Clinical Procedures - Nasogastric Tube Insertion Indications • Feeding in patients with poor swallow (e.g. post cerebrovascular accident) • Lavage of gastric contents in poisoning • Postoperative for stomach decompression • Bowel obstruction. Contraindications • Oesophageal stricture, obstructing tumour • Tracheo-oesophageal fistula • Achalasia cardia • Deviated nasal septum • Fractured base of skull Risks • Malpositioning in a lung • Trauma to the nasal and/or pharyngeal cavities • Perforation of esophagus. Procedure Tips •Medications such as proton pump inhibitors and acid suppressing drugs may elevate the pH of the aspirate giving a 'false-negative result. If in doubt, request a chest radiograph before using • Low pH-fluid may also be aspirated from the lung in cases of aspirated stomach contents. If in doubt, request a chest radiograph before using • Chest radiography should be performed routinely in high-risk patients (those that are unconscious, intubated or have poor swallow) • The absence of cough reflex does not rule out misplacement of the tube in the airways • Auscultation for gurgling in the stomach is not a recommended method for confirming position. Equipment • Lubricant (e.g. Aquagel®) • pH-testing strips • 50mL syringe • Gallipots • Dressing pack • Nasogastric tube (12-18 French size) • Hypoallergenic tape • Sterile gauze • Gloves • Disposable bowl. Procedure • Introduce yourself, confirm the patient's identity • Explain the procedure to the patient, stating that it may be uncomfortable and can cause gagging, which is transient • Make sure that the patient understands the procedure and agree a signal to be made if patient wants to you stop (e.g. raising hand) • To estimate the length of the tube required, measure the distance from the bridge of the nose to the tip of the earlobe and then to the xiphoid process • Position the patient semi-upright: • If unconscious, place the patient on their side • Check the patency of the nostrils and select a suitable side • Wash hands and put on gloves • Unwrap the tube and lubricate the tip by wiping it through a blob of lubricating gel • Insert the tip of the tube in the nostril and advance the tube horizontally along the floor of the nasal cavity in a backward and downward direction • As the tube passes into the nasopharynx, ask the patient to swallow if they are able to do so: • Using a cup of water and straw often helps here • If there is any obstruction felt during advancement, withdraw and try in the other nostril • © Watch for any signs of distress; namely cough or cyanosis and remove the tube immediately if any of these occur • Once the tube has reached the measured distance, secure it in place with the tape: • The gastro-oesophageal junction is generally 38-42cm from the nostril so advancement of the tube 55-60cm from the nostril usually positions the nasogastric tube tip within the stomach. • Aspirate a sample of fluid using a syringe • Place the aspirate on a pH-testing strip: • D A pH of 5.5 or less suggests that the tube is in the stomach • If no aspirate obtained, change position and try again. If still unsuccessful, perform chest radiography to confirm position: • Be sure to leave the internal wire in the tube if you are sending the patient to x-ray. The tube itself is not radio-opaque and will be invisible on the resultant image • Once satisfied that the tube lies within the stomach, remove the inner wire and secure the tube to the tip of the nose: • It is sometimes helpful to curve the remainder of the tube towards the ear and secure to the cheek also. Documentation • Date, time, indication, informed consent obtained • Size of tube inserted • Length of tube internally (there are markings on the tube: • This is important to allow other staff to assess whether the tube has moved in or out since insertion • Method by which correct placement was confirmed • Any immediate complications • Signature, printed name, and contact details.
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