Passing Naso-Gastric Tube and Tube Feeding (PEX 2.1.10)
Indications for Passing Naso-Gastric Tube:
- Unconscious patients.
- After operations in the mouth, pharynx or larynx.
- Obstruction or stricture of the oesophagus due to inflammation or tumour.
- Severe dysphagia (difficulty swallowing).
- Babies; too weak to feed or to suck.
- Severely burnt patients (due to increased metabolic needs or inability to take oral feeds).
- Mentally ill patient who cannot eat.
- In cases of persistent nausea and vomiting (to decompress the stomach or provide nutrition).
- Gastric lavage (washing out the stomach).
- Collection of gastric specimens.
Requirements:
Trolley (Top Shelf):
- Sterile naso-gastric tubes (appropriate size) in a bowl
- A bowl of warm water (to soften the tube)
- A gallipot with gauze swabs
- Orange sticks (or nasal speculum if needed for nostril inspection)
- Receiver (or kidney dish) with blue litmus paper
- Mackintosh cape and towel/dressing mackintosh
- A 10 ml syringe
- Spigot (or clamp)
- Cup of water (for rinsing patient's mouth)
- Vomit bowl (kidney dish)
- Strapping (adhesive tape to secure the tube)
- A receiver for used swabs/materials
Bedside:
- Hand washing equipment (access to sink, soap, water, towel)
- Screens (for privacy)
- Stethoscope (for checking placement)
- Patient's chart (for checking order and documentation)
- Waste receptacle
Procedure (Passing Naso-Gastric Tube):
| Steps | Action | Rationale |
|---|---|---|
| 1. | Observe the general rules. | Promotes adherence to standards and patient safety. |
| 2. | Assist the patient to be in a sitting up position or lateral position if unconscious but slightly raised to an angle of about 450. | Promotes patient ability to swallow during the procedure. |
| 3. | Explain the procedure to the patient (if conscious). Protect the patient's neck and chest with a mackintosh cape and towel. | To gain cooperation, reduce anxiety, and protect the linen from soiling. |
| 4. | Assess the patency of the nostrils and clean the nostrils using orange sticks or gauze. Identify the preferred nostril (usually the more patent one). | To facilitate easy passage of the tube and promote hygiene. |
| 5. | Wash hands and put on clean gloves. | Minimize the risk of infection. |
| 6. | Measure the required length of the tube which should be inserted. This should start from the tip of the nose to the ear lobe, and then down to the xiphoid process (chest bone). Mark the measured distance on the tube with a small piece of tape. | To ensure that the tube reaches the stomach. |
| 7. | Lubricate the tip of the tube (about 4-6 inches) with KY jelly or warm water. | For easy insertion and to prevent traumatizing the mucous membranes. |
| 8. | Select the clear nostril and insert the lubricated tube gently, directing it backward and downward. | To follow the natural passage and prevent trauma. |
| 9. | Once the tube reaches the nasopharynx (usually felt as resistance or gagging), ask the conscious patient to bend their head slightly forward (chin to chest) and swallow repeatedly (dry swallows or sips of water). Advance the tube as the patient swallows. | Swallowing closes the epiglottis over the trachea and helps guide the tube into the esophagus. Bending the head forward helps close the airway entrance. |
| 10. | If the patient coughs or shows signs of respiratory distress (cyanosis, inability to speak), the tube may be in the trachea. Withdraw the tube immediately, allow the patient to recover, and re-attempt insertion. | To prevent choking and aspiration. |
| 11. | Continue passing the tube until the measured length is reached. If there is any resistance, rotate the tube gently; avoid using force. | Forcing against resistance can cause trauma to mucosa and cause anxiety. |
| 12. | Secure the tube temporarily with tape while checking for placement. | To prevent displacement while confirming location. |
| 13. | Check to make sure the tube is in the stomach by: a. Aspirating stomach contents with a syringe and testing aspirates with blue litmus paper. If blue litmus paper turns red (acidic), it indicates that the tube is in the stomach. b. Injecting air (about 10-20 ml) using a syringe into the tube while listening over the stomach area with a stethoscope. A whooshing or bubbling sound should be heard as air enters the stomach. c. X-ray confirmation (most reliable method, especially for critical patients or those at high risk of aspiration). |
Aspiration of contents provides evidence of placement. Testing pH confirms the acidic environment of the stomach. Hearing air confirms the location in the stomach. X-ray is definitive. |
| 14. | Once placement is confirmed, secure the tube firmly to the patient's nose or cheek with adhesive tape, avoiding pressure points. Ensure the tape is not too tight. | Secures the tube in position and prevents dislodgement. |
| 15. | Clamp the end of the tube with a spigot or connect it to a drainage bag if the purpose is drainage or decompression. | Prevents leakage or allows continuous drainage. |
| 16. | Clear away the equipment and ensure the patient is comfortable. Wash hands. | Maintain cleanliness and patient comfort. |
| 17. | Document the procedure, including the date, time, type and size of tube, nostril used, measured length, method of placement confirmation, amount and characteristics of aspirate (if any), patient's response, and name/signature of nurse. | To promote follow up and ensure continuity of care. |
Points to Remember (Passing NG Tube):
- Never force the tube if resistance is met.
- Listen carefully for signs of respiratory distress during insertion.
- Always verify tube placement before administering anything through the tube.
- Change the tube as per policy or doctor's prescription (often weekly).
- Ensure a communication system (e.g., pen and paper, bell) is available for the patient if they cannot speak.
Feeding the patient using a naso-gastric tube (PEX 2.1.10 - Continued)
Naso-gastric feeding can be given in two ways:
- Intermittent feeding: Given at intervals as ordered by the doctor (e.g., four hourly).
- Continuous drip: Given as a continuous infusion over a specified period (e.g., 24-hour period).
Requirements (Feeding):
Trolley:
- Prepared feed (correct type, amount, and temperature)
- A feed bowl of warm water (if feed needs warming)
- A cup with warm water (for rinsing the tube)
- A 50 ml syringe barrel or a funnel with tubing and connection (appropriate for the tube)
- Vomit bowl (kidney dish)
- Mackintosh cape and towel/dressing mackintosh
- Stethoscope (for checking placement)
- Spigot or clamp
- Patient's chart
- Waste receptacle
Bedside:
- Hand washing equipment
- Screens (for privacy)
Procedure (Feeding):
| Steps | Action | Rationale |
|---|---|---|
| 1. | Observe the general rules. | Promotes adherence to standards and patient safety. |
| 2. | Assist the patient to be in a sitting up position or lateral position if unconscious but slightly raised to an angle of about 450 (or higher, up to 90 degrees for conscious patients). Ensure patient is comfortable. | Promotes patient ability to swallow (if conscious) and reduces the risk of aspiration during feeding. |
| 3. | Protect the patient's neck and chest with a mackintosh cape and towel. | To protect the bed linen and patient's clothing from spillage. |
| 4. | Wash hands and put on clean gloves. | Minimize the risk of infection. |
| 5. | Check tube placement and patency: a. Aspirate stomach contents and check pH with litmus paper (should be acidic, pH 1-4). b. Inject air (about 10-20 ml) while listening over the stomach with a stethoscope. c. Observe for signs of distress (coughing, cyanosis) during injection of air. d. Flush the tube with 10-20 ml of water to check patency and clear any obstruction. |
To confirm that the tube is still in situ in the stomach and is not blocked. |
| 6. | Prepare the feed. Ensure the feed is at the correct temperature (room temperature or slightly warmed in a warm water bath, 37°C-38°C). Check the feed amount as per order. | To ensure patient comfort and prevent discomfort or cramping. |
| 7. | Pinch the tube and remove the spigot. Connect the syringe barrel or funnel to the end of the NG tube. | To prevent air entry into the stomach. |
| 8. | Pour the warm water (about 10-20 ml) into the syringe barrel/funnel to prime the tube. Allow it to flow by gravity. | To ensure patency and clear any residual material. |
| 9. | Pour the prescribed feed slowly into the syringe barrel/funnel. Adjust the height of the syringe/funnel (usually about 12-18 inches above the patient) to control the rate of flow by gravity. Do not push the feed. | Allows gravity to facilitate flow and prevents overloading the stomach, reducing the risk of vomiting and aspiration. |
| 10. | As the level of the feed in the syringe barrel/funnel gets low, add more feed before it completely empties to prevent air from entering the stomach. | To prevent entry of air into the stomach which can cause discomfort and distension. |
| 11. | After the feed has run through, rinse the tube with a prescribed amount of warm water (e.g., 10-20 ml or as ordered) to clear any remaining feed. | Prevents clogging of the feeding tube. |
| 12. | Pinch the tube and remove the syringe barrel/funnel. Clamp the end of the tube with the spigot. | To prevent leakage and air entry. |
| 13. | Keep the patient in the upright or semi-upright position (at least 30-45 degrees) for at least 30-60 minutes after feeding. | To promote digestion and reduce the risk of regurgitation and aspiration. |
| 14. | Give the patient water to rinse the mouth and provide oral hygiene. | To stimulate secretion of saliva and promote oral hygiene and comfort. |
| 15. | Clear away the equipment and wash hands. | Maintain cleanliness and infection control. |
| 16. | Document the feeding, including the date, time, type and amount of feed given, amount of water for rinsing, patient's tolerance, any complications (e.g., nausea, vomiting, distension), and confirmation of tube placement method used. | Monitor input and output, ensure continuity of care. |
Points to Note (Feeding):
- Always verify tube placement before each feeding or medication administration.
- Never push feeds into the tube using the plunger of the syringe; allow gravity to control the flow rate.
- Keep the patient in a semi-Fowler's or Fowler's position during and after feeding.
- Monitor the patient for signs of intolerance such as nausea, vomiting, abdominal distension, diarrhea, or coughing.
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