Nasogastric drainage and feeding tubes

Passage of a nasogastric tube is not a difficult procedure but it is unpleasant for the patient.

1. Ensure that there is no contraindication to passage of the nasogastric tube, for instance fractured anterior cranial fossa.
2. Explain to the patient what you intend doing, to ensure that you get their cooperation
3. Collect all the equipment that you need
   • A selection of tubes
   • Anaesthetic lubricating jelly
   • Cup of water
   • 10 ml and 20 ml syringes
   • Stethoscope
   • Litmus paper
   • Bowl (large if passing tube for intestinal obstruction)
4. Position the patient sitting with the head flexed forwards
5. Put anaesthetic jelly into the side of the nose that you have selected, it is helpful to ask the patient to snort some of the jelly up the nose
6. Wait a minute or two for the anaesthetic to work
7. Stand on the patients right hand side if you are right handed or on the left if you are left handed
8. Hold the tube 6 to 8 inches from the end and push it into the nose, aim medially to avoid the sinuses and the turbinates. DO NOT FORCE the tube if there is resistance.
9. When the tube has passed 6 to 8 inches into the nose, you will usually feel a slight resistance as the tube touches off the back of the pharynx, push the tube a little bit to get it to point down between the pharynx and soft palate, you will feel the resistance disappear as the tube passes the corner
10. Now ask the patient to open their mouth and to hold some water in the mouth but NOT TO SWALLOW IT, put about 6 ml of water into the patients mouth with the 10 ml syringe
11. When you are ready to push the tube again ask the patient to swallow, look at the larynx and when it is elevated push the tub in a few inches, if the patient starts coughing alot or gets wheezy with red watering eyes then the tube is probably in the trachea and should be withdrawn back into the nose. Then the attempt to pass the tube into the esophagus should be repeated, when the patient can swallow again. Ensure that the patient is sitting with the head flexed forwards. If the patient vomits then it may be better to remove the tube completely until the episode has passed and then start again
12. If the tube passes easily down then it is probably in the esophagus
13. With the tube in the esophagus the tube is pushed a few inches at a time as the patient swallows
14. When you have passed the tube beyond the 40 cm mark (usually denoted by four bars on the tube, the tube should be in the stomach
15. Check that the tube is in the stomach;
    • If a large bore drainage tube has been passed then aspirate the tube with a large syringe; if there is a large volume of aspirate then you are in the stomach, check the aspirate with litmus paper to ensure it is acid, the paper should go pink or red. Inject air into the tube while listening with a stethoscope in the epigastrium, if you hear bubbling then you are in the stomach.
    • If a large bore drainage tube has been passed for intestinal obstruction, then empty the stomach by aspirating with the larger syringe and emptying the contents into a bowl. When no more fluid comes back, ensure that you are not stuck up against the stomach wall by injecting a little air and/or twisting the tube
    • If a small bore feeding tube has been passed, then there is usually a wire inside them to stiffen the tube and make introduction easier. It is best to X-ray (Chest) the patient with the wire in situ to see where the tube is. Prior to use of these small bore tubes for enteral nutrition it is essential to ensure that the tube is placed in the stomach. It is disaterous to feed the patient into the lungs
    • If you are in doubt about the position of the tube, ALWAYS ask for a check X-ray
16. Secure the tube to the patient, if you don't it will fall out and you will have to pass it again
17. If you have inserted a drainage tube then connect the tube up to a suitable drainage bag, ensure that the bag is positioned in such a way that should it fill, it will not pull the tube out of the patient, if necessary pin the bag to the patients pajamas
18. Document that a tube has been passed in the patients notes;
    • If an aspiration tube has been passed then document the volume of aspirate that was obtained and note if there was blood or coffee-grounds present. Make a recommendation that the tube should be left on free drainage with for example four hourly aspirations, and communicate with the nursing staff with regard to this
    • If a feeding tube has been passed, document that it has been passed and that the check X-ray is satisfactory and that feeding may commence.