Nasogastric Tube Removal

• A nasogastric (NG) or nasointestinal (NI) tube is inserted to decompress the stomach or administer nutrition and medications.
• A provider will prescribe its removal when the tube is no longer needed.
• A registered nurse (RN) can delegate the removal of an NG or NI tube to a practical nurse (PN).
• Assistive personnel (AP) cannot be delegated this skill because it is not within their range of function.

Safety Considerations

• Determine whether the client has allergies to prevent an allergic reaction.
• Verify client identification before care according to facility protocol to ensure the correct procedure is performed on the correct client.
• Use standard and infection control precautions to prevent the transmission of infectious organisms.
• Implement additional infection control measures based on the client’s medical history and facility protocols.

Equipment

• Nonsterile gloves and other personal protective equipment (PPE) are needed if there is a possibility of contact with blood or body fluids.
• A disposable pad or towel is placed across the client’s chest to collect any spillage of secretions from the tube.
• Tissues are provided to the client to wipe the nose and mouth after tube removal.
• A 50-mL syringe is used to either flush the tube or instill air through the tube immediately prior to removal.
• A plastic disposable bag is needed to dispose of the tube and suction equipment per facility policy.

Step-by-Step Procedure

• Review the client’s medical record to determine allergies (i.e., latex) that might require the use of alternate equipment and the presence of any condition or past medical history that could affect the technique or the results.
• Verify the provider’s prescription ensures that the provider wants the tube to be removed.
• Obtain the needed supplies.
• Provide privacy to maintain client confidentiality.
• Introduce yourself to the client to promote a therapeutic nurse-client relationship.
• Perform hand hygiene and put on appropriate PPE if indicated before client care is an important infection control measure.
• Identify the client using two unique identifiers according to facility protocol is a safety measure to ensure that the correct procedure is being performed on the correct client.
• Confirm the client’s allergy status as a safety measure to prevent an allergic reaction.
• Educate the client, decreasing client anxiety and promoting the nurse-client relationship.
• Explain to the client that there may be some throat discomfort upon removal.
• Instruct the client that they will be asked to hold their breath as the tube is removed.
• After explaining the procedure, the nurse should determine if the client has any questions or concerns and verify the client’s understanding.
• Evaluate the client for indications of an alteration that may indicate the need for the tube to remain in place:
• Inability to tolerate oral nutrition/fluids
• Absent bowel sounds or gag reflex
• Surgical sutures (nasal, gastric, or craniofacial surgery) that could be disrupted during removal
• Delay removal of the tube until further collaboration with the provider.
• Place the client in high-Fowler’s position, if tolerated, and raise the head of bed to a minimum of 30° to 45° unless contraindicated to reduce the risk of aspiration should the client vomit during the procedure.
• Place a towel or disposable pad across the client’s chest to prevent tube drainage or body fluids from soiling the client’s gown or bed linen.
• Offer tissues and emesis basin to help reduce contact with the client’s body fluids and reduces transmission of microorganisms.
• Put on clean gloves worn to decrease the chance of contact with the client’s mucous membranes, blood, or body fluids, and also to reduce transmission of microorganisms.
• Ensure that any wall suction tubing is disconnected from the NG tube or disconnect the feeding infusion prior to removal, preventing the contents of the tube from draining into the client’s lungs upon removal of the tube.
• Detach the NG or NI tube from the gown, allowing for unobstructed removal of the NG or NI tube.
• Remove the tape or tube holder from the top of the client’s nose, allowing for unobstructed removal of the NG or NI tube.
• Flush the tube with 10 mL of water or 0.9% sodium chloride irrigation solution or instill 30 to 50 mL of air through the tube to clear the tube of any feeding or gastric contents which, reduces the risk of aspiration during removal of the tube.
• Clamp the tube near the client’s nose, kinking the tube between the index finger and thumb to prevent aspiration of the tube contents and prevents the contents of the tube from leaking.
• Ask the client to take a deep breath and hold the breath, closing the epiglottis, thus preventing aspiration.
• Using the dominant hand, smoothly and steadily pull the tube to remove it while collecting the tube in a towel or disposable pad with the nondominant hand to avoid causing trauma to the client if the tube has become knotted or embedded.
• If any, resistance is met upon removing tube, stop immediately and notify the provider.
• Collecting the tube in a towel or disposable pad reduces exposure to the client’s body fluids.
• Check that the tip of the tube is intact, verifying that a foreign object (i.e., part of the tube) has not been left in the client’s stomach.
• If the tube was used to decompress the stomach, measure and record the amount of output in the collection container to facilitate accurate documentation and measurement of the client’s output.
• Per facility policy, dispose of the NG or NI tube and suction or feeding equipment immediately to prevents the transmission of microorganisms from the tube to other objects or people.
• Remove dirty gloves and apply clean gloves, good hygiene prevents contamination and the spread of microorganisms.
• Clean adhesive residue from the client’s face, clean the nares, and provide oral hygiene, removing potential harmful bacteria and microorganisms.
• Assess the client’s skin integrity and condition underneath the tube holder or adhesive tape and the external nares.
• Loss of skin integrity can occur in these areas due to pressure from the tube or irritation from the adhesive.
• Discuss findings with the client, decreasing client anxiety and promotes the nurse-client relationship, as well as client involvement in their care.
• Ensure client safety before leaving the room, reducing the risk of falls and client injury.
• Safety measures may include:
• Placing the call light within easy reach of the client
• Lowering the client’s bed to the lowest position with the brakes locked
• Placing needed items (water, telephone, etc.) within easy reach of the client

Interventions for Unexpected Outcomes

• Assess the client’s respiratory status for manifestations of aspiration, including cyanosis, sudden onset of coughing, or fever.
• Removal of the NG or NI tube can cause aspiration if gastric contents enter the client’s lungs.
• If any resistance is felt as the tube is being removed, stop immediately and notify the provider.
• If the tube has been inserted too far into the abdomen, it may form a knot.
• On rare occasions, if the tube has been in place for a prolonged period, tissue may grow around the tube and embed it to the gastric mucosa.
• To avoid trauma to the GI system, stop the procedure immediately and notify the provider.

Documentation

• Accurately document in the client’s medical record per facility policy.
• Date of removal of the tube
• GI assessment findings immediately prior to and after tube removal
• Skin integrity and condition where the nose holder or tape was present
• The client’s response to the procedure
• Measurement of drainage, if needed
• Accurate and timely documentation allows for immediate access of client data by members of the client’s health care team.