Skill Nasogastric tube insertion

Increased awareness of how to

Learning
outcomes • safely place a nasogastric tube into a patient

• ensure correct location of a nasogastric tube

All foundation Scheme doctors should be able to perform this procedure.

Placement of a nasogastric tube is a common procedure in both surgical
and medical patients. By inserting a nasogastric tube, you are gaining
access to the stomach and its contents. This enables you to drain gastric
contents, decompress the stomach, obtain a specimen of the gastric
contents, or introduce a passage into the GI tract. Nasogastric tube
insertion is a common procedure and usually occurs without incident.
However, there is a small risk that the nasogastric tube can become
misplaced in the mouth, upper oesophagus or the lungs during insertion,
Background or move out of the stomach at a later stage. It is therefore of paramount
importance that all students are aware of methods of how to demonstrate
the correct location of a nasogastric tube. Nasogastric tubes are
contraindicated in patients who have severe facial trauma or a basal skull
fracture. The concern here is that the tube may be inserted intracranially.
In this instance, an orogastric tube may be inserted. Caution should also
be taken in patients who i) have had recent oesphageal surgery 2)
Oesphageal strictures 3) Oesphageal varices. With regards to nasogastric
tube insertion - all practitioners should adhere to local guidelines and
policies in the health care trust that they work for.

Procedure

Introduction
and consent Introduce yourself to the patient and identify their correct details. Explain
 the procedure to the patient and gain their consent.

Ideally the patient should be lying

in bed.

If possible, sit the patient upright

for optimal neck/stomach
Patient
alignment.
position

Examine the nasal passages for

any deformity/obstructions - in
order to determine the best side
for insertion.

You will require:

• 50ml catheter tip syringe

• Water soluble lubricant
Equipment • pH testing paper
• Appropriate NG tube
• Tape
• Emesis basin

• Cup of water

Wash your hands and don a set of gloves. If you suspect the risk of
Infection
vomiting is high, you should consider wearing face and eye protection as
control
well as a disposable apron.
 With the nasogastric tube -
measure from the patients nose to
their earlobe and then to the
epigastric region.

Measure
required
length of
nasogastric
tube

Mark this measured length with a

marker or note the distance.

Lubrication Lubricate the first 4 cms of the

nasogastric tube with a water
based lubricant.

Also apply gel to meatus of the

nostril that you have selected to
 insert the nasogastric tube in.

Passing the Pass the nasogastric tube into the

NG tube nasal meatus.

Encourage the patient to swallow

(e.g. sip a glass of water) and
advance the tube as the patient
swallows. Swallowing enhances
the passage of tube into the
oesophagus. Never force the NG
tube. Withdraw the tube
immediately if the patients
demonstrates any signs of
respiratory distress.

Continue to pass the tube until the

required length has been inserted.
Checking for Checking for the placement of the
placement of nasogastric tube should always
NG tube take place:

• After initial insertion

• Before administering each
feed
• Before giving medication
via the NG tube
• At least once daily during
continuous feeds
• Following any episode of
vomiting or coughing
• If you suspect the
nasogastric tube has
moved (e.g. loose tape or
the tube appears longer)

Check for placement of the

nasogastric tube by aspirating a
sample with a 50ml syringe.Test
the pH of the aspirate with litmus
paper. Gastric contents should
have a pH below 5(there are no
known reports of pulmonary
aspirates at or below 5). It is
important that the resulting colour
change is easily distinguishable.
One of the limitations of testing the
pH is that stomach pH can be
affected by medication (e.g.
 antacid medication) Therefore you
should always enquire if the
patient is on any medication.

Ensure that the patient is not in

any respiratory distress and are
able to speak.

CAUTION : If there is ANY query

about the position of the NG tube -
no feeding or administration of
medication should take place.
Xray
The most accurate method for confirming the correct placement of a NG
tube is radiography. A xray is not required routinely to confirm correct
placement. If it is not possible to obtain an aspirate or if the pH of the
gastric contents is above 5 an xray is required. If you are unable to see the
NG tube tip clearly below the diaphragm do not allow the NG tube to be
used until the xray has been reviewed by an experienced doctor.
 Example of a CXR showing the placement of a NG tube in the
stomach
(Produced with the kind permission of Dr Ian Bickle)

Confirmation of correct position on a CXR should include:

• A Subdiaphragmatic location to the tube tip.

• The tube clearly separate from the airway in its descent through the
thorax into the abdomen.

Below is an example of an NG tube misplaced down the patients right

segmental bronchus.
 Example of a CXR showing a misplaced NG tube
(Produced with the kind permission of Dr Ian Bickle)

Secure the nasogastric tube with

Secure the
tape. Record the distance NG tube
NG tube
inserted in notes

Finish Thank the patient; correctly dispose of clinical waste and wash your hands.

Record
 Document

• date and time of procedure

• indication for insertion
• type and length of tube used
• the nature of the aspirate
• methods used to check location of the tube insertion

• any procedural comments

National Patient Safety agency - Reducing the harm caused by misplaced
nasogastric tubes
Useful links
Video on NG insertion from the New England Journal of Medicine (only
available if subscribed to NEJM - e.g. Queen's Online)

Return to top Skill resource Main page

Page kindly reviewed by

Dr Danny McAuley
Clinical Senior Lecturer,
Medicine & Therapeutics

Dr MK Traynor
Head of Division (UGNS)
Undergraduate Nursing Sciences
School of Nursing and Midwifery
Queen's University Belfast

&

Dr Ian Bickle
SpR in Radiology
North Trent Radiology
Specialist Registrar scheme

Page last updated 3/11/06