Slide 1: Nasogastric tube (NGT) insertion and removal Nursing Procedure
Slide 2: • Usually inserted to decompress the stomach, a nasogastric tube (NG) tube prevent vomiting after major surgery. An NG typically is in place for 48-72 hours after surgery, by which time peristalsis usually resumes.
Slide 3: The NG tube can also be used to assess and treat: Upper GI bleeding Collect gastric contents for analysis Perform gastric lavage Aspirate gastric secretions Administer medications and nutrients
Slide 4: Equipments needed
Slide 5: Equipments needed • Tube (usually #12, #14, #16 or #18 French for a normal adult.
Slide 6: Equipments needed • Towel or linen-saver pad
Slide 7: Equipments needed • Penlight
Slide 8: Equipments needed • 1” or 2” hypoallergenic tape or Opsite
Slide 9: Equipments needed • Liquid skin barrier
Slide 10: Equipments needed • Gloves
Slide 11: Equipments needed • Water soluble lubricant
Slide 12: Equipments needed • Cup or glass of water with straw (if appropriate)
Slide 13: Equipments needed • Stethoscope
Slide 14: Equipments needed • Tongue blade
Slide 15: Equipments needed • Catheter-tip or bulb syringe or irrigation set
Slide 16: Equipments needed • Safety pin
Slide 17: Equipments needed • Ordered suction equipment
Slide 18: Equipments needed (optional) • Metal clamp
Slide 19: Equipments needed (optional) • Ice
Slide 20: Equipments needed (optional) • Alcohol pad
Slide 21: Equipments needed (optional) • Warm water • (in the picture is a hot water bag)
Slide 22: Equipments needed (optional) • Large basin or plastic container
Slide 23: Equipments needed (optional) • Rubber band
Slide 24: Preparation • To ease insertion, increase a stiff tube’s flexibility by coiling it around your finger for a few seconds or by dipping it into warm water. • Stiffen a limp rubber tube by briefly chilling it in ice.
Slide 25: Procedure • Provide privacy, wash your hands, and put on gloves.
Slide 26: Inserting an NG tube • Explain the procedure to the patient. • Tell her that she may experience some discomfort and that swallowing will ease the tube’s advancement.
Slide 28: Inserting an NG tube • Help the patient into high Fowler’s position unless contraindicated.
Slide 29: Inserting an NG tube • Stand at the patient’s right side if you’re right-handed or at her left side if you’ left-handed to ease insertion.
Slide 30: Inserting an NG tube • Drape the towel or linen- saver pad over the patient’s chest.
Slide 31: Inserting an NG tube • To determine how long the NG tube must be to reach the stomach, hold the end of the tube at the tip of the patient’s nose. • Extend the tube to the patient’s earlobe and then down to the xiphoid process.
Slide 33: Inserting an NG tube • Mark this distance on the tubing with tape.
Slide 34: Inserting an NG tube • To determine which nostril will allow easier access, use a penlight and inspect for a deviated septum or other abnormalities.
Slide 36: Inserting an NG tube • Lubricate the first 3” (7.6 cm) of the tube with a water-soluble gel.
Slide 38: Inserting an NG tube • Instruct the patient to hold her head straight and upright.
Slide 39: Inserting an NG tube • Grasp the tube with the end pointing downward, curve it if necessary, and carefully insert it into the more patient nostril.
Slide 41: Inserting an NG tube • Aim the tube downward and toward the ear closest to the chosen nostril. • Advance it slowly to avoid pressure on the turbinates and resultant pain and bleeding.
Slide 42: Inserting an NG tube • When the tube reaches the nasopharynx, you’ll feel resistance.
Slide 44: Inserting an NG tube • Instruct the patient to lower her head slightly to close the trachea and open the esophagus.
Slide 46: Inserting an NG tube • Then rotate the tube 180 degrees toward the opposite nostril to redirect it so that the tube wont enter the patient’s mouth.
Slide 47: Inserting an NG tube • Unless contraindicated, offer the patient a cup of water with a straw. • Direct her to sip and swallow as you slowly advance the tube. • This helps the tube pass to the esophagus. (If you aren’t using water, ask the patient to swallow.)
Slide 49: Ensuring proper tube placement • Use a tongue blade and penlight to examine the patient’s mouth and throat for signs of a coiled section of tubing.
Slide 50: Ensuring proper tube placement • As you carefully advance the tube and the patient swallows, watch for respiratory distress signs, which may mean the tube is in bronchus and must be removed immediately.
Slide 51: Ensuring proper tube placement • Stop advancing the tube when the tape mark reaches the patient’s nostril.
Slide 52: Ensuring proper tube placement • Attach the catheter-tip or bulb syringe to the tube and try to aspirate stomach contents.
Slide 54: Ensuring proper tube placement • If you don’t obtain stomach contents, position the patient on her left side to move the contents into the stomach’s greater curvature, and aspirate again.
Slide 55: Ensuring proper tube placement • If you still can’t aspirate stomach contents, advance the tube 1” to 2” (2.5 - 5 cm). • Then inject 10cc air into the tube.
Slide 56: Ensuring proper tube placement • At the same time, auscultate for air sounds with your stethoscope placed over the epigastric region. • You should hear a whooshing sound if the tube is patent and properly positioned in the stomach.
Slide 58: Ensuring proper tube placement • If these test don’t confirm proper tube placement, you’ll need X-ray verification.
Slide 60: Example of a CXR showing a misplaced NG tube
Slide 61: Ensuring proper tube placement • Secure the NG tube to the patient’s nose with hypoallergenic tape, (or other designated tube holder). • If the patient’s skin is oily, wipe the bridge of her nose with an alcohol pad and allow to dry.
Slide 64: Ensuring proper tube placement • Apply liquid skin barrier to make the tape more adherent to the skin.
Slide 65: Ensuring proper tube placement • You’ll need about 4” (10 cm) of 1”tape. • Split one end of the tape up the center about 1 ½” (3.8 cm). • Make tabs on the split ends (by folding sticky sides together).
Slide 66: Ensuring proper tube placement • Stick the uncut tape end on the patient’s nose so that the split in the tape starts about ½” (1.3 cm) to 1 ½” from the tip of her nose.
Slide 67: Ensuring proper tube placement • Crisscross the tabbed ends around the tube. • Then apply another piece of tape over the bridge of the nose to secure the tube.
Slide 68: Ensuring proper tube placement • Alternatively, stabilize the tube with Opsite or a prepackaged product that secures and cushions it at the nose.
Slide 69: Ensuring proper tube placement • To reduce discomfort from the weight of the tube, tie a slipknot around the tube with a rubber band, and then secure the rubber band to the patient’s gown with a safety pin, or wrap another piece of tape around the end of the tube and leave a tab. • Then fasten the tape tab to the patient’s gown.
Slide 70: Ensuring proper tube placement • Attach the tube to suction equipment, if ordered, and set the designated suction pressure.
Slide 71: Ensuring proper tube placement • Provide frequent nose and mouth care while the tube is in place. • An NG tube may be inserted or removed at home.
Slide 72: *Confirming NG tube placement • When confirming NG tube placement, never place the tube’s end in a container of water. • If the tube is malpositioned in the trachea, the patient may aspirate water.
Slide 73: *Confirming NG tube placement • Besides, water without bubbles doesn’t confirm proper placement. • Instead, the tube may be coiled in the trachea or the esophagus.
Slide 74: Removing an NG tube • Explain the procedure to the patient and that it may cause some discomfort.
Slide 76: Removing an NG tube • Assess bowel function by auscultating for peristalsis or flatus.
Slide 78: Removing an NG tube • Help the patient into semi- Fowler’s position. • Then drape a towel or linen-saver pad across her chest to protect her from spills.
Slide 80: Removing an NG tube • Put on gloves. • Using a catheter-tip syringe, flush the tube with 10ml of normal saline solution to ensure that the tube doesn’t contain stomach contents that could irritate tissues during tube removal.
Slide 82: Removing an NG tube • Untape the tube from the patient’s nose, and then unpin it from her gown.
Slide 83: • Please wear gloves!!!
Slide 84: Removing an NG tube • Clamp the tube by folding it in your hand.
Slide 85: Removing an NG tube • Ask the patient to hold her breath to close the epiglottis. • Then withdraw the tube gently and steadily. (when the distal end of the tube reaches the nasopharynx, you can pull it quickly.)
Slide 86: • Please wear gloves!!!
Slide 87: Removing an NG tube • Assist the patient with thorough mouth care, and clean the tape residue from her nose with adhesive remover.
Slide 88: Removing an NG tube • Monitor the patient for signs of GI dysfunction.
Slide 90: Pointers • If the patient has a nasal condition that prevents nasal insertion, pass the tube orally after removing any dentures, if necessary.
Slide 91: Pointers • First coil the end of the tube around your hand. • This helps curve and direct the tube downward at the phaynx.
Slide 92: Pointers • While advancing the tube. • Observe for signs that it is entered the trachea, such as choking or breathing difficulties in a conscious patient and cyanosis in an unconscious patient or a patient without a cough reflex.
Slide 94: Pointers • If these signs occur, remove the tube immediately. • Allow the patient time to rest; then try to reinsert the tube.
Slide 95: Pointers • After tube placement, vomiting suggest tubal obstruction or incorrect position. • Assess immediately to determine the cause.
Slide 96: Complications of NG intubation • Although nasogastric (NG) intubation is a common procedure, it does carry risk.
Slide 97: Complications of NG intubation (Long-term concerns) • Potential complications of prolonged intubation includes: Esophagitis Esophagotracheal fistula Gastric ulceration Pulmonary and oral infection Sinusitis Skin erosion at the nostril
Slide 98: Complications of NG intubation (Suction reactions) • Additional complications include: Electrolyte imbalances Dehydration
Slide 99: Complications of NG intubation (Suction reactions) • Vigorous suction ,ay damage the gastric mucosa and cause significant bleeding, possibly interfering with endoscopic assessment and diagnosis.
Slide 100: Using an NG tube at home • If your patient will have a nasogastric (NG) tube in place at home, find out who will insert the tube. • If he will have a home care nurse, tell him to expect her.
Slide 101: Using an NG tube at home • Make a list; check it twice • If the patient or a family member will perform the procedure, you’ll need to provide additional instruction and supervision.
Slide 102: Using an NG tube at home • Use this checklist to prepare teaching topics: How and where to obtain equipment needed for home intubation. How to insert the tube.
Slide 103: Using an NG tube at home How to verify tube placement by aspirating stomach contents. How to correct tube misplacement. How to prepare formula for tube feeding. How to store formula, if appropriate.
Slide 104: Using an NG tube at home How to administer formula through the tube. How to remove and dispose of an NG tube. How to clean and store a reusable NG tube.
Slide 105: Using an NG tube at home How to use the NG tube for gastric decompression, if appropriate. How to set up and operate suctioning equipment. How to troubleshoot suctioning equipment. How to perform mouth care and other hygenic procedures.
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