Out line

Define the nasogastric tube

Discuss the types of nasogastric tube .

List the purpose of using the nasogastric tube

Discuss insertion nasogastric tube
Discuss removing nasogastric tube
Discuss administering a tube feeding
Discuss Irrigating Nasogastric Tube
Explain the procedure.

List the potential complications of Nasogastric Tube.

Demonstrate the procedure.

Introduction
Gastrointestinal intubation is

inserting of rubber or plastic tube into

the stomach , duodenum or intestinal
The tube inserted through mouth
.nose , or abdominal ( gastrostomy
.jejunostomy )
The tube short , medium , long

Types of Tubes
Short- Nasogastric tube
Introduced from the nose to the stomach
Levin and Gastric (Salem) Sump
Used to remove gas and fluid from the

upper GI tract or to obtain a specimen of

gastric contents
Sometimes used for medications or
feedings ( gavage )

Levin Tube
Single Lumen (hollow part of tube)
Size 14-18 French
Made of plastic or rubber with opening near

tip
It is 125 cm long
Circular markings on the tube serve as
insertion guides

Gastric (Salem) Sump

Gastric sump tube ( salem. Ventrole)
Double lumen catheter .clear plastic
Plastic, 12-18 FR.
It is 120 cm long
Used to decompress the

stomach, keeps it empty

Smaller, inner tube (blue pigtail) vents the

larger suction-drainage tube to the atmosphere

by way of an opening at the distal end of the
tube.
Keeps the suction force at the drainage
openings at less that 25 mm Hg to prevent
capillary irritation.
Connected to low continuous suction.
Vent lumen kept above the clients waist.

.Medium tubes
Medium length- nasoenteric used for feeding.

Example- Dobhoff
Placed in the duodenum or jejunum by fluoroscopy
(x-ray dept) or at clients bedside.
Verified by x-ray before feedings
begin. May take up to 24 hrs.
to pass through the stomach
into the intestines.
Place client on right side
to facilitate passage

.Long- nasoenteric tubes

Long- nasoenteric tubes introduced through

the nose and passed through the esophagus

and stomach into the intestinal tract.
Used to aspirate intestinal contents-ie. gas and
fluid
Used to (Decompression) to prevent intestinal
obstruction.
Due to peristalsis, prevents vomiting,
reduces tension at the incision line and
prevents obstruction.

.Long- nasoenteric tubes

Examples of long tubes:
Miller- Abbott is double lumen ( 12--- 18 fr ) 300 cm

rubber tube
one lumen used for aspiration and
other for Introduce with mercury,
water, or saline

Long- nasoenteric tubes

Harris Is single lumen ( 14 fr )
used for suction and irrigation
mercury-weighted of about 180 cm
This tube metal tip that lubricate
This use for irrigation & suction .

Long- nasoenteric tubes

Cantor tube
has a large balloon at distal end of

tube. Filled with

4- 5 ml of mercury, water or saline to
weight the tube
It is 300 cm long

Procedure of Inserting
nasogastric tube

Definition
Tube inserted through the nose into

stomach

: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.

Purposes
To drain fluid or air from the

stomach.
To promote healing after bowel
surgery.
To monitor bleeding in the
gastrointestinal (GI) tract.
To help treat an intestinal
obstruction.

:Assessment & Preparations

Assessment & Prepare the client
Presence of gag reflex
Mental status or ability to cooperate with

procedure
Check physician's order for insertion of
NG tube.
Explain procedure to patient.
Assist the patient to high Fowler's
position.
Drape chest with disposable pad

Assess the client nares

Ask client to hyperextend the head & using

flashlight
Observe ( intactness of tissue nostrils
including any irritation or abrasion )
Examine the patients nostril for septal
deviation. To determine which nostril is
more patent, ask the patient to occlude each
nostril and breathe through the other
Patency of nares & intactness of nasal tissue
( note especially history of nasal surgery or
deviated septum )

Assess & prepare the tube

If rubber tube :
used placed it on ice for 5 to 10 minutes
This stiffens the tube , facilitating insertion

If plastic tube
Used place it in warm water until tube

softer & more flexibility , facilitating

insertion

Nasogastric tube
Adult

- 16-18F
Viscous lidocaine 2%
Oral analgesic spray (Benzocaine spray or
other)
Oral syringe, 12 mL
Glass of water with a straw
Water-based lubricant

:Equipments
Non allergenic adhesive Tape 2,5 cm wide
Emesis basin or plastic bag
Wall suction, set to low intermittent suction
Suction tubing and container
Flashlight .
Stethoscope.
Toomey syringe (20 to 50 ml) .
Tissues
Disposable pad & gloves . .
Tongue blade .
Normal saline solution (for irrigation only).

: Procedure

Note
A nasogastric (NG) tube is used for

the procedure. The placement of an

NG tube can be uncomfortable for the
patient if the patient is not adequately
prepared with anesthesia to the nasal
passages and specific instructions on
how to cooperate with the operator
during the procedure

Determine how far to insert the tube

Measure the distance to insert tube by

placing tip of tube at client's nostril

and extending to tip of ear lobe and
then to tip of xiphoid process.
Mark tube with piece of tape.

Nasogastric tube lubrication with water-based

.lubricant

Estimation of nasogastric tube length

from nostril to stomach

Insert the tube

Prepare equipment.
Wash hands.
Wear disposable gloves.
Instill 10 mL of viscous lidocaine 2% (for oral

use) down the more patent nostril with the head

tilted backwards, and ask the patient to sniff
and swallow to anesthetize
Lubricate tip of tube with water soluble
lubricant.
Ask client to lift head, and insert tube into
nostril while directing tube upward and
backward.

Aspiration of viscous lidocaine into an

oral syringe

insert of viscous lidocaine 2%

,,Cont
If client gag when tube reaches

pharynx, provide tissues for tearing

or watering of eyes.
When pharynx is reached, instruct
client to touch chin to chest.
Encourage client to sip water through
a straw or swallow even if no fluids
are permitted.

Patient flexing
his neck and
drinking water
while a
nasogastric
tube is
.inserted

Advance tube in downward and backward

direction when client swallows.

Stop when client breathes.
If gagging and coughing persist, check
placement of tube with tongue blade and flash
light.
Keep advancing tube until tape marking is
reached.
Do not use force, rotate tube if it meets
resistance.
Discontinue procedure and remove tube if
there are signs of distress, such as gasping,
coughing, cyanosis, and inability to speak or
hum.

Confirming Placement
Tube placement is confirmed prior to any use

of the tube for suction, irrigation, medication

admin. or feedings.
Initially, an x-ray should be ordered to confirm
placement of weighted feeding tubes (Dobhoff).
Verify NG or Salem Sump tubes by auscultation
of an injected air bolus over the epigastrium or
aspirate stomach contents.
Measurement of tube length, visual inspection
and measuring of the aspirate pH is also
recommended.

Auscultation over the stomach

.Nasogastric tube in lung

Securing the GI tube

Use a skin barrier to prep the skin
Use NG strip or place a piece of tape

under the tube at the nose and secure

to the skin, place another piece of
tape over the first piece.
Secure tube to clients gown with a
safety pin.

.Secured nasogastric tube

Document
Document: Tube type and size
Drainage or aspirate (residuals)

amount, color and consistency

Irrigation type and amount
Suction- type and level (i.e. low
intermittent)
Feeding- type and amount
Patient tolerance
Patient/ Family education and response

NG Suction
Tube for decompression will be attached

to Intermittent Suction- keep suction

between 20-80mm Hg.
Continuous suction greater than 25mm
Hg can cause damage to the gastric
mucosa.
Do not clamp or plug the vent lumen.
A soft hissing sound will be heard from
the vent lumen if its patent.
Record amt. on I&O.

,,,Conte
Remove disposable gloves.
Wash hands.
Remove all equipment.
Keep the client at comfortable

position.
Assist with or provide oral hygiene at
regular intervals.

Complications
The main complications of NG tube

insertion :aspiration and tissue trauma.

Placement of the catheter can induce
gagging or vomiting, Patient discomfort
Epistaxis
Pulmonary complication
Esophageal perforation

Contraindications
Absolute contraindications

Severe mid face trauma

Recent nasal surgery

Relative contraindications

Coagulation abnormality
Esophageal varicose or stricture
Alkaline ingestion

Procedure of Administering a
.Tube
Feeding

Tube Feedings
Meet nutritional needs when oral

intake not possible

Advantageous over TPN
GI integrity is preserved
Normal insulin/glucagon ratios are
maintained
Admin. intermittent, continuous
Accessed by nasogastric, nasoenteric,
gastrostomy or jejunostomy tube

Assessment
Before a nasogastric or orogastric feeding

determine type amount frequency of feeding

& tolerance of previous feeding
Assessment signs of malnutrion or
dehydration
Assess allergies to any food
Presence bowel sound
Any tolerance of previous feeding ( delayed
gastric empty , abdominal distention .
Constipation )

:Purposes
To restore or maintain nutritional

status.
To administer medications.

:Equipments
Feeding container.
Large syringe with plunger or calibrated

plastic feeding bag with tubing or Prefilled

bottle with a drip chamber tubing & flow
regulator clamp
Stethoscope. Disposable gloves. Alcohol
swab.
Toomey syringe 20 to 50 ml with adaptor .
Water for irrigation or normal saline.
Emesis basin
Feeding pump as required

: Procedure

:Preparation
Explain procedure to client.
Prepare equipment.
Check amount, concentration, type,

and frequency of tube feeding on

client's chart.
Check expiration date of formula

Procedure
Use stethoscope to assess bowel

sounds.
Wash hands.
Wear disposable gloves.
Position client with head of bed
elevated at least 30 degrees or as near
normal position for eating as
possible. Fowlers position

:Performance
Check to see that the NG tube is properly

located in the stomach.

Flush tube with 30 ml of water for
irrigation.
Disconnect syringe from tubing.
Warm feeding to room temperature
Assess residual feeding content
Aspirate all stomach content & measure a
mount prior to administering the feeding

( (Feeding bag Open system

Cleanse top of feeding container with alcohol

before opening it.

Pour formula into feeding bag and allow
solution to run through tubing.
Close clamp.
Attach feeding setup to feeding tube.
Open clamp.
Regulate drip according to physician's order,
or allow feeding to run in over 30 minutes.

( (Feeding bag Open system

Add 30 to 60 ml of water for irrigation

to feeding bag when feeding is almost

completed and allow it to run through
the tube.
Clamp tubing immediately after water
has been instilled.
Disconnect from feeding tube.
Clamp tube and cover end.

Open system ) ) Syringe feeding

Remove plunger from 30- or 60-ml syringe.
Open clamp.
Attach syringe to feeding tube.
Pour amount of tube feeding into syringe.
Allow food to enter tube.
Regulate rate, by height of the syringe.
Do not push formula with syringe plunger.
When syringe has emptied, hold syringe

high.

Syringe feeding
Add 30 to 60 ml of water for irrigation to syringe when

feeding is almost completed, and allow it to run

through the tube.
Clamp tube .Disconnect from tube
Cover end of tube.
Observe the client's response during and after tube
feeding.
Keep client in upright position for
at least 30 minutes to 1 hour after feeding.
Remove gloves. Wash hands

:Documentation

Record type and amount of feeding,

residual amount ,and client's
response, monitor blood glucose
level, if ordered by physician.

Procedure of Irrigating Nasogastric

Tube

:Purposes
To clears the tube of feeding or

debris.
To prevent the spread of
microorganisms in the tube of
feeding.

:Equipments
Normal saline solution or water for

irrigation.
Disposable gloves.
Stethoscope.
Toomey syringe.
Container.
Disposable pad.

: Procedure

:Preparation
Check physician's order for irrigation.
Explain procedure to client.
Prepare necessary equipment.
Check expiration dates on irrigating solution.
Wash hands.
Wear disposable gloves.
Assist client to semi-Fowler's position.
Check placement of NG tube.
Pour irrigating solution into container.
Draw up 30 ml of saline solution.
Place tip of syringe in tube.

Hold syringe upright and gently insert the

irrigate or allow solution to flow in by

gravity.
Do not force solution into tube.
If unable to irrigate tube, reposition patient
and attempt irrigation again.
Withdraw or aspirate fluid into syringe.
If no return, inject 10 to 20 cc of air and
aspirate again.
Measure and record amount and description
of irrigant and returned solution.
Remove equipment& gloves.
Wash hands.

:Documentation
Record irrigation procedure,

description of drainage, and client's

response.

Procedure of Removing a
Nasogastric Tube

Purposes:
The

physician will order the tube to be

removed carefully, when the NG tube is no
longer
necessary for treatment:
To provide as much comfort as possible for
the client.
To prevent complications.

:Equipments
Tissues.
50-ml syringe (optional).
Disposable gloves.
Disposable plastic bag.
Disposable pad.
Normal saline solution or water for

irrigation (optional).
Emesis basin.

: Procedure

:Preparation
Check physician's order for removal of NG

tube.
Explain procedure to client.
Assist to semi- Fowler's position.
Prepare equipment.
Wash hands.
Wear clean disposable gloves.
Place disposable pad across client's chest.
Give emesis basin and tissues to client.
Attach syringe and flush with 10 ml of water or
normal saline solution.

Carefully remove adhesive tape from client's

nose.
Instruct client to take a deep breath and hold it.
Clamp tube with fingers by doubling tube on
itself.
Quickly and carefully remove tube while client
holds breath.
Dispose of tube.
Remove gloves and place in bag.
Clean and dry face, nose and mouth.
Remove all equipment and dispose of according
to agency policy.& Wash hands.

Total parental nutrition( TPN)

Definition of Parenteral Nutrition

The administration of complete and
balanced nutrition by intravenous
infusion in order to support
anabolism, body weight maintenance
or gain, and nitrogen balance, when
oral or enteral nutrition are not
feasible or are inadequate

Indications for TPN

Mall absorption syndromes, such as

short bowel syndrome

Conditions requiring complete bowel
rest for prolonged periods
Pre and post-operative support in
patients with pre-existing malnutrition,
in who GI function is impaired
Malignancy undergoing treatment,
surgery, radiation, chemo who are
unable to obtain adequate nutrition by an
enteral route

TPN is generally NOT indicated

When an inpatient has a functioning GI

tract
TPN therapy is expected to be less than 5
days
Prognosis does not warrant aggressive
nutrition support

Source of Nutrition
Eternal nutrition
Parenteral nutrition
Central

parenteral nutrition (CPN=TPN)

Peripheral parenteral nutrition (PPN)
Long-term home parenteral
nutrition (HPN)

Clinical decision algorithm route of nutrition support

Nutrition Assessment

Decision to institute special nutrition support

YES
Enteral Nutrition

: Short-term
NG, ND,NJ

Parenteral Nutrition

:Long-term
Gastrostomy Jejunostomy
GI function

Intact
Nutrients

Adequate

NO

Functional GI Tract

Defined
Formula

Inadequate Adequate
PN
Oral Feeding

PPN

TPN

GI function return

YES

NO

Components of TPN
Carbohydrate, Amino acid, Fat,

Electrolyte, Water, Vitamin, Trace

element
Standard solution
Dextrose,

Amino acid
Electrolyte (Na, K, Cl, Mg, Ca, P)
Vitamin (A, B1, B2, Niacin, B6,
Panthothenic acid, C, D, E, Zn, Cu, Mn, Cr)
Lipid emulsion

Total Parenteral Nutrition

Normal Diet-------------------

TPN

Protein--------------------------Amino Acids
Carbohydrates------------------Dextrose
Fat--------------------------------Lipid Emulsion
Vitamins--------------------Multivitamin Infusion
Minerals------------------------Electrolytes
and Trace Elements

complication
Mechanical: thrombosis, embolism,

skin slough
Infectious: particularly staph
epidermidis, Candida
Metabolic: hypoglycaemia,
hyperglycaemia,
cholestasis