The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [271]
Procedure guideline 8.10 Nasogastric intubation with tubes using an introducer
Essential equipment
Clinically clean tray
Fine-bore nasogastric tube
Introducer for tube
Receiver
Sterile water
50 mL enteral syringe
Hypoallergenic tape
Adhesive patch if available
Glass of water
Lubricating jelly
Indicator strips with pH range of 0–6 or 1–11 with gradations of 0.5
Preprocedure
Action Rationale
1 Explain and discuss the procedure with the patient.
To ensure that the patient understands the procedure and gives his/her valid consent (NMC 2008b, C).
2 Arrange a signal by which the patient can communicate if they want the nurse to stop, for example by raising their hand.
The patient is often less frightened if they feel that they have some control over the procedure. E
3 Assist the patient to sit in a semi-upright position in the bed or chair. Support the patient’s head with pillows. Note: The head should not be tilted backwards or forwards (Rollins 1997).
To allow for easy passage of the tube. This position enables easy swallowing and ensures that the epiglottis is not obstructing the oesophagus. E
4 Select the appropriate distance mark on the tube by measuring the distance on the tube from the patient’s earlobe to the bridge of the nose plus the distance from the earlobe to the bottom of the xiphisternum (see Action Figure 4a, 4b).
To ensure that the appropriate length of tube is passed into the stomach. E
5 Wash hands with bactericidal soap and water or bactericidal alcohol handrub, and assemble the equipment required.
Hands must be cleansed before and after patient contact to minimize cross-infection (Fraise and Bradley 2009, E).
6 Follow manufacturer’s instructions to prepare the tube, for example injecting sterile water down the tube and lubricating the proximal end of the tube with lubricating jelly.
Contact with water activates the coating inside the tube and on the tip. This lubricates the tube, assisting its passage through the nasopharynx and allowing easy withdrawal of the introducer. E
Procedure
7 Check that the nostrils are patent by asking the patient to sniff with one nostril closed. Repeat with the other nostril.
To identify any obstructions liable to prevent intubation. E
8 Insert the rounded end of the tube into the clearer nostril and slide it backwards and inwards along the floor of the nose to the nasopharynx. If any obstruction is felt, withdraw the tube and try again in a slightly different direction or use the other nostril.
To facilitate the passage of the tube by following the natural anatomy of the nose. E
9 As the tube passes down into the nasopharynx, unless swallowing is contraindicated, ask the patient to start swallowing and sipping water.
To focus the patient’s attention on something other than the tube. A swallowing action closes the glottis and the cricopharyngeal sphincter opens, enabling the tube to pass into the oesophagus (Groher 1997, E).
10 Advance the tube through the pharynx as the patient swallows until the predetermined mark has been reached. If the patient shows signs of distress, for example gasping or cyanosis, remove the tube immediately.
The tube may have accidentally been passed down the trachea instead of the pharynx. Distress may indicate that the tube is in the bronchus. However, absence of distress is not sufficient for detecting a misplaced tube (NPSA 2005, C).
11 Remove the introducer by using gentle traction. If it is difficult to remove, then remove the tube as well.
If the introducer sticks in the tube, this may indicate that the tube is in the bronchus. E
12 Secure the tape to the nostril with adherent dressing tape, for example Elastoplast, or an adhesive nasogastric stabilization/securing device. Alternatively Tegaderm/Deoderm can be applied