Nasogastric (NG) Tube Insertion (Nursing)

00:00 Now before insertion, let's look at a few key points. We always want to remember to perform our hand hygiene, provide privacy for our patient. So I will tell you, this is not the most pleasant procedure when you insert a nasogastric tube. So you want to make sure you provide the patient as much privacy and comfort as possible, and really be thorough about explaining the procedure to the patient. As a nurse, be honest, let them know "Hey, this is going to be uncomfortable and this is what's going to happen." Now, next, we want to raise the bed to the appropriate position. We also want to make sure we help the client to an upright position, so about at least 45 to 90 degrees. Now the higher the bed, the easier the insertion's going to be. Also, get a baseline idea of what the patient's GI status is going to be and how they feel before you insert the NG tube. What you're going to need is your nasogastric tube and so you're going to have to choose here depending on the need for your patient. So here we have a Salem samp, for example. You're going to need absorbent pad or maybe a towel and also a securement device. Now, it's really important that anytime that you put something into a patient like insertion of a Foley catheter or like a nasogastric tube we're doing here, you want to use a water soluble or lubricating jelly for comfort for your patient. We want a clean piston syringe, and we're also going to need a cup of water if it's not contraindicated for our patient. So this is important because we're going to help use this to help the patient swallow for advancing of the tube. So before we get started, we want to perform our hand hygiene and put on our gloves. Now, next it's really important to assess the client's nasal cavity. Now, this is important because maybe your patient has some facial trauma or maybe they have a deviated septum. So we want to look at each nare and to see which one is best to attempt to insert our NG tube. Now, we've got to determine the insertion length of the NG tube. You're going to take the tip of that nasogastric tube, put it to the tip of your patient's nose then you're going to stretch it across to their earlobe and then all the way down to their xiphoid process. Now just for safety, I usually go a few centimeters pass the xiphoid process. It's really better to go a little long than to be short.

02:29 Now, after we've done this, we can drape and absorb by pad or maybe a towel over the client's chest. Then we want to make sure we lubricate the tip of the nasogastric tube. This is going to be really key to help with insertion and make it much more smooth and comfortable for your patient. So once we've lubricated the tip of our nasogastric tube, have the client position their head straightforward. So then we want to take the distal tip of that nasogastric tube and insert it into their nostril. Now once that occurred, you want to teach your patient to position their chin to their chest like so. So this is really going to help advance that tube pass the back of the mouth into the throat and not into the trachea. Now once we reached to the back of the mouth, we can then have the client swallow through air or take a drink of water and help swallow to facilitate the movement of that tube further down the esophagus. Now, this is really key here. If the patient begins coughing or if the tube coils in the back of the throat, we need to stop the procedure. Now, here I like to take a penlight, for example and look in the back of a patient's throat making sure that if it coils or if I catch that early I can stop the procedure for the patient. Now, if it goes smoothly and there's no coughing or no gagging, we can continue to advance that nasogastric tube to the predetermined length. Now, one thing to know when advancing, if you go really slow it's just really dragging on the procedure. So if that nasogastric tube is going down, go quickly and keep going and advancing the tube. Now once that's done, you can secure the tube using a securement device of whatever your agency has to the correct insertion length. So once we've secured the tube, we want to confirm the tube placement by aspirating gastric contents with our piston syringe. Next, we need to obtain an order for an x-ray to verify the exact placement and positioning of our nasogastric tube. I'm going to show you how to insert a nasogastric tube. So before we get started, I'm going to perform my hand hygiene.

04:54 Alright, and I mean go ahead and put on my gloves. So one thing to note about nasogastric tube insertion - because we're through the GI tract, this is not a sterile procedure.

05:06 I know you may see some things that are in a package but just again note the GI tract is not a sterile environment. So this is helpful for you to know as a student. And at this point, I've already explained the procedure to my patient. I also let them know that when you insert a nasogastric tube, it is not the most comfortable procedure, so be really honest about this when you're approaching your client about it. Alright, so next let's go ahead and assess the client's nasal cavity. So when I do this, I'm going to look at each nare of our patient. You can even take your penlight for example, take a look up there, ask the patient if they have a deviated septum or any issue on one side or the other. The other thing you can do is have the patient close one nostril and blow, and see which one has a stronger airflow for example. So once we've assessed the patient's nasal cavity, I'm going to determine the insertion length of our nasogastric tube. Alright, so let's take a look at the equipment that we've got here. I've got a little tape for marker here. I've got our lubricant, I've got our piston syringe, I've also got a nasogastric securement strip, our nasogastric tube, and I'm using the Salem samp today, also my penlight for zip visualization, and sometimes if you need to look inside the patient's mouth it's handy to have maybe like a tongue depressor so you push down their tongue and take a look inside their mouth. So if you have some help any time you place a nasogastric tube, it's always great to have a second set of hands.

06:53 Okay, let's take out our nasogastric tube. So I want to show you a few things before we get started. So you're going to see this tip of the nasogastric tube. So this is our distal tip. The other thing I want to show you is here is that air vent port that we talked about earlier.

07:11 Now, this piece here has our little bit of adaptor and this is here to put suction down, for example, or hook to suctioning. We also can put our piston syringe here for feedings, medication delivery for example. When we're using a Salem samp tube, now the smaller blue lumen serves as the air vent. Now we also call this the samp port or the pigtail. And this is what allows atmospheric air to continually flow into the stomach. Now when I said that we weren't going to do anything with the smaller blue air vent, what I mean by this is that we don't connect that air vent to suction or use it to flush liquids or put anything down that air vent. Now a great pro tip is that the blue pigtail or the air vent should be positioned above the level of the stomach. This is going to help to avoid back flow of stomach secretions. Now, many times we're going to use an anti-reflux valve and this is attached to the blue pigtail to prevent gastric contents from sipping out. Okay. So, and remember I've got clean gloves, this is open, this is not a sterile procedure. So, I've got my nasogastric tube here. Okay, so now we've taken a look at our tubing, let me show you how to measure.

08:40 So, I'm going to take this distal tip here and I'm going to take it to the tip of the patient's nose. So we're going to take it to the tip, we're going to take it to the side of the earlobe, and then I'm going to take my measurement and go down and feel and palpate where his xiphoid process is and if you want to it's always a good idea just to go a few centimeters over. The reason why I do this like I spoke about earlier is that it's always better to go a little farther down because that's much less risk for aspiration. Okay, so a couple of tips once you measure the length. It's really important for you to mark this. So every nurse has a preference. You can use a black marker, it's a really great idea permanent marker. That way we know exactly where the insertion piece should be. Also another little tip, if you will take a piece of tape on insertion and you wrap it around where the insertion point should go, doesn't have to be neat, then when you're inserting you know exactly where to stop.

09:41 So this is really helpful in the meantime. And obviously once you're inserting, you can take this off as well. Okay, so now that we've measured this, we're ready to go. So we've got the measuring of this. The other thing is I want to make sure my client is comfortable. Notice that the patient's head of bed is up at least past 45 degrees. If they can tolerate it, 90 degrees is even better. The other thing is know that there are secretions, we're going to be going down the nasal cavity so I'm going to protect my patient as well and put absorbent sheet over him. That way if they cough or sputter, or anything like that we don't get it on their gown. Okay. So now that's set. So now I'm going to prepare my equipment and I'm going to lubricate the tip of my nasogastric tube. So, you may see a nurse lubricate like stick the tube down into the surgical lubricant, but I just want to be extra nice as a nurse and make sure this is really well lubricated. This is going to help for much more easier advancement if you will to the tube. And I'm just going nice down the tube and make sure that's nice and lubricated. May seem a little excessive but it definitely helps provide comfort for your patient. Okay, and before I start that, I'm going to go ahead and get my nasogastric strip ready. This is going to help secure when I'm ready, and once I've placed the nasogastric tube. Okay. And you're going to see why that's important here in a bit.

11:20 Okay. So I think we've got our lubricant, we've got that ready. Okay, so now I can go ahead and insert. So again, I've explained the procedure to my patient. So when I do this, I want to make sure my patient's head is tilted forward. It's never a bad idea to put your hand behind the patient sometimes. They're going to naturally resist you when you insert the nasogastric tube. But I don't think this guy's going to resist me much. Alright, so here's our nasogastric tube, I'm taking the tip and I'm going to go down this nare. So once I insert and I start feeding it in, this is a good time to have the patient chin-to-chest so I'm going to move his chin-to-chest and then I'm going to advance the tube because remember we're trying to make sure we get down to the back of the throat. And we're going to advance the tube. So notice, I'm going in a very pretty smooth situation. Right? I didn't take too slow, it advanced smoothly so I'm going to keep going. Now you see here why I like to mark that tube because without having to watch I can just keep going if my patient can tolerate it. Now, here is what I like to do before I lose my tube. I want to secure it. So this is where the securement strip comes in. It's a little hard, it's going to go around their nose, take off the securement strip and my measuring tape. So notice the whole time I'm doing this, I'm not letting go of the nasogastric tube and the reason why I don't want to do this, I don't want to lose placement. Okay, so now I've gotten that done. I'm going to place this on top of my tube and I'm going to wrap the wings around. Okay, so now this is secured. So again, this is why I like to secure my tube first because then I can check on my patient, I can make sure I look at them, make sure everything looks alright. And that way when I check for placement, I'm not having to fumble around and not lose my tube. Okay, so now that I've done this, the next thing that I can do is check for gastric contents and make sure it's in the right place. So when I do this, I'm going to take off my filter, now your hands maybe a little slippery from the lubricant. I'm going to insert my piston syringe and then you can pull back and when you do, if it's in the correct placement you're going to see gastric contents come through here. Now, one rule of thumb, anytime you remove gastric contents for NG tube you want to replace those. That's your patient's normal bacterial flora and you want to give it back to him. Okay, so that's one way to verify then we want to go by our agency protocol and get a chest x-ray and make sure it's in the right place. So one key note I want to talk about while I was advancing. Clearly this guy went pretty smooth but as I'm advancing, if you have a helper with you, it's a great time to have your helper as soon as I went pass the nostril, I'd like to take a tongue depressor, push down the patient's tongue, and penlight in my patient's mouth. So as soon as we go pass the nare and we go pass the back of the throat, we can assess and make sure that tube is not coiling in the back of the patient's throat. Now, during this procedure, if my patient were to cough or to gag, I need to stop immediately, assess where maybe the tube is, and stop the procedure and maybe even pull out. So if we need to do that, that's totally fine, you just want to take a rest, make sure your patients are comfortable, and then reattempt again. Now, any time you're inserting nasogastric tube, if you meet a lot of resistance you want to stop, you may need to try the other nostril on the patient to see if it's a little bit smoother.