5.3 Applying the Nursing Process

Assessments and Interventions Prior to Insertion of an NG Tube

Prior to the insertion of an NG tube, the following nursing assessments and interventions should be performed:

• Review agency policy for inserting and verifying placement of an NG tube.
• Verify the provider’s orders.
• Review laboratory results to check for coagulopathies or blood dyscrasias. If the client is on anticoagulation therapy, assess their most current INR before performing the procedure and notify the provider of any concerns.
• Ask the client if they have any allergies (e.g., to latex, medications, or other substances).
• Confirm client history for facial trauma, deviated septum, nasal fractures, or risk of increased intracranial pressure.
• Assess the client’s level of consciousness and their ability to participate in the procedure. Request assistance from a colleague as indicated.
• Perform a focused abdominal assessment to identify the client’s baseline status. Auscultate bowel sounds and palpate the abdomen for distention, pain, or rigidity.
• Assess the nares for obstructions and the surrounding skin. Select the nostril with the best airflow and skin condition.
• Provide patient education on the procedure and answer questions.
• Provide emotional support and comfort while being aware this is an uncomfortable procedure for the client. It is helpful to have an assistant nearby during this procedure; the assistant can also provide emotional support to the client as needed during the procedure.

Expected Outcomes of the Procedure

These are the expected outcomes related to insertion of an NG tube:

• The NG tube is placed without causing trauma.
• The correct placement of an NG tube is verified according to agency policy.
• The NG tube remains in place, patent, and functional for the duration of therapy.

Assessments and Interventions After Insertion of the NG Tube

Assessments and interventions immediately after insertion of an NG tube include the following^[1]:

• Observe for signs of misplacement post-insertion, such as circumoral cyanosis, coughing, choking, dyspnea, decreased oxygen saturation level, or vomiting.
  • Respiratory distress is a medical emergency, and emergency assistance should be obtained.
  • Strongly consider removing the NG tube if these signs are present as the tube may be lodged in the airway or lungs.
• Do not administer fluids or medications via the NG tube until accurate placement has been verified with an X-ray.
• Document the following information in the client’s medical record^[2]:
  • Time and date of the procedure
  • Type and diameter of the NG tube
  • Number on the tube where it enters the nares and verification that number was communicated during handoff reports
  • Method(s) used to verify tube placement
  • Color and consistency of aspirate, including pH of aspirate if assessed
  • Client’s tolerance of the procedure
  • Any unexpected client events or outcomes, interventions performed, and notification of the provider
  • Patient/family education, including topics presented, response to education provided/discussed, and the plan for follow-up education

Routine Nursing Care of Clients with NG Tubes

Clients with NG tubes are at constant risk for developing adverse effects. While caring for clients with NG tubes, nurses monitor risks and adopt strategies for client safety and quality of care.

When working with clients who have NG tubes, nurses perform the following interventions^[3]:

• • Keep the head of the bed 30 degrees or higher.
    • Clients with NG tubes are at risk for aspiration, especially if they are receiving enteral nutrition. The head of the bed should always be raised 30 degrees or higher to prevent aspiration.
  • Prevent migration and/or dislodgement of the tube.
    • The NG tube should be fastened to the client using a securement device and taped/pinned to the client’s gown to prevent the tube from slipping from out of the stomach, migrating into the lungs, or being accidentally removed.
  • Maintain and promote comfort.
    • The NG tube constantly irritates the client’s nasal mucosa and can cause discomfort and potential skin breakdown. Ensure that the tube is securely anchored to the client’s nose to prevent excess tube movement and is pinned to the gown in a manner that avoids excessive pulling or dragging. Routinely confirm the NG tube is not pressing against the client’s nares or septum and regularly assess the skin around the tube and securement device for breakdown. The tube should be periodically repositioned in the nares to help prevent pressure injuries. Notify the provider of any concerns.
    • If the client has abdominal distension or complains of abdominal pain, discomfort, or nausea or begins to vomit, perform the following actions:
      • If the client is receiving suctioning, verify suction settings are consistent with the provider order, including “continuous” versus “intermittent” suctioning and “low” versus “high” suction level. Check for kinking of the tube from the nare to the suction source.
      • Some NG tubes have valves that permit delivery of oral agents without disconnecting the tube. Ensure the valve is not turned in a direction that is blocking the tube.
    • Assess the patency of a tube according to agency policy, typically by irrigating with a 60-mL syringe and 30 mL of tap water. NG tubes are prone to clogging for a variety of reasons. The risk of clogging may result from tube properties (such as narrow tube diameter), the tube tip location (stomach vs. small intestine), insufficient water flushes, aspiration for gastric residual volume, contaminated formula, and/or incorrect medication preparation and administration. To prevent clogging, NG tubes should be flushed a minimum of once per shift or according to provider orders/agency policy. Feeding tubes should be flushed immediately before and after intermittent feedings and medication administration and follow appropriate medication administration practices. Read more information about tube irrigation in the “Basic Concepts of Enteral Tubes” section in the Open RN Nursing Skills book.
    • If the client is receiving enteral feedings, monitor for signs of tube feeding intolerance (i.e., abdominal bloating, nausea, vomiting, diarrhea, cramping, and constipation). If cramping occurs during bolus feedings, it can be helpful to administer the enteral nutritional formula at room temperature to minimize or help prevent symptoms.

• • Perform oral care.
    • Because one nostril is blocked, clients tend to breathe through their mouth, causing dehydration of the nasal and oral mucosa. Clients often complain of thirst, but they are typically NPO (nothing by mouth) when an NG tube is in place. Oral care keeps the oral mucous membranes moist and helps relieve dryness, as well as preventing infection. Oral care can include rinsing the mouth with cold water or mouthwash, as long as the client does not swallow. Some clients may be permitted to suck on ice chips per provider orders. Lubricant should be applied to the lips and the external nares.
    • Clients may have throat discomfort. Some providers may prescribe a numbing throat spray but use with caution because it can hinder the gag reflex and increase the risk of aspiration.

• • Monitor input/output, electrolyte balances, and weight trend.
    • Because a client with an NG tube is typically NPO, it is important to closely monitor their fluid, electrolyte, and nutritional statuses. They are also at risk for acid/base imbalance. NG tubes used for suctioning place clients at risk for hypokalemia and metabolic alkalosis when large volumes of stomach acid contents are removed from the body.
    • If the client is receiving suctioning, the drainage amount and color should be documented every shift.
    • Fluid flushes and enteral feedings should be documented in the Input and Output (I & O) area in the medical record.
    • Electrolyte and blood glucose levels should be monitored, as ordered, for signs of imbalances.
    • Daily weights are typically ordered, and weight trends should be monitored by the nurse.

• • Monitor for potential complications.
    • Signs of tube dislodgement into the respiratory tract include coughing, shortness of breath, adventitious lung sounds, or decreasing oxygen saturation levels.
    • Signs of esophageal perforation include neck or chest pain, dysphagia, dyspnea, subcutaneous emphysema, or hematemesis.

Life Span Considerations

When caring for older adults or children with NG tubes, there are additional factors to consider. For example, if the client wears dentures, remove them for the client’s safety and comfort prior to inserting the NG tube.

For pediatric clients, irrigation of an NG tube requires a smaller fluid volume. Check agency policy, but typically the flushing volume is 2 to 5 mL in pediatric patients and 1 mL or less of water in neonates. For neonates, care should be taken to use the appropriate size and type of NG tube to prevent injury to the delicate nasal and gastrointestinal tissues.^[4] 

Delegation and Collaboration

The task of inserting and maintaining an NG tube cannot be delegated to unlicensed assistive personnel (UAP). However, the nurse can delegate the following actions to UAP under appropriate supervision:

• Measuring and recording drainage
• Providing oral and nasal hygiene
• Anchoring the NG tube to the client’s gown during routine care to prevent displacement
• Immediately reporting to the nurse any signs of redness or irritation of the nares

Removal of NG Tube

See “Checklist: Remove an NG Tube” for procedural steps of removing an NG tube.

Note that accidental removal of an NG tube is not a medical emergency. If accidental removal occurs, assess the client and notify the provider.