5.4 Checklist: Insert a Nasogastric Tube

*Disclaimer: Always follow agency policy and manufacturer recommendations

Checklist: Insert a Nasogastric Tube^[1],[2]

Preparation Before Procedure

The following steps should be taken in preparation for the procedure^[3]:

• The indication for the procedure, potential complications, and alternative to treatment should be explained to the client by the provider. If an informed consent form is required by agency policy, the nurse should ensure the informed consent form has been signed and is present in the client’s medical record.
• Review the client’s medical record for conditions that may contraindicate insertion of an NG tube (e.g., facial trauma or fractures, deviated or swollen nasal septum).
• If the nasogastric tube is to be connected to suction, attach the NG tube to the suction tubing and suction container before placement of the tube to minimize the risk of spillage of gastric contents.
• Perform a thorough gastrointestinal (GI) assessment.
• Gather and prepare equipment. All supplies should be close at hand to minimize unnecessary movement during the procedure. *Note: Topical use of local anesthetics such as lidocaine has not been shown to be useful for NG insertion, but the evidence does show that nebulized lidocaine relieves discomfort and allows for an increased chance of NG tube placement.
• Gather the necessary supplies:
  • Nasogastric tube per provider order
  • Antireflux valve
  • Stethoscope
  • Pulse oximeter
  • Hypoallergenic tape or agency approved securement device
  • Cup of water and straw
  • Clean gloves
  • Suction equipment (if prescribed by provider)
  • Penlight
  • Tongue blade
  • Water-based lubricant
  • Oral hygiene supplies
  • Fluid-impermeable drape or towel
• Explain the procedure to the client and family members (if appropriate) according to their individual communication and learning needs. Assess client anxiety regarding insertion of the tube. Answer any questions and provide emotional support as necessary.

Procedure

• Verify the provider’s orders for tube insertion and associated premedications.
• Perform hand hygiene.
• Confirm the client’s identity using at least two patient identifiers and check allergies.
• Provide privacy.
• Assess the rigidity of the tube. If you need to increase the tube’s flexibility to ease insertion, coil it around gloved fingers for a few seconds or dip it in warm water. If the tube is too flaccid, stiffen it by filling the tube with water and then freezing it or dipping the tube in ice water.
• Advise the client they may feel some discomfort as the tube moves through the nose but that the tube will be lubricated to ease its passage. Topical anesthetic and nasal vasoconstricting medications may be administered, as prescribed.
• Explain to the client they will be given water to sip once the tube reaches the pharynx. The swallowing action will facilitate passage of the tube and minimize the natural tendency to gag.
• Ask the client to identify a signal they will use to communicate with you if it is necessary to stop briefly during the insertion, such as raising their hand.
• Raise the bed to waist level.
• Perform a focused gastrointestinal assessment.
• Because the dominant hand will be used to insert the tube, stand on the client’s right side if right-handed or on the client’s left side if left-handed.
• Position the client (in high Fowler’s position) with the head of the bed elevated at least 30 degrees; if this position is contraindicated, consider the reverse Trendelenburg position. Assist the client in positioning their head in a neutral position, neither tilted forward nor backward.
• Perform hand hygiene.
• Put on nonsterile gloves and other personal protective equipment as indicated.
• Assess the client’s nares to determine the best choice for insertion. Use a penlight to visualize nares as needed.
• Estimate the insertion length of the tube by measuring from the tip of the nose to the earlobe to the sternal notch of the xiphoid process. Mark this estimated exit point on the tube with a piece of tape or permanent marker.
• Drape a fluid-impermeable pad or towel over the client’s chest. Place an emesis basin within reach because the client may gag or vomit during the procedure.
• Lubricate the proximal tip of the tube about 2 to 3 inches with water-soluble lubricant.
• Encourage the client to hold their head upright. You may wish to support the client’s head with your nondominant hand while inserting the NG tube.
• Grasp the end of the tube with the distal end pointing downward, curve it if necessary, and carefully insert it into the most patent nare.
• Guide the tube at an angle parallel to the floor of the nasal canal and then gently downward as the tube advances through the nasal passage toward the distal pharynx.
• If resistance is met, try to gently rotate the tip until it advances past the nasal passage. If continued resistance is met, don’t force the tube. Instead, withdraw the tube and allow the client to rest, relubricate the tube, and retry or insert the tube in the other nare.
• After the tube reaches the oropharynx, have the client flex their head forward and tuck their chin down. Encourage them to sip water through a straw as you slowly advance the tube (unless contraindicated).
• As the tube is advanced, monitor the client for cues that might indicate that the tube entered the respiratory tract or the tube kinked or coiled in the oral cavity. If the client appears cyanotic or begins coughing severely during advancement of the tube, pull the NG tube backwards until normal breathing resumes. Severe coughing during tube insertion can indicate inadvertent placement in the trachea or bronchi. Reattempt advancement of the tube after the client begins breathing normally. However, never advance the NG tube against resistance because perforation may occur.
• Continue to advance the tube to the predetermined measured length.
• Following insertion, clean any excess lubricant from the client’s skin.
• Secure the NG tube to the client’s nose using a securement device, tape, or semipermeable transparent dressing. When securing the NG tube, use care to avoid applying undue pressure to tissue to reduce the risk of pressure injuries.
• Position the NG tube so the distal end is facing upwards and secure it to the client’s gown according to agency policy. If using a rubber band, place it over the NG tube. Wrap one end of the rubber band behind the NG tube and up through the open half of the rubber band and then continue to pull the end so that the band is tightened around the tube. Use a safety pin to attach the rubber band and NG tube to the client’s gown.
• Remove and discard the fluid-impermeable pad or towel.
• Discard used supplies in the appropriate receptacle.
• Remove and discard gloves and any personal protective equipment worn.
• Perform hand hygiene.
• Follow agency policy to verify correct placement of the NG tube. Do not instill anything through the NG tube or connect it to suction until correct placement has been confirmed.
• After correct placement is verified, document the length of the tube where it exits the nare. If a stylet is present, remove it at this point. Turn on suction, if ordered, to intermittent or continuous suction and typically set it to 30 to 40 mmHg. Ensure the suctioning equipment is working properly.
• Provide oral care, discard any used supplies, and then perform hand hygiene.
• Keep the head of the bed elevated at least 30 degrees.
• In an inpatient setting, help the patient into a comfortable position and place personal items, the tray table, and the call light within easy reach. Make sure the patient knows how to use the call light to summon assistance. To ensure the patient’s safety, raise the appropriate number of side rails and lower the bed to the lowest position. Ensure the bed is locked.
• Assess the client’s status and comfort level; reposition as necessary.
• Update the client’s plan of care, as appropriate.
• Perform hand hygiene.
• Document the procedure.

Documentation Cues:

• Pre-procedure assessments
• Type and size of tube placed
• Location of the distal tip of the tube (external measured length of the tube)
• Client’s tolerance of the procedure
• Confirmation of the tube’s position by X-ray examination
• Any unexpected outcome and related nursing interventions performed
• Pain assessment and management