Nasogastric Tube

Feeding
Nutrition - is what a person eats and how the body uses it.
Nutrients are organic and inorganic substances found in
foods that are required for body functioning. Adequate
food intake consists of a balance of nutrients: water,
carbohydrates, proteins, fats, vitamins, and minerals.
-three major functions: providing energy for body
processes and movement, providing structural material for
body tissues, and regulating body processes.
 Enteral Nutrition
(EN), also referred to as total enteral nutrition (TEN), is
provided when the client is unable to ingest foods or
the upper gastrointestinal tract is impaired and the
transport of food to the small intestine is interrupted.
Enteral feedings are administered through nasogastric
and small-bore feeding tubes, or through gastrostomy
or jejunostomy tubes.
Enteral Assistive Devices:

1. A nasogastric tube is inserted through one of the

nostrils, down the nasopharynx, and into the alimentary
tract. Traditional firm, large-bore nasogastric tubes (i.e.,
those larger than 12 Fr in diameter) are placed in the
stomach. Examples:

Levin tube, a flexible rubber or plastic, single-lumen tube

with holes near the tip

Salem sump tube, with a double lumen

 are used for feeding clients who have adequate gastric
emptying, and who require short-term feedings.

They are not advised for feeding clients without intact

gag and cough reflexes since the risk of accidental
placement of the tube into the lungs is much higher in
those clients.
Levin tube
Salem Tube
2. nasoenteric (nasointestinal) tube- a longer tube
than the nasogastric tube (at least 40 cm [15.75 in.] for
an adult) is inserted through one nostril down into the
upper small intestine.

used for clients who are at risk for aspiration. Clients

at risk for aspiration are those who manifest the
following:

Decreased level of consciousness

Poor cough or gag reflexes
Inability to participate in the procedure

Restlessness or agitation.
3. Gastrostomy and jejunostomy devices are used for
long- term nutritional support, generally more than 6 to 8
weeks. Tubes are placed surgically or by laparoscopy
through the abdominal wall into the stomach
(gastrostomy) or into the jejunum (jejunos- tomy).
Materials:
NGT tube
Non-allergenic adhesive tape, 2.5 cm (1 in.) wide
Sterile gloves
Water-soluble lubricant
Facial tissues
Bulb syringe
Stethoscope
Implementation:

Assist the client to a high Fowlers position if his

condition permits, and support the head with a pillow.

Rationale: It is often easier to swallow in this position and

gravity helps the passage of the tube.

Place a towel or a disposable pad across the chest.

 Prior to performing the insertion, introduce self and verify the
clients identity. Explain the procedure.

Perform hand hygiene and wear gloves. Provide for client

privacy.

Assess the clients nares for any obstructions or deformities.

Determine how far to insert the tube. Use the tube to mark
off the distance from the tip of the clients nose to the tip of
the earlobe, to the tip of the xiphoid.
Rationale: This length approximates the distance from
the nares to the stomach.

Mark this length with adhesive tape if the tube does not
have markings.

Insert the tube. Lubricate the tip of the tube by a water

soluble lubricant to ease insertion.

Rationale: A water soluble lubricant dissolves if the tube

accidentally enters the lungs.
 Ask the client to hyperextend the neck, and gently
advance the tube toward the nasopharynx.

Rationale: Hyperextension of the neck reduces the

curvature of the nasopharyngeal junction.

If the client gags and the tube does not advance with
each swallow, withdraw it slightly and inspect the throat by
looking through the mouth.

Rationale: The tube may be coiled, if so, withdraw it until

it is straight and insert it.
 Check correct placement:
Aspirate stomach contents
Place a stethoscope over the clients epigastrium and
inject 10-30 ml of air into the tube while listening for a
whooshing sound

Most reliable way is through xray

 Secure the tube by taping it to the bridge of the clients nose.
If the client has oily skin, wipe the nose first with alcohol
to defat the skin.
Cut 7.5 cm (3 in.) of tape, and split it lengthwise at one
end, leaving a 2.5-cm (1-in.) tab at the end.
Place the tape over the bridge of the clients nose, and
bring the split ends either under and around the tubing, or
under the tubing and back up over the nose. Ensure
that the tube is centrally located prior to securing with
tape to maximize air flow and prevent irritation to the side
of the nares. Rationale: Taping in this manner prevents
the tube from pressing against and irritating the edge of
the nostril.
 Secure the tube to the clients gown.
Loop an elastic band around the end of the tubing,
and
attach the elastic band to the gown with a safety pin.
or
Attach a piece of adhesive tape to the tube, and pin
the tape to the gown. Rationale: The tube is
attached to prevent it from dangling and pulling.
 Document relevant information: the insertion of the
tube, the means by which correct placement was
determined, and client responses (e.g., discomfort or
abdominal distention).
Removing an NGT
 Confirm the primary care providers order to remove the
tube.

Assist the client to a sitting position if health permits.

Place the disposable pad or towel across the clients chest
to collect any spillage of secretions from the tube.
Provide tissues to the client to wipe the nose and mouth
after tube removal.
 Prior to performing the removal, introduce self and
verify the clients identity . Explain to the client what you
are going to do, why it is necessary, and how he or she
can participate. Discuss how the results will be used in
planning further care or treatments.
Perform hand hygiene and wear clean gloves. Provide
for client privacy.
Unpin the tube from the clients gown.
Remove the adhesive tape securing the tube to the
nose.
 Ask the client to take a deep breath and to hold it.
Rationale: This closes the glottis, thereby preventing
accidental aspiration of any gastric contents.
Pinch the tube with the gloved hand. Rationale: Pinching
the tube prevents any contents inside the tube from draining
into the clients throat.
Smoothly, withdraw the tube.
Place the tube in the plastic bag. Rationale: Placing the
tube immediately into the bag prevents the transference of
microorganisms from the tube to other articles or people.
Observe the intactness of the tube.
 Ensure client comfort.
Provide mouth care if desired.
Assist the client as required to blow the nose. Rationale:
Excessive secretions may have accumulated in the nasal
passages.
Dispose of the equipment appropriately.
Rationale: Correct disposal prevents the transmission of
microorganisms.
Remove and discard gloves. Perform hand hygiene
Document all relevant information.
 Enteral Feedings
the type and frequency of feedings and amounts to be
administered are ordered by the primary care provider.
Liquid feeding mixtures are available commercially or may
be prepared by the dietary department in accordance with
the primary care providers orders.
Enteral feedings can be given intermittently or continuously.
Intermittent feedings are the administration of 300 to 500 mL
of enteral formula several times per day. Bolus intermittent
feedings - use a syringe to deliver the formula into the
stomach. Because the formula is delivered rapidly by this
method, it is not usually recommended but may be used in
long-term situations if the client tolerates it.
Enteric Feeding Pump
 PLANNING
Before commencing a tube feeding, determine the type, amount, and
frequency of feedings and tolerance of previous feedings.

Equipment

Measuring container from which to pour the feeding (if using open
system)

Water (60 mL unless otherwise specified) at room temperature

Feeding pump as required /Asepto-syringe

Correct formula /feeding solution

Stethoscope
 IMPLEMENTATION
Preparation

Assist the client to a Fowlers position (at least 30 degrees elevation) in bed or
a sitting position in a chair, the normal position for eating. If a sitting position is
contraindicated, a slightly elevated right side-lying position is acceptable.
Rationale: These positions enhance the gravitational flow of the solution and
prevent aspiration of fluid into the lungs.

Performance
Prior to performing the feeding, introduce self and verify the clients identity
.Explain to the client what you are going to do, why it is necessary, and
how he or she can participate. Inform the client that the feeding should not
cause any discomfort but may cause a feeling of fullness.
Perform hand hygiene
 Provide privacy for this procedure if the client desires it.
Tube feedings are embarrassing to some people.
Assess tube placement.
Assess residual feeding contents by aspirating all stomach
contents and measure the amount before administering the
feeding. Rationale: This is done to evaluate absorption of the
last feeding; that is, whether undigested formula from a
previous feeding remains. If 100 mL (or more than half the last
feeding) is withdrawn, refer first to inter/resident on duty.
 Rationale: At some agencies, a feeding is delayed
when the specified amount or more of formula remains
in the stomach.

Reinstill the gastric contents into the stomach if this is

the agency policy or primary care providers order
Rationale: Removal of the contents could disturb the
clients electrolyte balance.

If the client is on a continuous feeding, check the

gastric residual every 4 to 6 hours or according to
agency protocol.
 Administer the feeding.
Before administering feeding:
Check the expiration date of the feeding.
Warm the feeding to room temperature. Rationale:
An excessively cold feeding may cause abdominal
cramps.
When an open system is used, clean the top of the
feeding container with alcohol before opening it.
Rationale: This minimizes the risk of contaminants
entering the feeding syringe or feeding bag.
Syringe (Open System)

Remove the plunger from the syringe and connect the

syringe to a pinched or clamped nasogastric tube.
Rationale: Pinching or clamping the tube prevents
excess air from entering the stomach and causing
distention.
 Add the feeding to the syringe barrel.
Permit the feeding to flow in slowly at the prescribed
rate. Raise or lower the syringe to adjust the flow as
needed. Pinch or clamp the tubing to stop the flow for a
minute if the client experiences discomfort. Rationale:
Quickly administered feedings can cause flatus,
cramps, and/or vomiting.
 If another bottle is not to be immediately hung, flush the
feeding tube before all of the formula has run through
the tubing.

Instill 30 mL of water through the feeding tube or

medication port. Rationale: Water flushes the lumen of
the tube, preventing future blockage by sticky formula.
 Be sure to add the water before the feeding solution
has drained from the neck of a syringe or from the
tubing of an administration set. Rationale: Adding the
water before the syringe or tubing is empty prevents
the instillation of air into the stomach or intestine and
thus prevents unnecessary distention.

Clamp the feeding tube before all of the water is

instilled. Rationale: Clamping prevents air from entering
the tube.
 Ensure client comfort and safety.
Secure the tubing to the clients gown. Rationale: This
minimizes pulling of the tube, thus preventing
discomfort and dislodgment.

Ask the client to remain sitting upright in Fowlers

position or in a slightly elevated right lateral position for
at least 30 minutes. Rationale: These positions
facilitate digestion and movement of the feeding from
the stomach along the alimentary tract, and prevent the
potential aspiration of the feeding into the lungs.
 Administering a Gastrostomy or Jejunostomy Tube
Feeding

Prior to performing the feeding, introduce self and verify

the clients identity. Explain to the client what you are
going to do, why it is necessary, and how he or she can
participate. Discuss how the results will be used in
planning further care or treatments.

Perform hand hygiene and observe.

Provide for client privacy.
Assess and prepare the client.
 Determine correct placement of the tube by
aspirating secretions .
Remove the tube clamp. Insert the bulb syringe to
the end of the tube, then pour 30 mL of water into the
syringe. Allow the water to flow into the tube.
Rationale: This determines the patency of the tube.
If water flows freely, the tube is patent.
If the water does not flow freely, notify the nurse in
charge and/or primary care provider.
 Administer the feeding.
Hold the barrel of the syringe 7to15cm(3to6in.)
above the ostomy opening.
Slowly pour the solution into the syringe and allow it
to flow through the tube by gravity.
Just before all of the formula has run through and the
syringe is empty, add 30 mL of water. Rationale: Water
flushes the tube and preserves its patency.
 Remove the bulb syringe, and then clamp or plug the
tube to prevent leakage. Ensure client comfort and
safety.
Assess status of periostomal skin. Rationale: Gastric
or jejunal drainage contains digestive enzymes that can
irritate the skin. Document any redness and broken
skin areas.
 Observe for common complications of enteral feedings:
aspiration, hyperglycemia, abdominal distention,
diarrhea, and fecal impaction. Report findings to
primary care provider. Often, a change in formula or
rate of administration can correct problems.
MANAGING CLOGGED FEEDING TUBES

Even if feeding tubes are flushed with water before and

after feedings and medications, small bore tubes still
become clogged in about 35% of cases from medications.
This can occur when the feeding container runs dry, solid
medication is not ade- quately crushed, or medications
are mixed with formula.

To prevent clogged feeding tubes, flush liberally (at least

30 mL water) before, between, and after each separate
medication is instilled.

**
 Do not exert pressure into the tube--can rupture the
tubeespecially small-bore feeding tubes.

Do not add medications to formula or to each other

because the combination could create a precipitate that
clogs the tube.