Nasogastric and Nasointestinal Tube Insertion

• Inserting a nasogastric (NG) or nasointestinal (NI) tube involves inserting a flexible tube through the nose into the stomach (NG tube) or the first part of the intestines (NI tube).
• NG tubes are used to remove stomach contents, provide nutrition, or aid in diagnostic tests.
• NI tubes are typically used to deliver feedings or medications when stomach motility is impaired or needs to be bypassed due to the client's inability to tolerate feedings.
• A registered nurse (RN) can delegate NG or NI tube insertion to a practical nurse (PN) who has demonstrated competence in the skill.
• Assistive personnel (AP) cannot be delegated the insertion of NG or NI tubes.

Safety Considerations

• Determine allergies to prevent allergic reactions.
• Verify client identification to ensure the correct procedure is performed on the correct client.
• Use standard and infection control precautions to prevent the transmission of infectious organisms.

Equipment

• Nonsterile gloves and other personal protective equipment (PPE) are needed.
• Stethoscope is used to confirm proper NG tube placement.
• Select a nasointestinal tube with the correct diameter based on the provider’s prescription and the client’s needs.
• Water-based lubricant is needed for tube lubrication prior to insertion.
• Tongue blade is used to ensure the tube is not coiled in the back of the throat.
• 60-mL syringe or irrigation supplies are needed for irrigation and instillation.
• Hypoallergenic tape or a facility-approved NGT adherence device secures the tube to prevent dislodgement.
• Skin prep is used to protect skin prior to applying adhesive.
• Emesis basin is needed if the client needs to spit out water or vomit.
• Tissues or cotton swabs clear the client’s nares.
• A cup of water assists the client with swallowing during insertion, if appropriate.
• Towel or absorbent pad protects the client’s clothes and linens.
• pH strip or paper confirms placement when testing content aspiration.
• Permanent marker or pen is used for labeling the tube per facility policy.
• Safety pin adheres the tube to the client’s clothes or gown to promote comfort.

Step-by-Step Guide

• Step 1: Review the client’s medical record for allergies, medical history, medications, previous vital sign data, and pertinent laboratory values.
• Step 2: Obtain all necessary supplies.
• Step 3: Provide privacy as needed to maintain client confidentiality.
• Step 4: Introduce yourself to the client to promote a therapeutic relationship.
• Step 5: Perform hand hygiene and put on appropriate PPE if indicated to prevent infection.
• Step 6: Identify the client using two unique identifiers to ensure the correct procedure is performed on the correct client.
• Step 7: Confirm the client’s allergy status to prevent allergic reactions.
• Step 8: Educate the client about the procedure and develop signals for communication during the procedure to decrease anxiety and promote the nurse-client relationship.
• Step 9: Evaluate the client for indications of an alteration in nutrition, such as decreased weight or appetite, dry skin, decreased skin turgor, or dry mucous membranes.
• Step 10: Place the client in high-Fowler’s position or at a 45° angle and place a towel or absorbent pad on the client’s chest to assist with tube insertion.
• Step 11: Inspect the client’s nares with a pen light to observe for any anatomical abnormalities.
• Step 12: Measure the tubing:
  • NG tube: Measure from the nose (N) to the earlobe (E) to the xiphoid process (X) (NEX measurement).
  • NI tube: Measure from the nose (N) to the earlobe (E) to the xiphoid process (X), then add 8 to 10 inches (20 to 25 cm).
• Step 13: Mark the measurement on the tube with a marker to assist with visualization during insertion.
• Step 14: Have the client maintain their neck in a neutral position or extend it back against their pillow, depending on facility policy.
• Step 15: Insert the tube following the nasal passage and rotate it to help it pass through the nasopharynx.
• Step 16: Have the client extend their head forward to ease insertion and limit resistance.
• Step 17: Provide reassurance to the client to help them relax during the procedure.
• Step 18: When the pharynx is reached and gagging occurs, encourage the client to sip water through a straw or suck on ice chips or encourage them to swallow if NPO.
• Step 19: Continue advancing as the client swallows to help advance the tube.
• Step 20: Monitor for excessive gagging or coughing, which indicates misplacement, and stop the procedure immediately.
• Step 21: Continue advancing the tubing until the measured mark is reached and then loosely secure the tubing with tape.
• Step 22: NI tube: Allow the tube to move into the intestines through peristalsis per facility policy.
• Step 23: NI tube: Leave the guidewire in place until confirmation of placement.
• Step 24: Confirm placement with two methods. Checking the pH of the gastric contents can be used to confirm placement. The pH should be less than or equal to 4.0 to indicate gastric contents. A radiograph is the most reliable method to confirm placement.
• Step 25: Secure the tubing:
  • NG tube: Once placement is confirmed, secure the tube per facility policy and ensure the vent is above stomach level for double-lumen tubes.
  • NI tube: Once placement is confirmed, remove the guidewire and secure the tube per facility policy, securing the tube to the client’s gown.
• Step 26: Perform oral hygiene to prevent the spread of pathogens and provide comfort.
• Step 27: Remove gloves and perform hand hygiene to prevent infection.
• Step 28: Discuss findings with the client to decrease anxiety and promote the nurse-client relationship.
• Step 29: Ensure client safety before leaving the room by placing the call light and needed items within reach and lowering the bed to the lowest position with the brakes locked.

Client Considerations

• Consideration is needed before inserting an NG or NI tube on clients who have had surgical procedures involving the face, nose, throat, or stomach because it presents the risk of damaging their sutures and notification of the surgeon is required.
• When inserting an NG or NI tube in clients with a basilar skull injury or fracture, visual guidance must be used, such as a fluoroscope, to prevent the tube from going into the cranial area.

Interventions for Unexpected Outcomes

• Monitor the client’s respiratory function during insertion and stop the procedure if the client becomes cyanotic, unable to make any sounds, has continuous coughing or gagging, or if resistance is met when advancing the tube after rotating it because it indicates that the tube is in the airway.

Documentation

• Accurately document the size and type of tube inserted, method used to confirm placement, description of gastric contents aspirated (including pH reading), identification of the naris the tube was inserted into, client’s response to the procedure (assessment, objective and subjective), and client education provided.