NASOGASTRIC TUBE

• Temporary nutrition in loss of swallow reflex or to supplement an inadequate oral diet
• To allow aspiration of stomach contents

• Base of skull fracture
• Uncorrected coagulopathy
• Recent oesophageal surgery
• Oesophageal varices
• Unstable cervical spine injuries
• patient may still require NG tube, contact anaesthetist

• For enteral feeding, nasogastric tube polyurethane (PUR) 8 Fr (guide wire assisted)
• For aspiration/free drainage of gastric contents, nasogastric tube PUR 14/16 Fr (not guide wire assisted)
• Enteral/purple syringe 50 mL
• pH indicator paper
• Naso-fix adhesive patches and occlusive dressing
• Disposable gloves
• Apron
• Lubricant gel
• Receiver
• Fresh tap water

• Explain procedure and reassure patient
• Obtain and record consent 

• If not competent in procedure, organise supervision by a clinician experienced in the procedure 

Preparation

• If verbal communication not possible, arrange a signal by which the patient can communicate to nurse/clinician to stop, e.g. by raising his/her hand
• Sit patient in a semi-upright position in bed or chair
• support patient’s head with pillows
• do not tilt head forward or backward
• Determine length of tube to be inserted
• extend tip (end which will be inserted into patient) of tube from patient’s ear lobe to the bridge of the nose
• from the bridge of the nose, extend remainder of tube to the bottom of the xiphisternum
• note the mark on the point of the tube next to the bottom of the xiphisternum
• Wash hands and put on disposable gloves and apron
• Assemble equipment
• Check nostrils and determine which is more patent
• ask patient to blow his/her nose
• Check guide wire moves freely in NGT

Insertion

• Insert end of NGT into water for lubrication or add a small amount of lubrication gel to the tip
• Insert rounded tip into the nostril of choice and slide it backwards and inwards along the floor of the nose to the nasopharynx
• if any obstruction is felt, withdraw tube and try again in a slightly different direction
• if patient starts coughing, withdraw slightly and wait for coughing to stop then proceed as above
• if swallowing reflex is present, ask patient to swallow, and/or sip water as the tube passes down into the nasopharynx, to aid passage
• Advance the tube through the nasopharynx, oropharynx and oesophagus until required pre-measured depth reached
• if patient shows any sign of distress, e.g. gasping or cyanosis, remove tube immediately
• Secure tube to nostril and cheek with adhesive patch
• Do not administer drugs, feed or fluid via the tube until its position has been satisfactorily checked

Checking feeding tube position

• If tube has been placed in theatre, check position before using tube
• If tube inserted after feeding or medication, wait at least 1 hr from feeding/medication
• flush tube with 5 mL air to clear gastric lining before checking
• Never use the following methods to confirm NGT position
• auscultation
• use of ordinary litmus paper
• absence of respiratory distress

Procedure

• Aspirate 2 mL of stomach contents with 50 mL syringe
• test for acid response using testing pH strips
• a pH level of ≤5.5 will indicate gastric placement
• if a pH of ≥6.0, do not use NGT. Request chest X-ray

No aspirate obtained

• Attempt re-aspirating after each of the following:
• nurse patient in left lateral position
• inject 10–20 mL of air using a 50 mL syringe – wait 15–30 min and re-aspirate
• advance tube 10–20 cm
• patient who can safely swallow has sipped a coloured drink to determine if it can be aspirated back
• if still no aspirate, do not use NGT. Request chest X-ray
• Check pre-measured markings of the NGT at the nostrils remain the same
• If correct position confirmed, introduce 10 mL of fresh tap water into tube to activate the internal lubrication

Completion of insertion

• Remove the guide wire
• once removed, never reintroduce a guide wire back into a nasogastric tube

Document

• Record procedure in nursing record and, if undertaken by a doctor, the medical record
• note size of tube, length passed, and which nostril used
• Complete and insert the “NG insertion sticker” in patient’s hospital notes
• Complete the nasogastric tube placement bedside checklist

• Once correct position confirmed, NGT can be used immediately

• Follow procedure for aspiration/free drainage of gastric contents 

Check position

Measure aspirate pH

• After initial insertion and subsequent reinsertions
• Before administering each feed
• Before giving medication
• After vomiting, retching or coughing
• absence of coughing does not rule out misplacement or migration
• Evidence of tube displacement
• e.g. if tape loose or visible tube appears longer or kinked
• See Checking feeding tube position and record on NGT placement checklist

Chest X-ray

• Check position when chest X-ray taken for another reason

Integrity of skin

• Check around nostril at frequent intervals for signs of deterioration
• if signs of pressure appear, reposition tube and/or tape, or re-pass NGT via opposite nostril

Changing nasogastric tub

• If patient has recently undergone facial, airway or upper GI surgery, discuss with operating surgeon before removing NGT
• When changing NGT, follow manufacturer’s recommendations
• PUR tubes can be used for 60 days before replacing
• Pass new NGT via opposite nostril wherever possible