Naso-gastric tube insertion Mem Van Beek Clinical Educator Bradford Teaching Hospitals AIM To enable the student to understand the principles of safe NG tube use. Objectives By the end of this session students should be able to: State: Types of NG tubes & their uses Indications for insertion Complications Legal aspect around NG tube insertion Insert a naso-gastric tube safely and competently Types of NG tubes Fine –bore feeding tube Feeding Ryle’s tube for gastric drainage Draining INDICATIONS FINE BORE NG TUBE Short term enteral feeding (4-6 weeks) Malnutrition Head & neck surgery Ca Head & neck / oesophagus Inadequate intake Oral cavity fistulae To prolong & sustain life INDICATIONS cont RYLE NG TUBE To drain gastric contents Abdominal distension Unconscious pt Major surgery Intestinal obstruction To stop vomiting & prevent aspiration Contraindications Head injury – basilar skull # Rhinorrhea –CSF Obstructing oesophageal ca Epistaxis Feeding above an obstruction Recent gastro oesophageal anastomosis Hx of nasal or sinus surgery occlusions Cautions Neck & buccal flap repair Laryngectomy Oesophageal ca Head & neck surgery Uncooperative pts Complications of NG feeding Aspiration Nausea & vomiting due to feed regurgitation or incorrect tube placement due to rapid feeding poor gastric emptying Diarrhoea Type of feed ie Jevity Gut infection Complications cont Constipation Blocked tube inadequate fluid intake immobility use of opiates inadequate or no flushing of tube administering meds via tube Unstable BMs ↑BMs esp with high carb feed ↓BMs esp if feed is stopped quickly or interupted Complications cont Deranged electrolytes- re feeding syndrome Fluid overload Intestinal obstruction Dislodged tube Weight loss/ gain Due to feed imbalances – poor regime Excoriation of skin around tube Risks associated with NG tubes Pneumothorax Coiling of tube in the throat Parotiditis Retropharyngeal Abscess Sinusitis Acid reflux Aspiration pneumonitis Severe sepsis (the most serious risk) Legal Aspect 2005 NPSA – 11 deaths due to misplaced NG feeding tubes Correct & clear documentation National & Local guidelines Measuring length of feeding tube From bridge of nose to ear lobe to bottom of xiphisternum Position of pt during insertion Equipment required Tray Fine bore with introducer / Ryle’s tube Receiver Sterile water Glass of water 20ml syringe Tape (hypoallergenic) Lubricating jelly Indicator strips ( pH fix, 0-6, Fisher scientific) Procedure Clinically clean procedure Wash hands Introduce self ID patient Gain informed consent Arrange a signal of communication Pt to sit in high Fowler’s position Prepare equipment Measure tube (as previously stated) & mark with tape. Procedure Lubricate tube Check for nostril patency Insert the rounded end of tube into the clearer nostril & slide it backwards & inwards along the floor of the nose to the nasopharynx. When tube reaches nasopharynx (back of throat), ask pt to sip & swallow some water using a straw. Advance the tube through the pharynx (as pt continues to swallow) till the predetermined mark has been reached If at any point pt shows signs of distress/ cyanosis – remove tube. Procedure Secure the tube to nostril & cheek with tape Check the position of the tube to confirm that it is in the stomach by Check pH Do X-ray of chest & upper abdomen NO OTHER METHODS ARE ACCEPTED (NPSA 2005) If position is correct; Mark the tube at the exit site & record the tube length in the notes remove guide wire from fine-bore tube & start feeding per regime Connect drainage bag to Ryle’s tube for free drainage or spigot for prn aspiration. Checking pH Flush the NG tube with 20ml of air – to clear any substance already in tube Aspirate 2ml of stomach content and test on pH strip. (blue litmus paper should not be used) pH should be ≤5.5 (acidic) If checking pH in tube already in place, wait 1hour after feed or medication as these can affect pH reading. If pH of >5.5 is obtained – & pt is asymptomatic send for X-ray REMEMBER DO NOT use the ‘whoosh’ test DO NOT use blue litmus paper DO NOT use absence of respiratory distress DO NOT monitor bubbling at end of tube DO NOT use appearance of fluid aspirate NPSA 2005 Document Date Time Type of tube inserted Reason Length inserted & how it is marked pH of aspirate Nursing instructions