Gastrointestinal Intubation

: Naso-gastric Tube Insertion

Angkatan 14

Pembimbing : drg. David Kamadjaja, Sp.BM

TYPES
 Types of Tubes
• Short tubes: passed through the nose into the
stomach
– Levin tube: range in size from 14 to 18 Fr, single
lumen made of plastic or rubber with holes near
the tip.
– Gastric Sump (Salem): is radiopaque, clear plastic
double lumen
 Types Cont.
• Medium Tubes: tubes are passed through the
nose to the duodenum and the jejunum.
Used for feeding
– Polyurethane or silicone rubber feeding tubes
have a narrower diameter (6 to 12fr) and require
the use of a stylet for insertion
• Long tubes: passed through the nose, through
the esophagus and stomach into the
intestines. Used for decompression of the
intestines.
 Types of NG tubes

Fine –bore feeding tube Ryle’s tube for gastric drainage

Feeding Draining
INDICATIONS
 Indications for GI Intubation
• To decompress the stomach and remove gas and fluid
• To lavage the stomach and remove ingested toxins
• To diagnose disorders of GI motility and other disorders
• To administer medications and feedings
• To treat an obstruction
• To compress a bleeding site
• To aspirate gastric contents for analysis
 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
 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
 Complications of NG feeding
• Aspiration
– due to feed regurgitation
– or incorrect tube placement
• Nausea & vomiting
– due to rapid feeding
– poor gastric emptying
• Diarrhoea
– Type of feed ie Jevity
– Gut infection
 Complications cont
• Constipation
– inadequate fluid intake
– immobility
– use of opiates
• Blocked tube
– 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
 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)
PREPARATIONS
 Measuring length of feeding tube

From bridge of nose to ear lobe to

bottom of xiphisternum
 Position of pt during insertion

Position the client in a sitting or high fowlers position. If comatose-semi fowlers.

 Equipment required

• Tray
• Fine bore with introducer / Ryle’s tube (14 or 16
Fr NG tube)
• Receiver
• Sterile water
• Glass of water
• 20ml syringe
• Tape (hypoallergenic) or commercial fixation
device
• Lubricating jelly
• Indicator strips ( pH fix, 0-6, Fisher scientific)
PROCEDURES
 Procedure
• Clinically clean procedure
• Wash hands and put on clean gloves
• 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 or commercial
device
• Check the position of the tube to confirm that it is in the
stomach by
– Check pH of aspirate
– 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.
Nasogastric Tube Position
EVALUATIONS
 Evaluation
• Observe client to determine response to procedure.

• ALERTS!!! Persistent gagging – prolonged intubation and

stimulation of the gag reflex can result in vomiting and
aspiration
– Coughing may indicate presence of tube in the airway.
 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
X-ray of misplaced NG tube
 Testing Placement
• Wash hands and put on clean gloves
• Draw up 30cc of air into the syringe and attach to end of the
NG tube. Flush tube with 30cc of air prior to attempting to
aspirate fluid. Draw back on the syringe to obtain 5 to 10 cc of
gastric aspirate.
• If unable to aspirate:
– Advance tube – may be in air space above aspirate level
– If intestinal placement suspected (pH 4-6) withdraw tube 5 to 10
cm
– Have client lie on his/her left side wait 10-15 mins and attempt
aspiration again.
 Document
• Date
• Time
• Type of tube inserted
• Reason
• Length inserted & how it is marked
• pH of aspirate
• Nursing instructions
Thank You…