTRIC TUBE INSERTION, REMOVAL AND FEEDING A WARD CLASS FOR THE STAFFING ROTATION

SUBMITTED TO: Ms. Ynette R. Lagahit, RN Clinical Instructor

SUBMITTED BY: Acera, Clint Alain G. Aradani, Khassmeen S. Balagot, Rodesa Shaira B. Balagulan, Anne Rose C. Ballentos, Mary Ann A. Bantol, Julie Ann T. Borja, Ma. Concepcion M. Buhisan, Honey Grace T. Cagas, Jethro Anton A. Camay, Lovely Jane R. Carbajosa, Cachiny E. Cubelo, Ainee R. Daug, Kezia Keren Mae C. Del Rosario, Edracel C. BSN 4 ND

XAVIER UNIVERSITY ATENEO DE CAGAYAN COLLEGE OF NURSING

10 JANUARY 2011

NASOGASTRIC TUBE
Inserted through one of the nostrils, down the nasopharynx and into the alimentary tract Indications: o 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 o To prevent nausea, vomiting and gastric distention following surgery o To remove stomach contents for laboratory analysis o To lavage (wash) the stomach in cases of poisoning or overdose of medications Contraindications: o Clients without intact gag and cough reflexes o Clients without adequate gastric emptying Sizes 5-12: used for children Sizes 12-18: used for adults

INSERTING A NASOGASTRIC TUBE

Assessment o Check for history of nasal surgery or deviated septum o Assess patency of nares o Determine presence of gag reflex o Assess mental status or ability to cooperate with procedure Planning o Determine the size of the tube to be inserted and whether the tube is to be attached to suction o Equipment: - Nasogastric tube - Water soluble lubricant - Clamp or tubing - Adhesive tapes - Clean or sterile gloves - Glass of water and drinking straw - Irrigating set with 20ml syringe - Emesis basin - Stethoscope - Penlight - pH indicator strips - Xylocaine jelly

Implementation Preparatory Phase 1. Introduce self and verify the patients identity 2. Explain procedure to the patient and tell him how mouth breathing, panting and swallowing can help in passing the tube. 3. Have the patient in a sitting fowlers position and place a towel across his chest. Easier to swallow in this position and gravity helps the passage of the tube. 4. Determine with the patient what sign he might use to indicate distress and a desire for the nurse to pause the insertion 5. Remove dentures then place emesis basin and tissue with the patients reach 6. Place rubber tubing in chilled ince water to make the tube firmer. But if it becomes too stiff, dip in warm water. If the tubes are firm and rigid, they are less likely to coil in the back of the throat when inserted. 7. Have the patient blow nose to clear nostrils. 8. Inspect nostrils with penlight, observing for any obstruction. Occlude each nostril and have the patient breathe. To determine which nostril is more patent. Performance Phase 1. Wash hands for infection control. It is acceptable to use clean technique because the GI tract is not sterile. 2. Provide for client privacy 3. Gather the equipments needed. 4. If it is necessary, plan for assistance. 5. Put on sterile gloves. 6. Measure the patients NEX (nose, earlobe, xiphoid). This measurement represents the distance to the nasal pharynx. - Mark this length with adhesive tape if the tube does not have markings. - Infant: from the tip of the nose to the earlobe to a point halfway between the xiphoid process and the umbilicus 7. Coil the first 7-10cm (3-4 inches) of the tube around your fingers. This curves tubing and facilitates tube passage. 8. Lubricate the coiled portion of the tube with water soluble lubricant. Avoid occluding the tubes hole with lubricant. It reduces frictionpreventing injury to the nasal passages. Using a water soluble lubricant prevents oil aspiration pneumonia if the tube accidentally slips into the trachea.

9. Tilt back the patients head before inserting tube into nostril and gently pass tube into the posterior nasopharynx directing downward toward the ear. Follows the natural contours of the body. 10. The patient may gag when tube reaches the pharynx. Allow patient to rest for a few minutes. 11. Have the patient tilt head slightly forward. Offer several sips of water through straw or permit patient to suck on ice chips, unless contraindicated. Advance tube as patient swallows. Tube is less likely to enter trachea and facilitates passage of tube into the esophagus. 12. Gently rotate tube 180 degrees to redirect the curve. Prevents the tube from entering trachea. 13. Continue to advance tube gently each time patient swallows. 14. If obstruction occurs, rotate tube gently. If still unsuccessful, remove tube and try other nostril. Avoids discomfort and trauma. 15. If there are signs of distress (gasping, coughing or cyanosis), immediately remove the tube. May have entered the trachea. 16. Continue to advance the tube gently each time patient swallows until the tape mark reaches the patients nostrils. This is the reference point where the tube was measured. 17. To check whether the tube is in the stomach: a. Ask patient to talk - if the patient cannot talk, the tube may be coiled in the throat or passed through the vocal cords b. Use a tongue depressor and penlight to examine the patients mouth (unconscious patient) c. Inject 10-20 cc of air while auscultating the left quadrant of the abdomen - air can be detected by a whooshing, bubbling or gurgling sound d. Aspirate contents of stomach with a 50ml catheter tip syringe. - if acidic, indicates aspirated stomach contents e. X-rays - only positive method of confirming tube placement !!! Never place the end of the tube in water while checking placement. If the tube is in trachea, the patient could aspirate. 18. After tube is passed and correct placement is confirmed, secure the tube by taping it to the bridge of the clients nose by splitting lengthwise and only halfway a hypoallergenic

tape. Attach unsplit end of tape to the nose and cross split ends around tubing. Apply piece of tape to bridge of nose. Prevents tube from passing against and irritating the edge of the nostril. 19. Anchor the tubing to patients gown. Use a rubber band to make a slip knot to anchor tubing. Secure the rubber band using a safety pin. Permits mobility of patients.

Evaluation o Degree of client comfort o Client tolerance o Correct placement o Client understanding of restrictions o Color and amount of gastric contents if attached to suction or stomach contents aspirated

REMOVING A NASOGASTRIC TUBE

Assessment o Presence of bowel sounds o Absence of nausea and vomiting when tube is clamped

Planning o Equipment: - Towel - Disposable gloves - Mouth hygiene materials Implementation Preparatory Phase 1. Confirm physicians order to remove the tube. 2. Assist the patient to a sitting position if health permits. 3. Be certain that gastric or small bowel drainage is not excessive in volume, that audible peristalsis is present and if the patient is passing flatus. Tube may not be discontinued unless drainage is minimal, bowel sounds are present and flatus has been passed. Performance Phase 1. Introduce self and verify the patients identity

2. Explain procedure to the patient and how he or she can cooperate. 3. Wash hands for infection control. Provide for client privacy 4. Gather the equipments needed. 5. Place a towel across the patients chest and inform him or her that the tube is to be withdrawn. 6. Apply disposable gloves. 7. Detach the tube from the suction apparatus, if present. Unpin it from the patients gown and remove the tape from the patients nose. 8. Instruct patient to take a deep breath and hold it. This closes the epiglottis preventing accidental aspiration of gastric contents. 9. Pinch the tube with the gloved hand. Prevents any contents inside the tube from draining into the clients throat. 10. Slowly, but evenly, withdraw tubing and cover it with a towel as it emerges. (As the tube reaches the nasopharynx, you can pull quickly.) 11. Provide the patient with materials for oral care and lubricant for nasal dryness. 12. Assist the client as required to blow nose. Excessive secretions may have accumulated in the nasal passages. 13. Dispose equipment in appropriate receptacle. 14. Document time and removal, amount and appearance of drainage, patients reaction and other relevant assessments. 15. Continue to monitor patient for signs of GI difficulties. Recurrence of nausea or vomiting may require reinsertion of NGT. Changes in vital signs may suggest infection.

NASOGASTRIC FEEDING
Purposes: o To restore or maintain nutritional status o To administer medications

Assessment o Clinical signs of malnutrition and dehydration o Allergies to any food in the feeding o Presence of bowel sounds o Problems that suggest lack of tolerance of previous feedings

Planning o Equipments: - Stethoscope - Administration set - Water - Prescribed enteral feeding - Calibrated glass Implementation Preparatory Phase 1. Determine the type, amount and frequency of feedings. 2. Elevate head of bed to high fowlers position. Reduces risk of aspiration during feeding. Implementation Phase 1. Introduce self and verify the patients identity. 2. Explain procedure to the patient and how he or she can cooperate. 3. Wash hands for infection control. Provide for client privacy. 4. Gather the equipments needed. 5. Prepare administration set to administer formula. Check formulas expiration date and have it by room temperature. Cold formula causes cramping. 6. Check placement of feeding tube. 7. Check for gastric residual. a. Connect syringe to the end of feeding tube. Pull back evenly to aspirate gastric contents. Residual volume indicates if gastric emptying is delayed. Delayed gastric emptying may be reflected by 100ml or more remaining in the patients stomach. b. Return aspirated contents to stomach unless the volume exceeds 100ml or as defined by agency policy. 8. Initiate feeding. a. Pinch proximal end of feeding tube. b. Remove plunger from syringe and attach barrel of syringe to end of the tube. c. Fill syringe with measured amount of formula. Release tube and elevate syringe to no more than 18 inches above insertion site and allow it to gradually flow by gravity. Refill syringe until prescribed amount has been delivered to client. Reduces risk of abdominal discomfort, vomiting or diarrhea induced by bolus or too rapid infusion of tube feeding.

d. Flush feeding with 30ml water using Asepto syringe. Provides patient with source of water to help maintain fluid and electrolyte balance. Clears tubing of formula. e. Rinse syringe with warm water whenever feedings are completed. Rinsing removes formula left in equipment and reduces potential for bacterial growth

Troubleshooting o Gastric residual exceeds 100ml - Hold feeding and notify physician. - Maintain patient in semi-fowlers position or least has head of bed elevated 30 degrees. - Recheck residual in 1 hour. o Client aspirates formula. Respirations are rapid ans shallow, color is ashen. Breath sounds full of ronchi. Client coughs up secretions that are similar to tube feeding. - Turn off tube feeding immediately. - Position patient in Fowlers position, suction and notify physician immediately. - Prepare for chest x-ray examination. o Clients tube cannot be aspirated or injected with air or water. - For newly inserted tube, notify physician and obtain x-ray confirmation of placement. - Attempt to flush tubing with large bore syringe and warm water. (Avoid using a small bore syringe because this exerts large amount of pressure and may rupture tube.) - Notify physician in unable to clear feeding and medication infusion. o Client develops three or more times in 24 hours, before clamping off each time and before and after feeding and medication infusion. - Notify physician and confer with dietitian to determine need to modify type of formula concentration and rate of infusion. - Determine if receiving antibiotics and medications containing sorbital which can induce diarrhea. o Client develops nausea and vomiting. - May indicate gastric ilues. Withhold tube feeding and notify physician. - Be sure tubing is patent; aspirate for residual.

ADMINISTERING MEDICATION THROUGH A FEEDING TUBE

Assessment o Contraindications to client receiving oral medications such as bowel inflammation, reduced peristalsis and recent GI surgery. o History of allergies, types of medications and diet history. o Check bowel sounds, abdominal distention or pain, laboratory data that may influence drug administration. o Potential for drug-food interactions if drugs such as penicillin G and tetracyclines are administered with feedings.

Implementation 1. Prepare medication for instillation in feeding tube. a. Verify that medications do not include sublingual, enteric coated or sustained release medications. b. TABLETS: Crush pill (in its package) with pill crusher. Dissolve the powder in 15-30ml warm water. Crushing medication in its package prevents some from being lost. c. CAPSULES: Open and dissolve the powder in 15-30ml warm water. d. GELATIN CAPSULES: Aspirate with a syringe or capsule may be dissolved in warm water over several minutes. After capsule dissolves, remove its gelatin outside layer. Dissolving requires 15-20 minutes before administration. 2. Elevate head of bed to high fowlers at least 30 degrees. Reduces risk for aspiration. 3. Check placement of feeding tube. 4. Aspirate stomach contents for residual volume, determine volume and reinstill to client. 5. Pour dissolved medication into syringe and allow to flow by gravity into feeding tube. Flush with 100ml water after each medication. 6. Follow last medications with 30 to 60ml of water. Avoids tube clogging and helps medication to enter stomach where it can be absorbed. 7. After instillation of medications, position patient upright and turned slightly to left. If the medication is for local effect (e.g. antacids), have patient remain there for several minutes. Promotes drug absorption and delivery.

Troubleshooting o Client is unable to receive medication because of blockages in tube. - For newly inserted tube, notify physician and obtain x-ray confirmation of placement.

- Attempt to flush tubing with large bore syringe and warm water. (Avoid using a small bore syringe because this exerts large amount of pressure and may rupture tube.) - If unable to flush clog, contact physician for replacement of tube and potential need to reroute medication if dose cannot be skipped or delayed until a new feeding tube is placed.