Report

On
Nasogastric Tube
Course Code: NUR202
Course Name: Anatomy Lab

Submitted by
Name and ID Md. Didar (18212005)
Program Bachelor of Science in Nursing (BSN)
International University of Business Agriculture and Technology
4 Embankment Drive Road, Sector-10 (Off Dhaka-Ashulia Road), Uttara Model Town,
Dhaka-1230, Bangladesh

Submitted to
Khadiza Akther
Lecturer
College of Nursing
International University of Business Agriculture and Technology
4 Embankment Drive Road, Sector-10 (Off Dhaka-Ashulia Road), Uttara Model Town,
Dhaka-1230, Bangladesh

Date of Submission- 30 July 2022

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Nasogastric Tube

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 Table of contents

Chapter Name of the Chapter Pages

Cover Page 01

Title page 02

Table of content 03

01 Introduction 04

02 Anatomy and physiology 04-05

03 Purpose of NG tube 06

04 Types of NG tube 06

05 Indications 07

06 Contraindications 07-08

07 Advantages and Disadvantages 08

08 Equipment 08-09

9 Preparing the patient 09

10 Procedure 10-11

11 Confirming the tube placement 11

12 Resolving the obstruction in NG 12

13 Administer the feeding 12-13

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 14 Nursing consideration 14

15 Removing the NG tub 14-15

16 Complications of Nasogastric tube 15

17 Managing of the complication 16

18 Conclusions 17

References 18-20

1. Introduction

In the several conditions patients are restricted in oral feeding, that time we need an
alternative method for meeting the nutritional needs. There are two ways we can meet the
nutritional requirements like enteral nutrition and parenteral nutrition (Suzanne et al., 2010).
Perinatal nutrition is the process of providing nutrition and calorie direct to the vein, and
enteral nutrition is the process of providing liquid food through GI (gastrointestinal tract)
using a tube (Enteral and Parenteral Nutrition, 2021). There is several kind of enteral
nutrition tubes like Nasogastric Tube (NG Tube), Nasojejunal Tube (NJ Tube), Percutaneous
endoscopic gastrostomy (PEG), Jejunostomy tube (J-tube) (Types of Tube Feeding, 2020).
But parenteral nutrition is costly where enteral nutrition is easy, less costly, and safe and
more tolerated compared to the parental nutrition. We can only provide enteral nutrition, if
the lower part and middle part of the GI (gastrointestinal tract) is functioning well. Using this
method, we will provide liquid food and medication into the stomach (Suzanne et al., 2010).

Nasogastric tube is a slim flexible rubber or plastic tube which goes nose to the stomach

across the nasopharynx and esophagus. Basically, we will do it if someone is restricted in

taking food per oral (NPO) for 8-16 days. There are no chances to disturb breathing for the

NG tube (nasogastric tube) (Types of Tube Feeding, 2020). Not only we will do NG tube for

feeding, but also it has many purposes like gastric lavage, aspirate gastric content and

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intervention of medications (Suzanne et al., 2010). In one word, the tube is placed for a

period of time to administer liquid substance to the stomach (nutrition, medication etcetera)

and take out the substance (gastric content) from the stomach directly (Tresca & Yepuri,

2022).

2. Anatomy and Physiology

The anterior opening of the nasal sinuses is called the nostril. Nasopharynx is 5 to 7 cm
posterior to the nostril and this connects with the oropharynx. The length of the pharynx
considering the base skull to the esophagus is 12-14 cm. The esophagus is 25 cm long which
goes through the diaphragm to the stomach. And the stomach is around 25cm when it is
empty though it is a highly distensible organ (Sigmon & Jason, 2022).

Pharynx: It also called throat. It is the passageway from mouth and nose to esophagus and
larynx. It passes the solid or liquid food from mouth to the esophagus during swallowing and
it passes the air from nose to the trachea during inhalation. (Dowreken, 2020)

There are three kind pharynx -

1. Nasopharynx: It is the upper are region of the pharynx is nasopharynx which passes
the air from the nose to the throat. It also connects with the middle ear which help to
reduce the and maintenance the pressure in the ear. It also spread infection easily to
the nasopharynx and ear.
2. Oropharynx: It is the middle part of the pharynx which pass food from the mouth to
the laryngopharynx. It situated in the oral cavity. Epiglottis place between the
oropharynx and the laryngopharynx. Epiglottis prevent the food goes into trachea
instead of esophagus resulting aspiration.
3. Laryngopharynx: It is the lower part of the pharynx up to larynx. It connects with the
esophagus and the trachea. It made by stratified squamous tissue. (Liberetexts,2020)

Esophagus: It is a hollow tube which carry the food from the pharynx to the stomach. This
length is 10 Inc. and wide is around 1.5-2 cm. It located in front of the spinal column and
behind the trachea and heart. It has four layers; the mucosa, submucosa, muscularis, and

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tunica adventitia. one third of upper esophagus is made of voluntary muscle tissue and the
lower part is mad of smooth muscle tissue. Esophagus has two sphincters; upper esophageal
sphincter and lower esophageal sphincter. The function of the sphincter is close the route
whole the time except swallowing. Lower esophageal sphincter has a vital rule in protecting
the esophagus from reflux of gastric content which has HCl acid (Dowreken, 2020).

Stomach: It is located in the left upper quadrant of the abdomen but very close below to the
diaghram. It is hollow organ which receive the food from the esophagus and mixed the food
with the gastric juice and make the food more soluble. Mainly in the stomach digested the
protein and carbohydrate and make them into chyme (Dowreken, 2020).

3. Purposes of Nasogastric Tube

✔ To reduce the compression of the stomach and take out fluid and gaseous substances
✔ To perform gastric lavage to remove of toxic substances
✔ To aspirate gastric content for diagnosis
✔ To provide regular feeding
✔ To intervene the medications (Suzanne et al., 2010)

✔ To save from harm during bowel rest and after any kind of surgery

✔ To treat the blockage who is suffering from the IBD (Inflammatory Bowel Disease)
(Tresca & Yepuri, 2022).

4. Types of a Nasogastric tube

There are different kinds of tubes for different purposes. Usually, before or during the
surgery, or at the patient's bedside, an NG tube is inserted through the nose into the stomach.
NG tubes could be used to provide feedings, give medications for up to four weeks, or
perform a decompression procedure to remove fluid and gas from the upper GI tract.

The Levin tube and the gastric sump tube are two common types of nasogastric tubes.

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Levin tube: It is a single lumen tube that is made of plastic or rubber. The length of this tube
is 125 cm. The size of this tube is 14-16 French. It has circular labels which often helped us
during insertion by providing guidelines on how much we should insert the tube.

Gastric sump tube: It is a double lumen tube that is made of clear plastic. The length of this
tube is 120 cm. The size of this tube is 12-18 French. It is visible easily by x-ray. It has two
ports - a blue port lumen and a large lumen. And it also has an anti-reflux one-way valve
which prevents the reflux of gastric content. A large lumen is used for suctioning gastric
content (Suzanne et al., 2010).

5. Indications

There are some situations where we will go for a nasogastric tube-

❖ Unable to feed by himself due to unconsciousness (Shlamovitz, 2022)

❖ Patient with bowel obstruction (relief symptom of bowel obstruction)

❖  Uncontrollable recurrent nausea and vomiting

❖ Intoxication- If someone has been intoxicated by ethanol or alcohol, we can remove

this by the ng tube (AAEM/JEM Resident and Student Research Competition, 2007).

❖ Aspiration of gastric fluid content for diagnosis purpose

❖ Bleeding in the upper gastrointestinal area

❖ Patient with endotracheally intubated

❖ For medication administration

❖ For performing the gastric lavage (Reichman, 2013).

6. Contraindications

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There are some situations where we should avoid nasogastric tube

❖ Trauma or injury severely in the middle of the face.

❖ Surgery in the nose or nasal passageway recently

❖ If a patient has coagulation abnormality (clotting problem) we should avoid inserting NG

(nasogastric tube).

❖ Abnormal tight or narrow of the esophagus

❖ Presence of anastomosis (a surgical procedure to connect two tube structures) in between

esophagus and stomach

❖ An abnormally enlarged vein in the esophagus (Shlamovitz, 2022).

7. Advantages and Disadvantages

Nasogastric tube is a safe method for use. We can remove it as necessary. It is a wonderful
thing that we should not use ant anesthetic medication for performing this procedure. It is
easiest method for enteral feeding. But it has some disadvantages like it reduce the self
esteem of the patient, it can be very life-threatening if place in wrong area and it might cause
of distress. Distress might resolve automatically when patient will be habituated (Using a
Nasogastric Tube | Gillette Children’s, 2022).

8. Equipment

These are the pieces of equipment we have to collect before starting the procedure-

▪ Gloves for prevent contamination

▪ Marker for the point at the tube (Suzanne et al., 2010).
▪ PH Indicator (Nasogastric Tube Placement, 2016)

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 ▪ The NG tube (16 -18 French) whose length is 125 cm for adults and {(16 + age)/2}
French will be for pediatric patients. For example, if the child is 4 years old then we
will take {(16 +4)/2} =10 French sizes.
▪ Syringe 10cc
▪ Water one glass with a straw
▪ A lubricant which is water based for easier the insertion and reduce the friction
▪ Tape for secure the tube with the nose
▪ Toomey syringe 60 cc
▪ Emesis basin
▪ Suction tube and container
▪ Oral analgesic spray like benzocaine spray (optional)
▪ Viscous lidocaine 2% to relieve pain and discomfort (optional)
▪ Wall suction
(Shlamovitz, 2022)

9. Preparing the patient

Before going to the procedure, we have to prepare the patient like

❖ Palpate the patient upper abdomen for assessing the pain and discomfort, and assess
the LOC (level of consciousness), teach a signal that will show if patient get any
discomfort,
❖ Ensure patient safety
a. We will ensure hand hygiene
b. We will introduce our self
c. We will make sure the right patient by checking the patient ID
d. We will explain the procedure and before starting the procedure
e. We should be patient to listen the client concern
f. We have to check the vital sign
g. Confirm the privacy and maintain the confidentiality of the client
h. Ensure focus assessment (Doyle, 2015).
❖ We will discuss the procedure, difficulty, risk, alternatives of this procedure (if any),
and patient written consent

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 ❖ We should confirm that the patient nostril is fine and there is an absence of deviation
(Nasogastric Tube Placement, 2016).
❖ We will explain the purpose of the nasogastric tube to encourage the cooperation of
the patient during the procedure.
❖ Inform the patient about gagging might be experienced until the tube will pass the
throat (Suzanne et al., 2010).
❖ Provide topical anesthesia (Viscous lidocaine 2%) for reducing pain and discomfort or
gagging feeling during the procedure. We will give viscous lidocaine 1% through
inhalation or nebulization using a face mask.
❖ The individual must be positioned in his upright position (Shlamovitz, 2022).
10. Procedure

⮚ Stand on the right side of the patient (Doyle, 2015).

⮚ Collect all the equipment at first. Then we will wear non-sterile gloves.
⮚ Then make sure patient position
⮚ Make sure the nostril has no obstruction, and select the nostril which has no
obstruction
⮚ After that, we will measure the length of the tube and how much we should enter to
reach the stomach.
⮚ We will measure the length of the tube from the tip of the nose to the xiphoid process
through the ear lobe. After measuring the length, we should add six inc more with the
measuring length for nasogastric tube placement.
⮚ We will give a point by marker how much we will enter.
⮚ During the inserting, the patient should be seated in an upright position with a towel
in his body.
⮚ After that, we will swab the nostril with benzocaine for relief from the pain,
discomfort or for numbing the area and preventing gas reflex.
⮚ Then, we will lubricate the tube with water soluble lubricant to prevent friction during
the insertion.
⮚ We will tilt the tip of the patient nostril, then we will enter the tube in the nostril.
⮚ We will instruct the patient to lower his head a little and start swallowing, when the
tube is entered in the nasopharynx.
⮚ We will instruct him to drink water through the straw to facilitate the patient's
swallowing if patient has not fluid restriction
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 ⮚ In this time, we will observe the oropharynx to confirm that the tube did not twist in
this area. (Suzanne et al., 2010)
⮚ We will enter the tube gradually until the marking point has been reached.
⮚ Using a tap fixd the tube in the nose to prevent displacement for checking if the tube
enters in the right place or not.
⮚ Ensure the tube enter in the correct place by using confirming technique of tube
placement like x-ray, pH, color of gastric content
⮚ When the place in the right place is confirmed, secure the tube with the nose using
tape and pin with the patient gown for preventing the displacement
⮚ Finally, document that the patient has a nasogastric tube for feeding and document the
patient's concern, feeling and any discomfort. It will ensure patient safety (Doyle,
2015).

11. Confirming the tube placement

It is important for us to confirm the placement of the tube insertion because it ensures the
patient's wellbeing. Mostly a tube is inserted in the right lung. During insertion the tube, high
chances to insert in wrong places if patient is unconscious, experience less gag reflex,
agitation during insertion and patient who has endotracheal intubation. However, we should
confirm that the tube is not entered in the wrong place. So, we will use some technique for
ensuring this:

⮚ X-ray: It can be the accurate technique for confirmation and it is gold standard. But it
has some limitations like it is costly, and patients should be placed under the
radiation.
⮚ Measuring length of the tube: It is the easiest way, but does not confirm the location it
only shows us the position of the tube.
⮚ Aspirate the gastric content: We observe the color of gastric content; color should be
green, brown, cloudy and off white. Low amount of content may indicate the tube
placement in the lung.
⮚ The pH of the aspirate contents: It is used to identify whether the tube is placed in the
stomach or in the intestine. Gastric content pH will be 1-5 where intestinal content pH

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 is above 6 basically. But Ph can be altered sometime like if a patient takes antacid.
(Suzanne et al., 2010)

12. Resolving the obstruction in NG

❖ Ensure tube placed in the correct place

❖ Change the patient position
❖ Take doctor orders
❖ Infuse 20 ml of air with 60 ml syringe pull and push the plunger, if it’s not working
then again take 20 ml of air and pull and push. At this time, we should aspirate fluid
as much as possible by nasogastric tube.
❖ We will infuse 5 ml warm water in 60 seconds using syringe and push and pull, if
warm water does not work than we will use or digestive enzyme (corpak) as a
substitute of water (take doctors order for make solution of digestive enzyme and
carbon dioxide)
❖ Insertion of endoscopy by expert
❖ Provide cranberry juice
❖ We should declogged as soon as possible after assessing the clogged, because it high
chance if we do this right after the clogged
(Suzanne et al., 2010)

13. Administer the feeding

During administer the feeding we have to maintain some measures like-

1. Prepare the formula

i. Checking the expiratory date
ii. Mixed the formula following the instruction of the package if it is powder formula

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 iii. Store in refrigerator of breaking pack for next time
iv. Wait a few minutes until the formula reaches room temperature (Wayne, 2018).
v. For calculation of the formula feeding liquid amount we will use a mathematical
formula:

Volume of orders formula

=Strength of order
x
Requirement of water for dealation ¿ X −volume of the ordered formula feeding(ml)

X= total volume should be administered

For example:

The patient is ordered jevity 1.2 calories. Nurses have a supply of a Can of Jevity that
contains 200 ml of formula. Doctor order is ¼ strength of formula and should administer
eight hourly. How much water is required for the dealation?

Solutions: Given, Volume of orders formula = 200 ml

And strength of the formula = ¼

Volume of orders formula

We know, =Strength of order
x
200 ml 1
Or, =
x 4

Or, x × 1=4 ×200 ml

Or, x=800 ml

So, the total volume of the feeding will be x= 800 ml

Now,

the amount of water required to dilate ¿ X −volume of the ordered formula feeding ( ml )

¿ 800 ml−200 ml

¿ 600 ml

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So, we should dilate the formula using 600 ml of water. (RegistredNurseRN, 3-7 minutes, 2020)

2. Give the information that what we are going to do for getting the cooperation from the patient
3. Ensure the position of the patient is semi fowler or full fowler before starting the feeding for
preventing the aspiration (Wayne, 2018).

14. Removing the NG tube

⮚ Before going to remove the tube, we have to decompress the tube and flush with 10
ml normal saline to ensure there is no debris in the tube (Suzanne et al., 2010).
⮚ Ensure the safety measure at first
⮚ Taking permission from the doctor
⮚ Collect all the required equipment for removing the tube-like waterproof pad,
syringe, tissue, general gloves, and garbage bag.
⮚ Ensure the correct patient using patient ID and patient name
⮚ Patient should be place in the high fowler position
⮚ Make sure aseptic technique for reducing the cross contamination
⮚ Provide a pad which is waterproof on the patient chest area
⮚ Stop feeding, disconnect from the suction also
⮚ Remove all security devices like tap and pin from the attach area, like tap from nose
and pin from the gown
⮚ Tell the patient for taking the deep breath and hold the breath
⮚ We should prevent the backflow of the residual feed by kink the tube
⮚ After that we should pull out the tube gently, smoothly and slowly.
⮚ After that we will keep the tube and gloves in the garbage
⮚ Provide mouth care and clean the nostril or beside the nostril area using sift tissue
paper for clean any kind of secretion
⮚ Make the patient in comfortable position and maintain hygiene both patient and health
care provider
⮚ Finally, we should document the things about the removal of Nasogastric tube and
patient response (Doyle, 2015).

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15. Nursing Consideration

▪ We will ensure the correct placement of the nasogastric tube by using observing the
color, pH of the gastric content and by observing the marking length of the tube
▪ Routine evolution about the patient will ensure the position of the tube and it will
reduce the chances of the aspiration.
▪ Do not administer anything before confirming the correct placement of the
Nasogastric tube
▪ During changing the position of the patient and exchanging the gown of the patient
have to confirm the unpin the tube from the gown, and make sure that tube will not
get ant pull or displacement
▪ If, accidentally, a nasogastric tube comes out or falls out we should not be worried
and patients should not panic because it is not an emergency. But we should do the
assessment for any confirm the ABCCS (airway, breathing, circulation,
consciousness, safety)
▪ If the patient experiences respiratory distress (like coughing, low oxygen saturation
and choking) which indicates the emergency condition, this patient should follow the
procedure of the emergency (Doyle, 2015).
▪ We should provide oral and nasal hygiene (Suzanne et al., 2010)

16. Complications of Nasogastric tube

Diarrhea: It is a common complication if NG feeding for a long period of time. Because of

the composition of formula, chances of bacterial contamination with the formula and many
medications which have sorbitol (Shai et al., 2008).

Aspiration: It is the most life-threatening complication of the Nasogastric tube because it

leads to pneumonia. It does not show symptoms like vomiting and regurgitation as clinical
manifestation. We can recognize it in serious conditions like respiratory distress and
pneumonia. Some individuals are at high risk of developing the aspiration of an older age,
impaired level of consciousness and gastroesophageal reflux. (Shai et al., 2008).

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Pulmonary complication: There is a high chance of developing pulmonary complication
because the patient is unable to cough and unable to clear the pharynx properly.
Fluid volume deficit- It might be indicated if patients suffer from dry skin and mucous
membrane, amount of urine reduces, heart rate increases and weakness.
(Suzanne et al., 2010)
Injury: In the time of inserting the tube, there is a chance of injuring the esophagus, throat
and stomach. (Tresca & Yepuri, 2022).
17. Managing of the complication

❖ Fluid volume defecate-

i. We have to document the input and output by calculating the addition of IV
fluid amount, flashing fluid amount, feeding fluid amount and oral fluid intake.
And monitor the output by calculating the addition of emesis, amount of fluid by
urination, amount of fluid in NG drainage and diarrhea.
ii. If the patient output result is greater than the input amount in 24-hour records,
we have to increase the intake fluid amount.
iii. We have to monitor the lab values of BUN (Blood urea nitrogen and creatinine)
(Suzanne et al., 2010).

❖ Pulmonary complication-
i. At first, we have to confirm the proper placement of the NG tube before
providing any kind of fluid or medication
ii. Routine assess the respiratory sound by auscultation
iii. We have to monitor the vital signs regularly (Suzanne et al., 2010).

❖ Diarrhea-
i. Review the formula by physician
ii. Maintain hygiene properly for prevent the contamination
iii. Open formula should be store in the refrigerator
iv. Diagnose the stool for confirming the underlying microbes, mainly
Clostridium difficile
v. If diarrhea is resulting from lactose intolerance then provide the formula
which is lactose free (Shai et al., 2008).
❖ Aspiration-
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 i. Immediately stopping the feeding
ii. Administer antibiotics if any sign of infection is observed
iii. Use gastromy tube to prevent the aspiration (Shai et al., 2008).

❖ Injury- Place the tube through the mouth instead of nasal cavity (Tresca & Yepuri,
2022).
18. Conclusion

Nasogastric tube is a procedure which is used all over the world under the emergency

department. Basically, we use it to remove the toxin, give medication, and provide nutrition

(Foster, 2021). Though the Nasogastric tube has some disadvantages and complications like

injury and discomfort, it is a lifesaving tool for a patient (Tresca & Yepuri, 2022).

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References

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