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The use of nasogastric tube in healthcare

This should include an assessment of re-feeding risk To ensure that a NG insertion is in the best interest of the patient 2 Prior to starting the feeding regimen baseline biochemistry should be obtained, including calcium, phosphate, magnesium and liver function. Support the patient's head with pillows To allow for easy passage of the tube. This position enables easy swallowing and ensures that the epiglottis is not obstructing the oesophagus. To minimize cross-infection 7 Estimate the length the tube will need to be by placing exit port at the Xiphisternum.

Extend tube to the tip of the nose and then to the earlobe. Add an additional 10 cm to this measurement. This distance should be confirmed before each feed on the Nasogastric tube confirmation record in the bedside folder. To ensure that the appropriate length of tube is passed into the stomach. This mark should be documented in notes for future reference.

Regularly measuring the use of nasogastric tube in healthcare length of the external tube to monitor for signs of tube displacement It has been shown that the XEN measurement alone is only 2 cm more than the pre-GOJ position and 13cm short of mid stomach 8 Check patency of tube by pushing a syringe full of air into the tube 9 Inspect nostrils and nasal septum to decide which nostril to insert tube into. Most people have a deviation of the nasal septum. If blocked, repeat with the other nostril.

To identify any obstructions liable to prevent intubation 11 Lubricate the tip of the tube with water. NB do not use aqueous jelly the use of nasogastric tube in healthcare a lubricant Contact with water activates coating inside tube and on the tip. This lubricates the tube assisting its passage through the nasopharynx and allowing easy withdrawal of the introducer.

If any obstruction is felt, withdraw the tube and try again in a slightly different direction or use the other nostril. To facilitate the passage of the tube by following the natural anatomy of the nose. To focus the patient's attention on something other than the tube. A swallowing action closes the glottis, enabling the tube to pass into the oesophagus. If the patient shows signs of distress, e. The tube may have accidentally been passed down the trachea instead of the pharynx.

Distress may indicate that the tube is in the bronchus. The first line test method is to check for gastric aspirate. All test results including pH measurements and x-ray, must be documented on the Nasogastric tube placement checklist appendix 2 and actions — i. Ensure results are communicated to relevant staff. This should be done after an x-ray if necessary to ensure correct placement of the tube. An adhesive patch will secure the tube to the cheek.

Insertion and Care of Nasogastric Tubes

To hold the tube comfortably and securely in place. To ensure patient comfort. Feeding via the tube must not begin until the correct position of the tube has been confirmed. The recommended procedure for checking the position of nasogastric feeding tubes in adults Action Rationale Check whether the patient is on medication that may increase the pH level of gastric contents Medication that could elevate the pH level of gastric contents includes; antacids, H2 antagonists and proton pump inhibitors.

Result Filters

For those patients who are regularly on antacids, the initial risk assessment needs to identify actions that staff should take in this scenario, and document them in the care plan. NPSA 2005 recommends checking aspirate 1 hour after the medication dose to allow the stomach to empty and the pH to fall NPSA 2005 or consider checking aspirate prior to administering drug.

Check for signs of tube displacement the external tube length will have been recorded on the Nasogastric tube placement checklist appendix 2 when the tube was inserted. The external length of the tube must be documented on initial insertion. Checking external markings prior to feeding will help to determine if the tube has moved. The documentation will also assist radiographers if an x-ray is needed First line test method: To test gastric aspirate A pH between 1-5.

If the pH is 5. This is recognised as the safest method for checking position of NG the use of nasogastric tube in healthcare The bedside record sheet Nasogastric tube placement checklist must be completed to evidence safe practice. This may alter the pH reading The advice not to flush until after gastric placement is confirmed is important because: Allow ten seconds for any colour change to occur.

Not being able to obtain enough aspirate to cover the test zones reagent zones on the pH indicator strips suggests the tube may be misplaced — the NPSA flowchart provides advice on how this situation should be safely managed see Appendix 3 Aspirate is pH 5. There are no known reports of pulmonary aspirates at or below this figure.

Aspirate is pH 5. Possible bronchial secretion; leave up to one hour and try again. We are no longer accepting the risk of feeding with a pH of 5. Wait up to one hour before re-aspirating to check pH level The most likely reason for failure to obtain gastric aspirate below pH of 5. Waiting for up to an hour will allow time for the stomach to empty and the pH to fall.

The time interval will depend on the clinical need of the patient and whether or not they are on continuous or bolus feeds. Inject air 10-20ml for adults using a 50ml purple ENFitsyringe. Wait for 15-30 minutes and try to aspirate again to check pH DO NOT carry out auscultation of air 'whoosh' test to test tube position -this is not a recognised test to confirm NG position Injecting air through the tube will dispel any residual fluid feed, water or medicine and may also dislodge the exit-port of the nasogastric the use of nasogastric tube in healthcare tube from the gastric mucosa.

Using a large syringe allows gentle pressure and suction; smaller syringes may produce too much pressure and split the tube check manufacturers guidelines. Polyurethane syringes are preferable to other syringes. Second line test method — X-ray confirmation All X-ray requests for confirming position of NG tubes must clearly indicate purpose of X-ray on X-ray request form. The Nasogastric tube placement checklist must be sent with the patient for completion in Radiology to ensure confirmation is recorded appropriately.

A Radiologist will be available to check tube position from 09. In all cases if there is any doubt about the tube position this should be discussed with the Radiologist on call.

For high risk patients which include those with depressed consciousness or ventilated intensive care patient, the tube position should be confirmed radiologically The use of nasogastric tube in healthcare Document the reason for x-ray on the request form 4 - X-ray should only be used as a second line test to confirm NG tube position if pH checking of the gastric aspirate has failed to confirm the tube tip is in the stomach.

The radiographer will need to know that this advice has been followed, what the problem has been and the reason for the request. The radiographer should document this. Fully radio-opaque fine bore nasogastric tubes with markings to enable measurement, identification and documentation of their external length should be used. If the tube is non radio-opaque the guidewire should be left in place for the X-ray.

1.2 Aim/purpose

It is the radiographers responsibility to ensure that the nasogastric tube can be clearly seen on the x-ray to confirm tube position Where possible x-rays should be done before 5pm 1700 hours.

These x-rays will not be done after 8pm 2000hours unless nasogastric tube is necessary for essential drug administration. If this is the case please state on the request card. X-ray checking procedures must be timely and carried out by clinicians trained to read them. Clinicians should always seek to eliminate the possibility of a misplaced tube in patients who have a nasogastric tube inserted irrespective of any other clinical reasons for the x-ray request.

Stimulation of the vagus nerve can cause bradycardia due to para-sympathetic nervous system activity. This is an especially high risk with spinal cord injury above the level of T1, and cardiac arrest can occur as vagal stimulation is unopposed.