NASOGASTRIC INSERTION AND FEEDING A nasogastric tube is inserted through one of the nostrils, down the nasopharynx, and

into the alimentary tract. Traditional firm, large-bore nasogastric tubes are placed in the stomach. Examples are the Levin tube, a flexible rubber or plastic, single-lumen tube with holes near the tip, and the Salem sump tube, with a double lumen. The larger lumen of the Salem sump tube allows delivery of liquids to the stomach or removal of gastric contents. When the Salem tube is used for suction of gastric contents, the smaller vent lumen (the proximal port is often referred to as the blue pigtail) allows for an inflow of atmospheric air, which prevents a vacuum if the gastric tube adheres to the wall of the stomach. Irritation of the stomach is thereby avoided. Softer, more flexible and less irritating small-bore tubes( smaller than 12 Fr in diameter) are frequently used. Nasogastric tubes are used for feeding clients who have adequate gastric emptying, and who require short-term feedings. They are not advised for feeding clients without intact gag and cough reflexes since the risk of accidental placement of the tube into the lungs is much higher in those clients. These reflexes are present if a tongue depressor advanced to the back of the throat elicits retching or coughing responses. Nasogastric tubes may be inserted for reasons other than to provide a route for feeding the client, including these: To prevent nausea, vomiting and gastric distention following surgery. In this case, the tube was attached to a suction source. To remove the stomach contents for laboratory analysis. To lavage (wash) the stomach in cases of poisoning or overdose of medications. INSERTING A NASOGASTRIC TUBE 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 the history of nasal surgery or deviated septum. Assess patency of nares. Determine the presence of gag reflex. Assess mental status or ability to cooperate with procedure.

Planning: Before inserting a nasogastric tube, determine the size of tube to be inserted and whether the tube is to be attached to suction. Indications: Pre-operative preparation with elemental diet. Gastro-intestinal problems with elemental diet. Cancer therapy. Convalescent care. Coma, Semi-consciousness. Hypermetabolic conditions. Charting: Date and time insertion Intactness of the nasogastric tube. Nasogastric tube size. Patients response/behaviour toward insertion.

Equipment: Large- or small bore tube (non-latex 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- to 50-mL syringe with an adapter Basin pH test strip or meter Bilirubin dipstick Stethoscope Disposable pad or towel Clamp or plug (optional) Antireflux valve for air vent if Salem sump tube is used Suction apparatus Safety pin and elastic band CO2 detector (optional) ACTION 1. Check order for insertion of nasogastric tube.

Rationale: Clarifies procedure and type of equipment required. 2. Explain procedure to client. Rationale: Explanation facilitates cooperation. 3. Gather equipment. Rationale: Provides for organized approach to task. 4. If nasogastric tube is rubber, place it in basin with ice for 5-10 min (optional). Rationale: Cold will stiffen the rubber tube making it easier to insert. Plastic tubes is usully firm enough 5. assess the clients abdomen Rationale: determine the presence of bowel sounds and amount of abdominal distention. 6. wash your hands Rationale: hand washing deters the spread of microorganism 7. assist the client to high fowlers position, and drape is chest with bath towel or disposal pad. Have emesis basin and tissues handy. Rationale: an upright position is more natural for swallowing and protects against aspiration, should the client vomit. Passga of tube may stimulate gagging and tearing of eyes 8. check the nares for patency by asking the client to occlude ones nosetril and breath normally though the other. Select the nostril through which air passage more easily. Rationale: tube will pass more easily through the nostril with the largest opening. 9. measure the distance to insert the tube by placing tip of tube at clients nostril and extending to tip of earlobe and then to tip of xiphoid process. Mark tube with a piece of tape. Rationale: the measurement ensures that the tube will be long enough to enter the clients stomach 10. lubricate the first 10 cm to 20 cm (4-8) of the tube with a water soluble jelly. Rationale: lubrication reduces friction and facilitate passage of the tube in the stomach. Watersoluble will not cause pneumonia if tube accidentally enters the lungs. 11. ask the client to lift his head, and insert the tube into the nostril while directing the tube downward and backward. The client may gag when the tube reaches the pharynx Rationale: following the normal contour of the nasal passage while inserting the tube reduces irritation

and the likelihood of musocal injury. The gag reflex is readily stimulated by the tube. 12. instruct the client to bring his head forward. Advance the tube in a downward and backward direction. Swallowing or sipping water through a straw may be helpful. If gagging and coughing persist, check placement of tube with a tongue with blade and flashlight. Keep advancing the tube until the tape marking is reached. Do not use force. Rotate the tube if it meets resistance. Rationale: Bringing the head forward helps close the trachea and open the esophagus. Swallowing helps advance the tube and causes the epiglottis to cover the opening of the trachea. Excessive coughing and gaging may occur if the tube has curled in the back of throat. Forcing the tube may injure mucous membranes. 13. discontinue the procedure and remove the tube if there are signs of distress such as gasping, coughing, cyanosis, and the inability to speak or hum. Rationale: the tube is not in the esophagus if the client shows signs of distress and is able to speak or hum. 14. determine that the tube is in the clients stomach: a. attach the syringe in the end of the tube and aspirate 10- 50 mL of stomach content. Rationale: the tube is in the stomach if its content can be aspirated. b. place 10- 50 mL of air in syringe and inject air into the tube. Simultaneously Auscultate over the epigastric area with a stethoscope. Rationale: a whoosing sound can be heard when the air enters the stomach through the tube. 15. Secure the tube with tape to the clients face. Be careful not to pull the tube too tightly against the nose: a. cut a 4- inch piece of tape and split bottom 2 inches. b. Place unsplit end over bridge of clients nose. c. Wrap split ends under the tubing and up and over onto the nose. 16. attach the tube to suction or clamp the tube with a screw- type clamp according to the physicians orders. Rationale: Suction will provide for decompression of stomach ad drainage of gastric contents. 17. secure the tube to the clients gown by using a rubber band or tape and a safety pin rationale: this prevents tension and tugging on the tube.

18. wash hands. Remove all equipment and make client comfortable. Rationale: handwashing deters the spread of microorganisms 19. Record the insertion procedure, type, and size of tube, description of gastric contents, and clients response. Rationale: facilitates documentation and provides for comprehensive care.