NASOGASTRIC TUBE INSERTION

Diagnostic
o Diagnosis of trachea esophageal fistula. (with x ray).

Therapeutic and feeding

o Infants unable to oral feed due to poor suck or swallow reflexes
o Infants with respiratory problems
o To facilitate aspiration and deflation of the stomach
o Paralytic ileus, acute gastric dilation, intestinal obstruction.
Contraindications
Nasal fracture
Unilateral choanal atresia or stenosis
Oesophageal stricture

Contraindications
Nasogastric tubes are contraindicated in the presence of severe facial trauma
(cribriform plate disruption), due to the possibility of inserting the tube intracranially. In this
instance, an orogastric tube may be inserted.
omplications
The main complications of NG tube insertion include aspiration and tissue trauma. Placement of
the catheter can induce gagging or vomiting, therefore suction should always be ready to use in
the case of this happening. Minor complications include nose bleeds, sinusitis, and a sore throat.
Equipment:
All necessary equipment should be prepared, assembled and available at the bedside prior to
starting the NG tube. Basic equipment includes:
Personal protective equipment
NG/OG tube
Catheter tip irrigation 60ml syringe
Water-soluble lubricant, preferably 2% Xylocaine jelly
Adhesive tape
Low powered suction device OR Drainage bag
Stethoscope
Cup of water (if necessary)/ ice chips

Emesis basin
pH indicator strips

Equipments
Wt. Based criteria
Size 4-5F gauge for weight <1Kg
Size 5 for weight 1K 1.5Kg and
Size 6 for weight >1.5Kg
For babies > 3.5Kg you may consider using a size 8 tube

Determine length of tube to be inserted keeping tube in its packet, extend tip of tube from nose to outer aspect
of ear lobe and then from earlobe down to xiphisternum, aiming for the
space in the middle below the ribs; note the mark on the tube or keep your fingers on the
point measured.
More patent nostril is selected for passing the tube.
In neonates, lubrication of terminal part is done with water to prevent aspiration of oily substance.
Resistance is felt when it reaches the naso -pharynx, a slight twisting of the tube puts it into the nasopharynx.
Observe baby throughout procedure for colour change, vomiting, respiratory distress or resistance.
If it is observed, that means It indicates that the tube is in trachea.
Conformation of proper placement

Aspiration of stomach contents on applying suction by attaching a syringe on the outer end of the tube.
Air is injected in the tube, while the epigastric area is auscultated. A sound is heard if the tube is in stomach.
(Whoosh test)
By Radiography.

troduction

Introduce yourself
Confirm patient details Name / DOB
Wash hands

Explain procedure

At the moment youre having trouble swallowing food in the normal way and therefore we
need to place a fine tube through the nose going into the stomach, to enable you to receive
nutrition in the meantime

The procedure will be uncomfortable, but shouldnt be painful, and it wont take very long. If
at any point it becomes too uncomfortable and you want me to stop, let me know. You can tap
my arm, if you are unable to talk

Gain consent Are you ok to go ahead with the procedure?

Insertion of an NG tube is contraindicated in cases of head trauma where there are
concerns regarding base of skull fractures compromising the cribriform plate (as the tube
could potentially enter the intracranial space)

ertion of NG tube

4. Lubricate the tip of the NG tube

5. If available, a local anaesthetic spray can be used on the back of the throat
6. Insert the NG tube in through a nostril warn the patient prior

7. Gently advance the NG tube through the nasopharynx:

This is often the most uncomfortable part for the patient, so dont go too
slowly

If resistance is met, rotating the NG tube can help, however DO NOT force the
NG tube

If the patient is becoming distressed or gagging, pause to allow the patient to

relax

Its useful to look inside the patients mouth intermittently to ensure the NG
isnt coiling in there

8. Continue to advance the NG tube down the oesophagus

Ask the patient to take some sips of their water & swallow

This can help facilitate the advancement of the NG tube

However avoid giving patients a drink if their swallow is deemed unsafe

9. Once you reach the desired insertion length, fix the NG tube to the nose with a dressing

Lubricate the tip of the NG tube

Aspiration

10. Attempt to aspirate gastric contents:

If aspiration is successful, test the pH if <4 this suggests correct placement

If aspiration is unsuccessful or the pH is >4 the patient will require a CXR

Some hospitals require a CXR regardless of pH, so check your local guidelines

Acceptable pH ranges also vary between hospitals, so consult local guidelines

11. Once NG tube is deemed safe for feeding, the guidewire can be removed
12. Dispose of used equipment into a clinical waste bin
13. Wash hands
complete the procedure

Explain to patient that the procedure is over

Reassure that the NG tube will become more comfortable over the next few hours
Offer patient paper towels to clean face / nose

Document clearly the procedure of NG tube placement:

Your full name & medical grade

Procedural details & any complications

Aspirate pH (if you were able to aspirate anything)

CXR details if used e.g. NG tube visible dissecting the carina & sits below
the left hemidiaphragm

Outcome e.g. SAFE to commence feeding

Your signature, bleep/DECT number and GMC number

Inform nursing staff that the NG tube is inserted & safely positioned

Subject steps

1. Ensure that you have the following necessary equipment:

o

a sphygmomanometer

a stethoscope

hand cleansing gel

Equipment for measuring blood pressure

2. It is important when measuring blood pressure to build a rapport with your patient to
prevent White Coat Syndrome which may give you an inaccurately high reading.
Therefore, ensure you introduce yourself to the patient, explain the procedure answering
any questions they may have, and ask for their consent. You should also explain to them
that they may feel some discomfort as you inflate the cuff, but that this will be shortlived. Make sure they are sitting comfortably, with their arm rested.

Introduce yourself to the patient

3. As with all clinical procedures, it is vital that you first wash your hands with alcohol
cleanser and allow to dry.

Sanitise your hands using alcohol cleanser

4. Ensure that you have selected the correct cuff size for your patient. A different cuff size
may be required for obese patients or children.

Select the correct cuff size to suit your

patient

5. Wrap the cuff around the patients upper arm ensuring the arrow is in line with the
brachial artery. This should be determined by feeling the brachial pulse.

Ensure correct placement of the cuff

The brachial artery

6. Determine a rough value for the systolic blood pressure. This can be done by palpating
the brachial or radial pulse and inflating the cuff until the pulse can no longer be felt. The
reading at this point should be noted and the cuff deflated.

Inflate the cuff to determine a rough value

for the systolic blood pressure

7. Now that you have a rough value, the true value can be measured. Place the diaphragm of
your stethoscope over the brachial artery and re-inflate the cuff to 20-30 mmHg higher
than the estimated value taken before.
Then deflate the cuff at 2-3 mmHg per second until you hear the first Korotkoff sound
this is the systolic blood pressure.
Continue to deflate the cuff until the sounds disappear, the 5th Korotokoff sound this is
the diastolic blood pressure.

Record the true blood pressure

8. If the blood pressure is greater than 140/90, you should wait for 1 minute and re-check.
Please note, normal reading differ for diabetic patients.
9. Furthermore, you should explain to your examiner that you would want to check the
blood pressure standing to check for a significant drop (>20 mmHg after 2 minutes). This
would suggest a postural hypotension.
10. Finally, you should inform the patient of their reading, and thank them. If, after
rechecking, the blood pressure remains elevated advise the patient they will need this
repeated in future which ensures appropriate follow-up

ather equipment

Before you see the patient, ensure you have the appropriate equipment to perform blood
pressure measurement.

1. Stethoscope

2. Sphygmomanometer:

Ensure you have an appropriately sized cuff

A cuff too small may overestimate BP

A cuff too large will underestimate BP

troduction

Introduce yourself state your name and role

Wash hands with the appropriate 7 stage technique

Explain the procedure:

I will be measuring your blood pressure
This will involve inflating a cuff around your arm briefly and listening to your pulse with a
stethoscope
It shouldnt be painful, but it may feel a little uncomfortable temporarily

Check understanding Does everything Ive said make sense? Do you have any questions?
Gain consent Are you happy for me to record your blood pressure?
Check the patient has a preference as to which arm to use e.g. avoid arms with post
mastectomy lymphoedema
taching the cuff

Ensure the cuff size appears appropriate

Wrap the cuff around the patients upper arm
Line up the cuff marker with the brachial artery slightly medial to the the biceps brachii
tendon
easuring the blood pressure
Estimate an approximate systolic blood pressure

1. Palpate the radial pulse

2. Inflate the cuff until you can no longer feel this pulse
3. Note the reading on the sphygmomanometer
This is a rough estimate of the systolic blood pressure
easure the blood pressure accurately

1. Place your stethoscopes diaphragm over the brachial artery

2. Re-inflate the cuff to 20-30 mmHg above your approximate systolic BP measured earlier

3. Begin to slowly deflate the cuff around 2-3 mmHg per second

4. Listen carefully and at some point you will begin to hear a thumping pulsatile noise:

This is known as the 1st Korotkoff sound

The pressure at which this 1st sound is heard is the systolic blood pressure

Continue to deflate the cuff, continuing to listen until the sounds completely disappear:

The point at which you hear the last sound is referred to as the 5th Korotkoff sound

This is the diastolic blood pressure

6. If the patient is noted to be hypertensive (>14o/90) or hypotensive you should re-check

the blood pressure after 2 minutes to confirm this is an accurate result (use the other arm
and reconsider if the cuff size is appropriate)
o complete the procedure

Document the blood pressure recordings in the patients notes

Explain the need for follow up if hypertensive BP monitoring / antihypertensives
Thank patient
Wash hands