NG tube (nasogastric tube insertion)

Nasogastric tube (NG) insertion essentially involves placing a plastic tube in through the patient'snose and in to their stomach. The main purposes of this are for feeding/medication or for freedrainage. Often patients who have bowel obstructions will be kept nil by mouth and given an NGtube to drain the stomach content. While patient's that are very poorly in ITU who are unable to eatwill get a feeding tube to help maintain their nutritional status.

Wide bore NG (e.g Ryle’s)

Emptying of stomach content – secondary bowel obstruction

Fine bore NG

Nutritional input e.g patient NBM (fine bore)

Contraindication

  1. Basal skull fracture
  2. Facial/oropharyngeal trauma
  3. Caution in the following patients (d/w seniors):
  • oesophageal varices
  • coagulopathy.

Wash hands

Wash your hands using the Ayliffe technique

Introduce yourself

Introduce yourself and give your name and grade

“Hi, my name is Danny Archer and I am a 4th year medical student”

Check patient details

Clarify patients identity by confirming their name and asking for their DOB

Describe examination

Explain what examination you are performing and what this involves

Today I will be placing a small tube in through your nostril and in to your stomach.This will allow us to feed you via the tube in to your stomach. It should not be painful but may be a little uncomfortable. ”

Gain verbal consent

“Would this be okay with you?”

Equipment

  • Gloves+ Apron
  • NG tube ( appropriate size)
  • Lubricant jelly
  • Glass of water with straw
  • Bowl
  • Drainage bag
  • Adhesive tape

Pre-Procedure

  • Ensure adequate patient position - sat up in chair/bed.
  • Measure length of tube from nostril → angle of jaw → xiphisternum. This will give you an estimate of how far to insert.
  • Wash hands and glove up

Procedure

  • Lubricate NG with the jelly insert in to nostril,
  • Advance towards occipital region (back of head)
  • Continue to advance NG tube.
  • If slight resistance felt, advance in a twisting motion but do not force it if this doesn’t help.
  • Check in the patient’s mouth to ensure NG is not coiling up.
  • Once tube reaches the  back  of their throat,  ask them to take  a sip  and  advance  as they swallow.
  • Continue to the measured mark from earlier.
  • Secure with tape around nostril and attach drainage bag.

Confirmation

Method

Technique

CXR

Essential test for both types of NG. Tip has to be below the diaphragm and not either main bronchus. Confirmation needed before starting feeds. Get senior help if unsure.

Aspiration and pH test

pH of stomach usually <4. This method can be unreliable if patient on certain meds e.g PPI. Advises to get CXRs if in doubt as this method is not always reliable. (check local protocol)

Injecting air

Should not be used on its own to judge NG placement. Inject 20ml of air in to NG and listen over stomach. CXR still required for confirmation

Thank patient

Let the patient know you have finished examining them and thank them for their time. Be courteous.

That’s the end of the procedure. Thank you for your time.”

Accurate documentation

Document in the patient’s notes (most wards have NG stickers) Date, time, indication, location, complications and confirmation modality. It is important to inform the nursing staff NOT to use the NG until the CXR has been done and confirmation given, if awaiting xray.

Complications

  • Patient discomfort

  • Epistaxis

  • Oesophageal inflammation

  • Oesophageal/gastric perforation

  • Misplacement → Lungs.

Top Tips

  • Place NG in fridge for 20 minutes prior to procedure, this hardens it and makes it easier to pass.

  • If difficulty passing NG tube, consider passing it orally if the patient is unconscious (ITU).

  • After passing NG document this in notes including the type of tube, time passed and when position checked on CXR. Inform nursing staff as soon as satisfactory so they can start feeds.

  • Try the other nostril if unsuccessful at first.

  • Sometimes keeping the NG tube in the fridge helps stiffen them, making it easier to pass.

  • Add more lube!

  • Seek senior help if struggling.