Nasogastric Tubes

Need to know:
How to check placement
How to do a tube feeding

Blue piggy tail must be free of fluid. Purpose: prevent tube from sucking against the stomach wall

*Obtain equipment:
60 mL catheter tip syringe
Water
pH paper
Stethoscope
Aspirate gastric content: note color, consistency and amount
Apply small amount of gastric material to pH paper:
pH of 1-5 indicates gastric content
Six or greater may indicate intestinal placement
Fluid from the respiratory tract typically has a pH greater than 7.
Re-instill the aspirate
Place stethoscope over abdomen
Instill 10 mL of air and listen for "whoosh" sound

Check to see if medication should be given on an empty stomach and can medication be crushed
*hold tube feeding if necessary for meds
*If med cannot be crushed, is it available in liquid form?
Crush medication and dilute in 30 mL of warm water
*Check compatibility of medication with feeding formula
Place client in semi-Fowlers positiion
*Keep in semi-Fowlers position during medication administration and for 30 minutes later
Obtain 60 mL catheter tip syringe
Verify tube placement
*Aspirate residual volume, note amound and test the pH of a small amount and reinstill the remaining
Place stethoscope over abdomen
*Remove syringe, draw up 10 mL of air
*Instill air and listen for "whoosh" sound
Administer medication
*Be sure and stir mixture well to prevent any clogging
Flush with 30 mL of water
Document medication given and document total amount of fluid administered on the I&O record

Possible Causes & Nursing Interventions

Improper client positioning
- Place client in upright position (at least 30 degrees) during feedings. Keep him elevated for at least one hour after intermittent feedings.

Feeding rate too rapid or volume too large
- Request an order to switch from intermittent to continuous feedings
- Decrease the rate or volume of feedings

-Check balloon for leakage by using syringe to withdraw water or saline solution from the balloon
-If the volume is less than was originally instilled, add water or saline as needed. If the balloon leak persists, the tube needs to be replaced.

-To prevent tension on the tract, be sure to stabilize the tube by affixing it with surgical tape to the abdomen, leaving sufficient slack. (This is not necessary with percutaneous endoscopic gastrotomy and percutaneous endoscopic jejunostomy tubes, which use internal and external bumpers for stability).
-For balloon type tubes, add water or saline solution to the balloon (in 2-5 mL increments) until leakage subsides. Don't exceed balloon capacity.
-Be sure the balloon is gently pulled up against the stomach wall
-Consult with an enterstomal nurse for other ways to reduce tract size
-If other measures aren't successful, the MD may replace the tube with one that's larger in diameter. However, this may further enlarge the tract.

-Hold feedings and alert MD. Assess for decreased or absent bowel sounds, abdominal distention, nausea, vomiting and increased residual volume.

-Check tube length or ink mark. If tube is shorter or ink mark isn't visible, stop feeding.
-Assess for nausea, vomiting and abdominal distention. If symptoms are present, alert MD, x-ray may be needed to determine tube's location.

-Check tube length or ink mark. If tube is longer or mark is farther out, stop feeding and alert MD, tube may need replacing. Assess for pain, redness, swelling and drainage.

Gastric fluid leakage around tube
-Assess cause of leakage and correct problem (see problem #1)
-Keep skin clean and dry
-Check dressing (if used). Change if wet or soiled.
-Use waterproof barrier (polyurethane foam dressing, ointment or commercial wafer with paste) around the site to protect skin. Follow instructions and precautions for barrier use. If wafer is used, be sure it fits properly so leakage seeps under it.
Allergic reaction to soap or ointment
-Clean with water alone or try a different soap or ointment
Reaction to tube material
-Suggest replacing the tube with one made of a more biocompatible material

Inadequate flushing of tube
-Flushing feeding tube with at least 20 mL of warm water before and after each feeding and medication administration and every 3 to 4 hours if client is on continuous feeding
Backup or curding of gastric contents and formula in the tube
-Flush tube with 20 to 30 mL of warm water after checking for residual volume
-Flush tube and clamp it between feedings to prevent gastric content backup

-Avoid mixing medication with feeding formula
-To give medication through the tube, use a liquid form (if possible) or finely crushed tablets dispersed with water
-Always rinse the tube with at least 30 mL warm water before and after giving medication
-Give medication one at a time, rinsing the tube between each medication with at least 5 mL of warm water
-Caution: Never try to relieve blockage by inserting objects into the tube. This could injure the gastric mucosa. Also, avoid using excessive force while irrigating.