Nasogastric Intubation and Feeding

Definition

Nasogastric intubation refers to the process of placing a soft plastic nasogastric (NG) tube through a patient's nostril, past the pharynx, and down the esophagus into a patient's stomach.

Purpose

Nasogastric tubes are inserted to deliver substances directly into the stomach, remove substances from the stomach, or as a means of testing stomach function or contents.

The most common purpose for inserting a nasogastric tube is to deliver tube feedings to a patient when they are unable to eat. Patients who may need a NG tube for feedings include: premature babies, patients in a coma, patients who have had neck or facial surgery, or patients on mechanical ventilation. Other substances that are delivered through a NG tube may include ice water to stop bleeding in the stomach or medications to neutralize swallowed poisons.

Another purpose for inserting a nasogastric tube is to remove substances from the stomach. A NG tube is used to empty the stomach when accidental poisoning or drug overdose has occurred. A NG tube is used to remove air that accumulates in the stomach during cardiopulmonary resuscitation (CPR). It is used to remove stomach contents after major trauma or surgery to prevent aspiration of the stomach contents. Placing a NG tube helps prevent nausea and vomiting by removing stomach contents and preventing distention of the stomach when a patient has a bleeding ulcer, bowel obstruction, or other gastrointestinal diseases.

A NG tube may be inserted to take samples of stomach contents for laboratory studies and to test for pressure or motor activity of the gastrointestinal tract.

Precautions

Do not use force when inserting a NG tube. If resistance occurs, rotate and retract the tube slightly and try again. Forcing the tube can cause traumatic injury to the tissue of the nose, throat, or esophagus.

Always check the tube positioning before giving feedings. If the tube is out of place, the patient may aspirate the feeding solution into the lungs.

Keep the patient in an upright or semi-upright sitting position when delivering a tube feeding to enhance peristalsis and avoid regurgitation of the feeding.

Check patients who are receiving continuous feedings via a pump or gravity hourly or according to the medical settings policy, to assure that the tube is in position, the formula is flowing at the correct rate, and the patient is comfortable with no signs of distention or distress.

Cap or clamp off the NG tube when not in use to prevent backflow of stomach contents or accumulation of air in the stomach.

If a patient has severe sinus conditions, nasal obstruction, or has had facial surgery, it may be necessary to place a oral-gastric tube to avoid further nasal trauma.

If the amount of gastric aspirate is large prior to a bolus or intermittent feeding, notify the physician and follow the protocol of the medical setting for re-instilling the gastric aspirate. The feeding size may need to be decreased if the patient is not digesting it.

NG tube placement is meant to be a short-term solution for feeding problems. Patients that require long term tube feeding should have surgical placement of a gastrostomy tube or gastrostomy button. Long-term NG tube usage can cause nasal erosion, sinusitis, esophagitis, gastric ulceration, esophageal-tracheal fistula formation, oral infections, and respiratory infections.

Description

To insert a nasogastric tube, the nurse or other health care professional should have the patient tilt his or her head slightly back and gently ease the lubricated tubing into the nares. As the tube rounds the bend into the throat, the patient should tilt the head forward into a neutral upright position, hold his or her breath, and swallow. The nurse should gently rotate the tubing 180 degrees to redirect the curve of the tube and ease the tubing down the throat, past the closed epiglottis. Gravity and swallowing will help move the tube down the esophagus as the nurse gently continues to advance the tube. The patient can assist by swallowing and can even take sips of water to help move the tubing down into the stomach. The tubing should be advanced until the marker tape is reached (applied when measuring the distance to the patient's stomach). The tubing should be secured with tape and checked for placement. If the patient gags during the procedure, the nurse should stop advancing the tube and allow the patient to rest. If the tubing comes out of the mouth, retract the tubing and try again. If the patient is unconscious, the nurse should advance the tube between respirations to avoid placing the tube into the trachea. If the patient becomes cyanotic, coughs, or displays any signs of respiratory distress, the tubing should be removed, allowing the patient to rest before beginning again.

Once the NG tube is inserted, there are several methods for checking tube placement. The nurse can ask the patient to talk. If the patient cannot make sound, the tube has passed through the vocal cords and into the trachea. The tube should be removed and the process started again. If the patient can talk, use a flashlight to look into the patient's mouth to view the tubing. It should appear straight in the back of the throat with no coiling into the mouth. Next, a 30 or 60 cc catheter tip syringe should be connected to the end of the NG tube and aspirated to see if stomach contents return into the tubing. Stomach aspirate is often clear or yellow in color, but this depends on what is in the patient's stomach. Stomach aspirate has a pH of 1-4, and an effective way to establish that the tube is in the stomach is to check the pH of the aspirate. Methods for checking tube placement, however, vary according to the medical setting. The policy for the medical establishment should be checked regarding tube placement. Another, more traditional method for checking tube placement is to draw 10-20 cc of air into the syringe, place the stethoscope over the patient's stomach, and quickly inject a bolus of air into the stomach. A whooshing sound should be audible through the stethoscope over the stomach if the tube is in the stomach. If the tube is in the esophagus or trachea, the air sounds will be absent or muffled. The most accurate way to check for tube placement is an x ray of the abdomen. The NG tube is radiographic and will show up clearly on the x ray. A chest x ray is rarely done for NG tube placement because of the cost, but if performed for other purposes the radiologist will usually note the positioning of the NG tube on the report.

Preparation

The patient should be positioned in bed with the head of the bed elevated 45-90 degrees, with a towel placed across the chest up to the patient's neck. The nasal intubation procedure should be explained to the patient. The nurse should let patients know that by holding their breath as the tube is passed through the pharynx, they will close off the airway and that if they swallow when instructed, it will help move the tubing down the esophagus into the stomach. Patients should blow their noses to clear out the nasal passages and remove dentures if they have them. The nurse should question patients about whether they have had sinus problems, nasal problems such as nosebleeds or nasal surgery in the past. The physician should be consulted if the patient has a history of nasal problems. The nurse should then select a nostril to use for intubation and assemble the equipment needed, including a nasogastric tube, flash light, emesis basin, tissues, 30-60 cc catheter-tip syringe and irrigation set, a glass of water, water-soluble lubricant, clear plastic tape, transparent dressing, stethoscope, and gloves. A suction apparatus and connection tubing should be obtained if the NG tube is to be used for suctioning the stomach. The nurse should prepare a piece of 1-inch (2.5 cm) tape that is cut horizontally half way through the piece of tape to make two tails. The uncut end will be placed along the patient's nose and the tails wrapped around the tube in opposite directions to secure the tube to the nose after insertion. A hand signal should be used with patients so that they can ask to stop the procedure if they are in distress.

NG tubes are available in a variety of types, lengths, and sizes. Large-bore tubes (some with a second lumen) are used for suctioning stomach contents. Small-bore tubing is used for feedings. The tube that is selected should be appropriate to the patient's size and the purpose for which the tube is being inserted. The health professional who is performing the procedure should wash his or her hands and put on gloves. He or she should then remove the tube from the packaging and uncoil it, examining the tubing for flaws. Some water should be run through the tubing to check for leaks. To find the distance to the patient's stomach, the nurse should use the tube to measure from the tip of the patient's nose back to the ear and then down to the tip of the sternum and mark this place on the tube using a small piece of tape. The tip and first few inches of the tubing should be moistened with water-soluble lubricant and laid back into the packaging.

Aftercare

After correct positioning of the NG tube has been established, the NG tube should be secured to the nose with a second piece of plastic tape or a transparent dressing used to hold the tubing to the nose. The intent is to secure the tube so that it will not slip in or out. The method of securing the tube may vary according to the size of the patient, their type of skin, and the amount of perspiration on the nose. Securing the other end of the NG tube to the patient's gown with a looped rubber band and safety pin can prevent accidental pulling on the NG tube as the patient moves around. The end of the NG tube should be plugged or clamped when not connected to suction or in use for feedings. Ongoing care of the patient with a NG tube includes encouraging good mouth care and cleansing the nostrils routinely. The tape position should be changed daily and the tissue around the nose and under the tape examined for signs of irritation or breakdown. The head of the bed should be elevated 30 degrees at all times to decrease gastric reflux. The head of the bed should be at 30-45 degrees during tube feedings and for 30-60 minutes after intermittent tube feedings if the patient can tolerate this position.

When a NG tube is used to administer tube feedings, they may be given by gravity or by pump. Tube feedings may also be given either intermittently or continuously. Th physician will calculate the patient's nutritional needs within a 24-hour period and order the solution, frequency, and rate of flow. Tube feedings are supplemented liquid nutrition and may be prepared by the dietary department in a medical setting or provided in prepared cans of formula (such as Ensure) that are manufactured for this purpose. There are a large number of formulas to select from, according to the patient's nutritional needs. The formula used for tube feeding should exactly match the physician's orders.

Intermittent tube feedings may be given using a large catheter-tip syringe or a feeding bag. The position of the NG tube should be checked according to the policy of the medical center. The stomach contents should be aspirated for residual formula from the last feeding. If the residual exceeds 100 cc for an adult, a nurse should hold the feeding and notify the physician. He or she should re-instill the gastric aspirate according to the policy of the medical center or the physician's order. The physician's order should be reviewd and the appropriate type and amount of feeding selected. The patient should remain in an upright position during the feeding. Prepared formulas should be shaken before administration. Formulas that have been refrigerated should be allowed to warm up to room temperature. To give the feeding using a syringe, the nurse should remove the barrel from the syringe, open the end of the NG tube, and connect it to the end of the syringe. The feeding should be poured into the wide end of the syringe, and the syringe should be held or secured to the bed or an IV pole just above the patient's head so that it will flow in slowly by gravity over 15-30 minutes. If more feeding is needed than can be held in the syringe, the nurse should watch the syringe and refill the syringe until the feeding is complete. When the feeding is complete, the tube should be rinsed with 30 cc of water. The end of the NG tube should be disconnected and recapped; the syringe should be rinsed according to the medical setting's policy. To give an intermittent feeding using a feeding bag, the nurse should pour the correct feeding amount into the bag and through the tubing connected to the bag down to the tip of the tubing. The tubing should be clamped using the roller clamp apparatus. Hang the bag on an IV pole just above the patient's head. Open the NG tube and connect it to the feeding bag tubing. Open the feeding bag roller clamp apparatus and adjust the flow rate to run the feeding in over the prescribed amount of time (usually 15-30 minutes). When the feeding is complete, the nurse should purge the line by putting 30 cc of water into the bag and allowing it to flow in wide open. The feeding bag tubing should be clamped and disconnected and the NG tube recapped. The feeding bag should be rinsed and reused according to the medical center's policy. Feeding bags and syringes are usually replaced every 24 hours to prevent bacterial contamination.

Continuous tube feedings are given using a feeding bag with connected tubing and an automatic food pump to deliver the feeding at a specific rate of flow. Patients receiving continuous tube feedings should be kept in an upright position of 30-45 degrees to prevent reflux of formula. The feeding bag is filled with formula solution for no more than four hours and the pump is set at the flow rate that the physician has ordered. The NG tube should be checked for correct placement every four hours and aspirated to check for formula residual. If the residual is 1.5 times greater than the amount administered each hour, the physician should be notified. The nurse should re-instill the residual by gravity using a syringe and flush the line with 30-60 cc of water, then refill the formula bag for the next four hours. The patient should be observed hourly to be sure that he or she is in no distress, that the abdomen is not distended, the formula is flowing at the correct rate, and that the tubing connections are secure. The bag should be refilled as necessary or every four hours. The feeding bag and tubing should be changed according to the medical setting's policy, usually every 24 hours to prevent bacterial contamination.

Complications

The complications of nasogastric intubation may include:

• aspiration of the stomach contents leading to asphyxia, abscess formation or aspiration pneumonia
• trauma injury including perforation of the nasal, pharyngeal, esophageal or gastric tissue
• pulmonary hemorrhage, empyema, pneumothorax, pleural effusion or pneumonitis from a malpositioned tube
• nosebleeds
• secondary infection in the sinus, throat, esophagus or stomach
• development of a tracheal-esophageal fistula
• erosion and/or necrosis of nasal, pharyngeal, esophageal or gastric tissue

The complications of nasogastric tube feedings may include:

• obstruction of the tube
• perforation of the tube
• tube migration out of correct position
• regurgitation and aspiration of the feeding
• diarrhea
• nausea and vomiting
• abdominal distention, cramping and discomfort from too much feeding or a rate of feeding that is too rapid
• any of the complications listed above in the complications of nasogastric intubation

Results

The use of a nasogastric tube for feedings can effectively prevent malnutrition in the patient who is unable to eat. A nasogastric tube is also an effective temporary measure for decompression and removal of stomach contents and free air in a variety of gastrointestinal illnesses, major trauma, or surgery.

Health care team roles

Nasogastric intubation is usually performed by a licensed nurse or physician in the medical setting. Paramedics or other emergency personnel may receive special training to insert NG tubes as appropriate in the field. Patients' families may be trained to insert or change nasogastric tubes in the home setting if a patient is discharged with a NG tube in place. It is unusual, however, to continue NG tube feedings in the home setting. Most patients who require long-term tube feedings will have a gastrostomy tube or gastrostomy button placed for feedings.

Tube feedings are usually administered by a licensed nurse in the medical setting. Non-licensed personnel may receive special training to start, stop or check tube feedings under the direction of a licensed nurse in some medical settings. Patients and patients' families may be taught by a licensed nurse to administer tube feedings in the home. Patients receiving tube feedings in the home should be monitored by visiting nurses or undergo frequent medical check-ups to assess their responses to the feedings and their ongoing nutritional needs.

Resources

OTHER

Elliott, Noel, R.N., B.S.N., C.R.N.A. "Care of the Patient Requiring a Nasogastric Tube." Nursewise Online, 1998. 〈http://www.nursewise.com/courses/ng_hour.htm〉.

"Enteral Feeding." Chapter 20. Nutritional Problems. In Lippincott Manual of Nursing Practice. Books at Ovid Online. 2001. 〈http://pco.ovid.com/lrppco/〉.

"Enteral Nutrition." Adult Guidelines for Parenteral and Enteral Nutrition. University of California Davis Online. February 1998. 〈http://wellness.ucdavis.edu/diet_exercise/nutrition/parenteral_and_enteral_nut/〉.

Hendrickson, Gail R.N., B.S. "Stomach Tube Insertion." Health Answers.com, May 2000. 〈http://www.healthanswers.com〉.

Knies, Robert C., R.N., M.S.N., C.E.N. "Confirming Safe Placement of Nasogastric Tubes." Emergency Nursing World Online, 2001. 〈http://www.enw.org/ResearchNGT.htm〉.

"Nasal Gastric Bolus Feeding." Patient Education Program. Children's Hospital Medical Center Cincinnati Online. August 1998. 〈http://www.cincinnatichildrens.org/family/pep/homecare/2110/〉.

"Nasogastric Feeding Tube Insertion." Patient Education Program. Children's Hospital Medical Center Cincinnati Online. August 1998. 〈http://www.cincinnatichildrens.org/family/pep/homecare/2010/〉.

"Tube Feeding with Gravity Feeding Set." Patient Education Program. Children's Hospital Medical Center Cincinnati Online. September 1998. 〈http://www.cincinnatichildrens.org/family/pep/homecare/2006〉.

Empyema— A collection of pus in the lung cavity.

Fistula— A passageway or connecting duct that is abnormal and connects body cavities or tissues that should not be connected. Fistulas develop as the result of injury, disease or congenital deformity.

Gastrostomy button— A soft plastic apparatus with a button closure that is surgically inserted and sutured onto the surface of the abdomen. The gastrostomy button is placed in a surgical opening that leads from the stomach to the surface of the abdomen and is used for long term tube feedings in patients who cannot eat to prevent malnutrition.

Gastrostomy tube— A soft plastic tube that is inserted and sutured into a surgical opening that leads from the stomach to the surface of the abdomen. A gastrostomy tube is used for long term tube feedings in patients who cannot eat to prevent malnutrition.

Peristalsis— Muscular contractions of the gastrointestinal tract that move food, fluids and refuse in a wave-like motion through the system.

Reflux— A backward flow of food or fluid from the stomach into the esophagus.

Regurgitation— A vigorous reversed flow of the stomach contents up the esophagus and out of the mouth.