The purpose of this video is to provide general information and education about the care of
a critically ill child.
It is in no way a substitute for the independent decision-making and judgment by a qualified
health care professional.
The information contained in this video should not be used to make a diagnosis or to overrule
the advice of a qualified healthcare provider, nor should it be used to provide advice for
emergency medical treatment.
Nasogastric Tube Placement by Susan Hamilton.
Please note that in this video we will be following the guidelines used at Boston Children's
Hospital.
Some of this information may need to be modified based on the equipment, guidelines, and practices,
in place in your institution.
Introduction.
My name is Susan Hamilton.
I'm a clinical nurse specialist at Children's Hospital, Boston.
I'm going to talk to you today about placing an NG, or oral tube either for drainage, or
for feeding.
I'm going to show you the different types of tubes that you could use, and then actually
how to do the procedure.
Indications.
The first indication is to provide enteral feeding or deliver medications to a child
who cannot eat orally secondary to-- known or suspected risk for aspiration; depressed
mental status; poor pharyngeal muscle control; endotracheal intubation; or poor appetite.
Another indication is to aspirate gastric secretions or air in patients who-- require
continuous drainage of gastric secretions, such as a patient with a bowel obstruction;
or to aspirate air from the stomach following bag mask ventilation or during the use of
non-invasive positive pressure ventilation.
Contraindications.
The first contraindication that would prompt health care providers to refrain from this
procedure is the presence of any nasal, facial, basilar skull fractures.
Another contraindication would be any clinical disorders of the esophagus or stomach, including
esophageal atresia, severe esophageal stricture, and esophageal or gastric perforation.
Please exercise caution when performing this procedure in patients who have esophageal
or gastric varices, are receiving anticoagulant therapy, or that have a bleeding disorder
or thrombocytopenia with a platelet count of less than 50,000.
Equipment.
You will need the following equipment to perform the procedure.
You may use one of three nasogastric tubes for the nasogastric tube placement procedure.
A nasogastric sump tube, shown on the left, a styletted feeding tube, shown in the middle,
and a non-styletted feeding tube shown on the right.
Please note that a sump tube should only be used for aspiration and should not be used
for feeding.
Also, not all feeding tubes for nasogastric tube placement have a stylette.
There are some tubes that have an accompanying stylette, and some that don't.
Non-styletted feeding tubes are generally used for short-term or intermittent nasogastric
feeds, and styletted tubes are used for longer term placement.
You will also need a suction source with a receptacle, lubricant, catheter tip syringe,
suction connector, anti-reflux valve, tape, gastric pH paper, clear adhesive dressing.
Procedure.
I'm going to get ready to prepare this patient for the tube placement now.
If your patient is awake, then the best position for the patient is in a semi-Fowler's or a
semi-upright position so that the patient can actually sit up and swallow.
If you have a child who's old enough to help you, you can ask them to practice swallowing
a few times, because that will help move the tube along.
So you can practice that or get them-- if they're allowed to drink, you could get some
water with a straw, and they could actually sip on water while you put the tube in.
If the patient is sedated or obtunded, the safest way to do this would be to lay the
patient down a little bit, still with the head of the bed up a little bit.
And potentially place the patient on the left side, because that way if the patient vomits
during the procedure, then they will be safer to not aspirate, hopefully.
So this patient here today, he's awake and alert, and he's willing to cooperate with
me to put this tube in.
So I'm first going to explain to him what we're going to do, that I'm going to have
to put a tube down his nose, and then it's going to feel uncomfortable going down.
And once it gets past his throat, he shouldn't really feel it so much anymore.
What I wanted to do is make sure he's in a comfortable position, and if we can practice
with swallowing.
Then I want to pick the appropriate sized tube for this size patient.
I want to make sure that I have my lubricant, and I want to have something to secure the
tube with when I'm done, as well as a suction source and my anti-reflux valve.
So I'm going to put your tube in now.
And the first thing I want to do is measure.
What you want to do is to make sure that you measure so that you will get stomach placement.
The appropriate way to measure is to go from ear to nose, and then from nose to the halfway
point between the xiphoid process and umbilicus or belly button, that should get you to the
stomach.
Some tubes have markings on them, and if you can aim for one of the markings-- but in this
patient, he's too small, and you don't actually even get to the first marking.
So the best thing to do would be to take a small piece of tape and mark the tube.
And that's how far you will advance the tube into the stomach.
You want to lubricate your tube with some water-soluble jelly.
So now I've prepared my patient, and he's all ready to have his tube put in.
When you're putting the tube in, sometimes it helps, if the patient's awake, to have
them bring their head-- their chin to their chest a little bit.
That helps the tube go down.
When you enter the tube into the nose, you want to go back and down, because if you go
up you actually could head up towards the brain instead of down to the stomach.
So you want to start with back and down.
This is the time that you want to ask the patient to swallow if they can.
And continue to advance your tube.
If the patient starts to have coughing at this point that they can't stop, and they
appear distressed, immediately pull out the tube and allow the patient to recover.
Excessive coughing can be a sign that the tube is actually heading into the lung instead
of the stomach.
Once you get the tube into place, you want to confirm placement.
The first way you can confirm placement is to put air into the belly and listen for a
gush of air.
You want to use your cath-tip syringe and fill it to 5 to 10 mL of air, and listen with
the stethoscope over the stomach.
You should hear a rush of air over the stomach, but remember that in smaller children you
could still potentially hear that rush of air even if the tube was in the lung, so besides
listening for air, you need to have a secondary way to confirm placement, such as getting
a pH aspirate or getting an x-ray.
So once that tube is thought to be in, you can try to get an aspirate for pH testing.
And then you need to secure your tube and get it hooked up to suction.
I'm going to use a transparent dressing for him.
You want to make sure that you tape the tube, A, if it's a small child, that they can't
get at it.
And secondly, you want to not have it sit against the side of the nose, because it potentially
could cause trauma and breakdown.
There are some pre-made devices that actually just go around the nose.
Some people like to tape them up.
I prefer to tape it to the side with a small, transparent dressing so that you can monitor
the skin underneath as well.
I'm going to put that off to the side.
As you can see, my confirmatory spot is right there, and that would be important to know
every time you approach this patient.
If you're going to put anything into the tube, to know that the tube is where you put it
when you first put it in.
I'm going to get this hooked up now to suction.
I'm going to take this off, and I'm going to add a connector, and I'm also going to
put on the air valve so that he can get air out of his belly.
Remember, when hooking up the suction you want to make sure that you're only hooking
up to low-wall suction, because if the suction is too high, the suction could potentially
hurt the mucosa of the stomach.
You want to assure that your patient's now comfortable after the procedure, and you want
to now talk about the care and maintenance of these tubes.
You need to visually confirm the placement of the tube every time you're going to instill
into the tube or make any changes.
So whatever kind of marking you want to use would be important.
You also need to offer the patient mouth care frequently, because their mouth actually may
feel dry, at least every four hours, or more often as needed.
When you're talking about feeding tubes, you want to routinely flush them every eight hours.
Some tubes don't necessarily have to be flushed, but if you're having decreased drainage, or
you if you see very thick secretions, it may be needed to give a small flush with normal
saline to clear the tube.
Or if you see blood in the tube, you may want to get a doctor's order to flush the tube
and see what you get for a return.
I've obtained an aspirate from this patient's stomach, and I'm going to test the pH on it
now.
I'm going to use pH paper that's been housed inside a container that is air tight, and
I'm going to just take a small piece of the paper and put a small drop of aspirate.
You can read the results of this immediately.
You don't have to wait.
You can see that the pH of this aspirate is 4.
Any pH of 5 or less is confirmatory for being in the stomach.
If the pH is greater than 5, it may be that the patient's on medications that alter the
pH of the stomach, so you will need to use a secondary method to confirm placement prior
to using the tube.
But in this case, this patient's tube is in place, and we're all set to use it.
Complications.
The complications that you may observe include inadvertent placement into the lungs, nasal
or gastric bleeding from mucosal irritation or injury, esophageal or gastric perforation,
sinusitis, breakdown of the nare.
Please note that you may or may not observe any of these complications during or following
this procedure.
I encourage you to monitor your patient closely for signs or symptoms of complications.
And to be prepared to manage them, which includes having the necessary equipment available to
treat the complications should any arise.
Assessment and Monitoring.
First of all, it is important to monitor the patient's vital signs, including oxygen saturation.
You will also want to observe for significant and/or unresolving coughing.
Finally, you will want to assess the patient's comfort during the procedure.
Documentation.
Following nasogastric tube placement, you should document the following information
in the patient's medical record, the indication for the procedure, the time and date of the
procedure, the depth of tube insertion, a confirmation of gastric placement, which includes
the presence or absence of air in the stomach on auscultation, a pH of 5 or less indicating
the presence of gastric contents, the presence of the tube in the stomach on abdominal x-ray,
the vital signs before, during, and after the procedure.
You will also want to document the patient's comfort with the procedure and any adverse
outcomes.
That concludes our video on nasogastric tube placement.
Thank you.
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