Samantha Soto University of Central Florida Nasogastric Tube Placement, Removal, and Maintenance for the Bedside Nurse Samantha Soto University of Central Florida Figure 1 Retrieved from Microsoft clip art software on 11/22/11 2/17/2019 Figure 1

Objectives articulate the anatomy of the upper gastrointestinal tract Figure 2 After a two hour class including a PowerPoint presentation, handout, and demonstration of nasogastric tube placement, security, and removal on a mannequin, the nurse will perform the following correctly: articulate the anatomy of the upper gastrointestinal tract describe two types of nasogastric tubes and their uses verbalize three conditions where a nasogastric tube would be indicated perform a return demonstration of patient assessment prior to nasogastric tube placement verbalize the supplies and equipment necessary for nasogastric tube placement Figure 2 retrieved from Microsoft clip art software on 11/22/11 2/17/2019

Objectives cont. demonstrate a suction set up perform a return demonstration of patient education on nasogastric tube placement perform a return demonstration of nasogastric tube insertion, security, and removal list two methods to verify correct nasogastric tube placement describe maintenance of the nasogastric tube list three documentation methods list two expected and two unexpected outcomes for the course of nasogastric tube placement Figure 29 Figure 29 Retrieved from Microsoft clip art program on 11/23/11. 2/17/2019

Anatomy of the Upper Gastrointestinal Tract Figure 3 anatomy of upper gastrointestinal tract. Retrieved from www.lifescript.com on 11/22/11 Figure 3 2/17/2019

Nasogastric Tubes Figure 6 Figure 5 Figure 4 Figure 7 Figure 8 Figure 4 Retrieved from healthmad.com on 11/22/11. Figure 5 Retrieved from allegromedical.com on 11/22/11 Figure 6 Retrieved from www.kendallcriticalcare.com on 11/22/11. Figure 7 Retrieved from radiographicceu.com on 11/21/11 Figure 8 Retrieved from studentrntiffany.wordpress.com on 11/22/11. Figure 7 Figure 8 2/17/2019

Conditions requiring Nasogastric Tube Placement Stomach decompression for small bowel obstruction such as an ileus Gastric contents evacuation such as overdose or hemorrhage Gastric lavage Sampling of gastric contents for analysis, medications, and fluids Feedings (McHale Wiegand & Carlson, 2005) Figure 9 Figure 9 Retrieved from medicaldevicenow.com on 11/22/11. Figure 32 retrieved from Microsoft clipart program on 11/23/11. Figure 32 2/17/2019

Patient Assessment prior to Nasogastric Tube Placement If possible ask patient for information regarding their past medical history, be sure to include questions about: ingestion of drugs or toxins nasal deformities epistaxis facial surgery trauma-facial or head sinusitis transphenoidal pituitary resection history of basilar skull fracture varicies recent esophageal or gastric surgeries (McHale Wiegand & Carlson, 2005) Figure 10 Retrieved from Microsoft clipart software on 11/22/11. Figure 10 2/17/2019

Patient Assessment prior to Nasogastric Tube Placement Please note signs and symptoms such as: Abdominal distention Nausea Vomiting Absence of bowel sounds (McHale Wiegand & Carlson, 2005) Absence of bowel movements Note last bowel movement and type Figure 11 Retrieved from Microsoft clip art program on 11/22/11. Figure 11 2/17/2019

Orders Orders Nasogastric tube placement requires physician orders whether verbal or written. Do not forget to write them. Figure 12 Retrieved from cardinalhealth.com on 11/22/11. Figure 13 Retrieved from surgical-products.salvin.com on 11/22/11. Figure 14 Retrieved from covidien.com on 11/22/11. Figure 12 Figure 13 Figure 14 2/17/2019

Supplies and Equipment supplies may include: Figure 15 Nasogastric tube Water soluble lubricant Gloves Cup of water Irrigation kit, fill with tap water Stethoscope Nasogastric tube holder towel Suction tubing x2 Suction regulator Suction canister Silk tape and safety pin Antireflux valve if no suction is needed Figure 15 Retrieved from Microsoft clip art program on 11/22/11. Figure 16 Retrieved from studentrntiffany.wordpress.com on 11/22/11. Figure 16 2/17/2019

Supplies and Equipment supplies may include: Figure 17 Figure 19 Figure 20 Figure 18 Figure 17 Retrieved from Microsoft clip art program on 11/22/11. Figure 18 Retrieved from pstdental.com on 11/22/11. Figure 19 Retrieved from sci.rutgers.edu on 11/22/11. Figure 20 Retrieved from Microsoft clip art program on 11/22/11. Figure 21 Retrieved from penncare.net on 11/22/11. Figure 22 Retrieved from hellotrade.com on 11/22/11. Figure 23 Retrieved from gomedsource.com on 11/22/11. Figure 21 Figure 22 Figure 23 2/17/2019

Patient Education Explain the procedure to your patient Let the patient know that they have an important role as well Explain that discomfort will be felt briefly and that the gag reflex may be elicited (McHale Wiegand & Carlson, 2005) Explain to the patient that you may have someone help you with a few things Figure 24 Figure 24 Retrieved from sjbhealth.org on 11/22/11. 2/17/2019

Nasogastric Tube Preparation Figure 25 You may want to review your facility’s policy and procedure first Place patient in a high Fowler’s position if awake and alert Place patient with the head down on the left side if they are comatose or sedated Place a towel on the patient’s chest (McHale Wiegand & Carlson, 2005) Figure 25 Retrieved from medtrng.com on 11/23/11. Figure 26 Retrieved from paramedicine.com on 11/23/11. Figure 26 2/17/2019

Nasogastric Tube Preparation cont. Figure 27 Measure the tube from the bridge of the nose to the earlobe to the tip of the xiphoid process and mark the tube Have your supplies and equipment ready Setup suction if necessary(remember that suction for nasogastric tubes is almost always low and intermittent) Have patient close a nare and breath through the other to assess which is the most patent (McHale Wiegand & Carlson, 2005) Figure 27 Retrieved from med.uottawa.ca on 11/23/11. 2/17/2019

Nasogastric Tube Insertion and Security Wash hands Place gloves Lubricate 6-10cm of the nasogastric tube Insert the tube through the nare directing it slightly upward first then down and back You may rotate the tube with a twisting motion if resistance is met, but do not force it (McHale Wiegand & Carlson, 2005) Figure 28 Figure 28 Retrieved from isisthescientist.com on 11/22/11. 2/17/2019

Nasogastric Tube Insertion and Security cont. Figure 22 Continue to advance the tube and have patient drink a few sips of water while advancing If the patient gags or coughs, stop and let the patient rest Confirm the tube placement Secure tube with nasogastric tube holder or tape and safety pin to gown with tape If the physician has requested suction then the end of the tube will attach to the suction tubing coming from the suction container (McHale Wiegand & Carlson, 2005) 2/17/2019

Placement Verification Figure 30 Nasogastric tube placement can be confirmed by injecting air into the distal end of the tube via a syringe or chest x-ray. Most facilities require that nasogastric tube placement be confirmed via chest x-ray prior to its use Figure 30 Retrieved from csee.usf.edu on 11/23/11. Figure 31 Retrieved from patientsafetyauthority.org on 11/23/11. Figure 31 2/17/2019

Maintenance of the Nasogastric Tube Every facility or hospital will have a policy for maintenance of the nasogastric tube, however here are a few tips. Check for patency every 4 hours Monitor output for amount, color, type Perform oral care Monitor nare/insertion site for redness, swelling, drainage, bleeding, or breakdown Irrigate nasogastric tube if necessary Maintain tube to suction if ordered so Monitor vital signs and assess respiratory and gastrointestinal Reposition and retape tube if necessary (McHale Wiegand & Carlson, 2005) Figure 33 Retrieved from Microsoft clipart program on 11/23/11. Figure 33 2/17/2019

Nasogastric Tube removal Wash hands and place gloves Cover patient with a towel Have a red biohazard bag prepared Gently remove the tape or holder from nose Withdraw tube gently and in one fluid motion Place tube in red bag Provide nasal care if necessary Place powder for gelatin in container of gastric secretions and also place in red bag Dispose of red bags appropriately (McHale Wiegand & Carlson, 2005) Figure 34 Figure 34 Retrieved from Microsoft clipart program on 11/23/11. 2/17/2019

Documentation Patient education placement and patient’s tolerance to procedure type and size of tube proof of placement removal nasogastric tube output in I/O charting What the output appears like and amount Nasal care Unexpected outcomes Any nursing interventions (McHale Wiegand & Carlson, 2005) Figure 35 Retrieved from Microsoft clipart program on 11/23/11. Figure 35 2/17/2019

Expected Unexpected Outcomes Outcomes “Decompression of the stomach Evacuation of the stomach and proximal small intestine Instillation of fluid, medications, or feedings Tube placement in to trachea, bronchus or esophagus Bleeding from nose, mouth, stomach, esophagus Vagal response Skin ulceration, sinusitis, esophageal-tracheal fistula, gastric ulceration, infection Vomiting Aspiration” Figure 36 and 37 Retrieved from Microsoft clipart program on 11/23/11. Figure 36 (McHale Wiegand & Carlson, 2005) Figure 37 2/17/2019

References Mchale Wiegand, D., Carlson, K. (2005). AACN Procedure Manual for Critical Care-Nasogastric Tube Insertion, Care, and Removal(5th ed.). St. Louis, MO: Elsevier Saunders. 2/17/2019