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Nasogastric Tube

Nutrition - is what a person eats and how the
body uses it.
Nutrients are organic and inorganic
substances found in foods that are required
for body functioning. Adequate food intake
consists of a balance of nutrients: water,
carbohydrates, proteins, fats, vitamins, and
-three major functions: providing energy for
body processes and movement, providing
structural material for body tissues, and
regulating body processes.
Enteral Nutrition
(EN), also referred to as total enteral
nutrition (TEN), is provided when the
client is unable to ingest foods or the
upper gastrointestinal tract is impaired
and the transport of food to the small
intestine is interrupted. Enteral
feedings are administered through
nasogastric and small-bore feeding tubes,
or through gastrostomy or jejunostomy
Enteral Assistive Devices:

1. A nasogastric tube is inserted through

one of the nostrils, down the nasopharynx,
and into the alimentary tract. Traditional
firm, large-bore nasogastric tubes (i.e.,
those larger than 12 Fr in diameter) are
placed in the stomach. Examples:

Levin tube, a flexible rubber or plastic,

single-lumen tube with holes near the tip

Salem sump tube, with a double lumen

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.
Levin tube
Salem Tube
2. nasoenteric (nasointestinal) tube- a longer
tube than the nasogastric tube (at least 40
cm [15.75 in.] for an adult) is inserted
through one nostril down into the upper
small intestine.
used for clients who are at risk for
aspiration. Clients at risk for aspiration
are those who manifest the following:

Decreased level of consciousness

Poor cough or gag reflexes
Inability to participate in the procedure

Restlessness or agitation.
3. Gastrostomy and jejunostomy devices are
used for long- term nutritional support,
generally more than 6 to 8 weeks. Tubes
are placed surgically or by laparoscopy
through the abdominal wall into the
stomach (gastrostomy) or into the jejunum
(jejunos- tomy).
NGT tube
Non-allergenic adhesive tape, 2.5 cm (1 in.)
Sterile gloves
Water-soluble lubricant
Facial tissues
Bulb syringe
Assist the client to a high Fowlers
position if his condition permits, and
support the head with a pillow.

Rationale: It is often easier to swallow

in this position and gravity helps the
passage of the tube.
Place a towel or a disposable pad across
the chest.
Prior to performing the insertion, introduce
self and verify the clients identity. Explain
the procedure.

Perform hand hygiene and wear gloves. Provide

for client privacy.

Assess the clients nares for any obstructions

or deformities.

Determine how far to insert the tube. Use the

tube to mark off the distance from the tip of
the clients nose to the tip of the earlobe, to
the tip of the xiphoid.
Rationale: This length approximates the
distance from the nares to the stomach.
Mark this length with adhesive tape if the
tube does not have markings.
Insert the tube. Lubricate the tip of the
tube by a water soluble lubricant to ease

Rationale: A water soluble lubricant

dissolves if the tube accidentally enters
the lungs.
Ask the client to hyperextend the neck, and
gently advance the tube toward the nasopharynx.

Rationale: Hyperextension of the neck reduces

the curvature of the nasopharyngeal junction.

If the client gags and the tube does not advance

with each swallow, withdraw it slightly and
inspect the throat by looking through the

Rationale: The tube may be coiled, if so,

withdraw it until it is straight and insert it.
Check correct placement:
Aspirate stomach contents
Place a stethoscope over the clients
epigastrium and inject 10-30 ml of air
into the tube while listening for a
whooshing sound

Most reliable way is through xray

Secure the tube by taping it to the bridge of the
clients nose.
If the client has oily skin, wipe the nose
first with alcohol to defat the skin.
Cut 7.5 cm (3 in.) of tape, and split it
lengthwise at one end, leaving a 2.5-cm (1-in.)
tab at the end.
Place the tape over the bridge of the clients
nose, and bring the split ends either under and
around the tubing, or under the tubing and back
up over the nose. Ensure that the tube is
centrally located prior to securing with tape
to maximize air flow and prevent irritation to
the side of the nares. Rationale: Taping in
this manner prevents the tube from pressing
against and irritating the edge of the nostril.
Secure the tube to the clients gown.
Loop an elastic band around the end of
the tubing, and
attach the elastic band to the gown
with a safety pin. or
Attach a piece of adhesive tape to the
tube, and pin the tape to the gown.
Rationale: The tube is attached to
prevent it from dangling and pulling.
Document relevant information: the
insertion of the tube, the means by which
correct placement was determined, and
client responses (e.g., discomfort or
abdominal distention).
Removing an NGT
Confirm the primary care providers order to remove
the tube.

Assist the client to a sitting position if health


Place the disposable pad or towel across the

clients chest

to collect any spillage of secretions from the tube.

Provide tissues to the client to wipe the nose and

after tube removal.

Prior to performing the removal, introduce
self and verify the clients identity .
Explain to the client what you are going to
do, why it is necessary, and how he or she
can participate. Discuss how the results
will be used in planning further care or
Perform hand hygiene and wear clean gloves.
Provide for client privacy.
Unpin the tube from the clients gown.
Remove the adhesive tape securing the tube
to the nose.
Ask the client to take a deep breath and to hold
it. Rationale: This closes the glottis, thereby
preventing accidental aspiration of any gastric
Pinch the tube with the gloved hand. Rationale:
Pinching the tube prevents any contents inside
the tube from draining into the clients throat.
Smoothly, withdraw the tube.
Place the tube in the plastic bag. Rationale:
Placing the tube immediately into the bag
prevents the transference of microorganisms from
the tube to other articles or people.
Observe the intactness of the tube.
Ensure client comfort.
Provide mouth care if desired.
Assist the client as required to blow the
nose. Rationale:
Excessive secretions may have accumulated in
the nasal passages.
Dispose of the equipment appropriately.
Rationale: Correct disposal prevents the
transmission of microorganisms.
Remove and discard gloves. Perform hand
Document all relevant information.
Enteral Feedings
the type and frequency of feedings and amounts to
be administered are ordered by the primary care
provider. Liquid feeding mixtures are available
commercially or may be prepared by the dietary
department in accordance with the primary care
providers orders.
Enteral feedings can be given intermittently or
continuously. Intermittent feedings are the
administration of 300 to 500 mL of enteral formula
several times per day. Bolus intermittent feedings
- use a syringe to deliver the formula into the
stomach. Because the formula is delivered rapidly
by this method, it is not usually recommended but
may be used in long-term situations if the client
tolerates it.
Enteric Feeding Pump
Before commencing a tube feeding, determine the type,
amount, and frequency of feedings and tolerance of
previous feedings.

Measuring container from which to pour the feeding (if
using open system)
Water (60 mL unless otherwise specified) at room
Feeding pump as required /Asepto-syringe
Correct formula /feeding solution


Assist the client to a Fowlers position (at least 30 degrees

elevation) in bed or a sitting position in a chair, the
normal position for eating. If a sitting position is
contraindicated, a slightly elevated right side-lying
position is acceptable. Rationale: These positions enhance
the gravitational flow of the solution and prevent aspiration
of fluid into the lungs.

Prior to performing the feeding, introduce self and verify
the clients identity .Explain to the client what you are
going to do, why it is necessary, and how he or she can
participate. Inform the client that the feeding should not
cause any discomfort but may cause a feeling of fullness.
Perform hand hygiene
Provide privacy for this procedure if the client
desires it. Tube feedings are embarrassing to some
Assess tube placement.
Assess residual feeding contents by aspirating all
contents and measure the amount before administering
the feeding. Rationale: This is done to evaluate
absorption of the last feeding; that is, whether
undigested formula from a previous feeding
remains. If 100 mL (or more than half the last
feeding) is withdrawn, refer first to
inter/resident on duty.
Rationale: At some agencies, a feeding is
delayed when the specified amount or more of
formula remains in the stomach.
Reinstill the gastric contents into the
stomach if this is the agency policy or
primary care providers order Rationale:
Removal of the contents could disturb the
clients electrolyte balance.
If the client is on a continuous feeding,
check the gastric residual every 4 to 6
hours or according to agency protocol.
Administer the feeding.
Before administering feeding:
Check the expiration date of the feeding.
Warm the feeding to room temperature.
Rationale: An excessively cold feeding may
cause abdominal cramps.
When an open system is used, clean the top
of the feeding container with alcohol
before opening it. Rationale: This
minimizes the risk of contaminants entering
the feeding syringe or feeding bag.
Syringe (Open System)
Remove the plunger from the syringe and
connect the syringe to a pinched or
clamped nasogastric tube. Rationale:
Pinching or clamping the tube prevents
excess air from entering the stomach and
causing distention.
Add the feeding to the syringe barrel.
Permit the feeding to flow in slowly at
the prescribed rate. Raise or lower the
syringe to adjust the flow as needed.
Pinch or clamp the tubing to stop the
flow for a minute if the client
experiences discomfort. Rationale:
Quickly administered feedings can cause
flatus, cramps, and/or vomiting.
If another bottle is not to be
immediately hung, flush the feeding tube
before all of the formula has run through
the tubing.
Instill 30 mL of water through the
feeding tube or medication port.
Rationale: Water flushes the lumen of the
tube, preventing future blockage by
sticky formula.
Be sure to add the water before the feeding
solution has drained from the neck of a syringe
or from the tubing of an administration set.
Rationale: Adding the water before the syringe
or tubing is empty prevents the instillation of
air into the stomach or intestine and thus
prevents unnecessary distention.
Clamp the feeding tube before all of the water

instilled. Rationale: Clamping prevents air from

entering the tube.
Ensure client comfort and safety.
Secure the tubing to the clients gown.
Rationale: This minimizes pulling of the tube,
thus preventing discomfort and dislodgment.
Ask the client to remain sitting upright in
Fowlers position or in a slightly elevated
right lateral position for at least 30 minutes.
Rationale: These positions facilitate digestion
and movement of the feeding from the stomach
along the alimentary tract, and prevent the
potential aspiration of the feeding into the
Administering a Gastrostomy or Jejunostomy
Tube Feeding
Prior to performing the feeding, introduce
self and verify the clients identity. Explain
to the client what you are going to do, why it
is necessary, and how he or she can
participate. Discuss how the results will be
used in planning further care or treatments.
Perform hand hygiene and observe.
Provide for client privacy.
Assess and prepare the client.
Determine correct placement of the tube by
aspirating secretions .
Remove the tube clamp. Insert the bulb
syringe to the end of the tube, then pour
30 mL of water into the syringe. Allow
the water to flow into the tube.
Rationale: This determines the patency of
the tube. If water flows freely, the tube
is patent.
If the water does not flow freely, notify
the nurse in charge and/or primary care
Administer the feeding.
Hold the barrel of the syringe
above the ostomy opening.
Slowly pour the solution into the
syringe and allow it to flow through the
tube by gravity.
Just before all of the formula has run
through and the syringe is empty, add 30
mL of water. Rationale: Water flushes
the tube and preserves its patency.
Remove the bulb syringe, and then clamp
or plug the tube to prevent leakage.
Ensure client comfort and safety.
Assess status of periostomal skin.
Rationale: Gastric or jejunal drainage
contains digestive enzymes that can
irritate the skin. Document any redness
and broken skin areas.
Observe for common complications of
enteral feedings: aspiration,
hyperglycemia, abdominal distention,
diarrhea, and fecal impaction. Report
findings to primary care provider. Often,
a change in formula or rate of
administration can correct problems.
Even if feeding tubes are flushed with water
before and after feedings and medications, small
bore tubes still become clogged in about 35% of
cases from medications. This can occur when the
feeding container runs dry, solid medication is
not ade- quately crushed, or medications are
mixed with formula.
To prevent clogged feeding tubes, flush
liberally (at least 30 mL water) before,
between, and after each separate medication is
Do not exert pressure into the tube--can
rupture the tubeespecially small-bore
feeding tubes.
Do not add medications to formula or to
each other because the combination could
create a precipitate that clogs the tube.