Nasogastric tube insertion

NB In an OSCE situation it is unlikely that you will have to perform this procedure but it is possible you will have to explain it.

Introduction

• Wash hands, introduce self, check patient name and DOB/CHI,
• explain the procedure
  • ‘Tube that goes from your nose into your stomach’ +/- ‘It allows us to take unwanted fluid out and/or put in nutrients when needed’
• Gain consent

Prepare

• Collect
  • Gloves
  • NG tube (fine bore for feeding only; ‘Ryles’ tube for all other indications)
  • Lubricant
  • Syringe
  • Bile bag
  • Securing device/tape
  • Cup of water
  • pH indicator paper
  • (anaesthetic throat spray)
• Position the patient in an upright position with head flexed slightly forwards
  • It is good practice to agree with the patient a signal by which they can indicate to stop the procedure e.g. raising a hand
• Wash hands and put on gloves/apron
• Estimate the length of NG tube to be inserted by measuring from the earlobe to the bridge of the nose and from there to the xiphisternum (use the mark on the NG tube to gauge distance)
• Choose which nostril to enter based on patency (no obstruction) with patient preference (may be suitable to ask the patient to blow their nose)

Procedure

• Lubricate the tip of the tube and enter the nostril, advancing horizontally/posteriorly along the floor of the nasal cavity
  • If obstruction is felt, withdraw and try another angle
• As the tube approaches the nasopharynx, as the patient to swallow water and advance the tube as the patient swallows.
  • If the patient starts to cough/gag, stop advancing until settled, then continue
  • If the patient becomes distressed/agitated, remove the tube and postpone the procedure
  • If the patient becomes short of breath, cyanosed or has chest pain, withdraw the tube and seek help.
• When the mark on the tube is reached, stop advancing the tube.
• Lightly tape the tube to the patient’s face

Confirming position

• Attach a large (60ml purple) syringe and aspirate gastric contents (~1-2ml) and test aspirate with pH paper
  • pH<5.5 suggests the correct placement
  • You may also inject in some air into the stomach whilst auscultating over the LUQ (may be able to hear bubbles)
• If no aspirate is gained, ask the patient to drink some more water (this may make things easier to aspirate)
  • NB If a fine-bore tube is used, it may be difficult to aspirate stomach contents
• If there is any doubt, confirm placement using a CXR

End

• Some tubes have guidewires and internal lubricant which require removal/activation (the latter using tap water injected into the guide port)
• Secure the tube to the patient’s face with tape
• Attach a bile bag or spigot to the end of the tube.
• Remove gloves and apron and dispose of waste appropriately
• Wash hands and thank patient (ensure they are comfortable)
• Note the procedure in the patient’s notes and start a fluid chart (if not already done so)