The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [272]
To hold the tube in place. To ensure patient comfort. E
Postprocedure
13 Measure the part of the visible tube from tip of nose and record in care plan. Mark the tube at the exit site with a permanent marker pen (nares) (Metheny and Titler 2001).
To provide a record to assist in detecting movement of the tube (NPSA 2005, C).
14 Check the position of the tube to confirm that it is in the stomach by using the following methods.
Feeding via the tube must not begin until the correct position of the tube has been confirmed (NPSA 2005, C). To confirm placement of radiopaque nasogastric tube.
Either
Take an X-ray of chest and upper abdomen.
Or X-ray of radiopaque tubes is the most accurate confirmation of position and is the method of choice in patients with altered anatomy, those who are aspirating or are unconscious with no gag reflex (NPSA 2005, C).
Aspirate 0.5–1 mL of stomach contents and test pH on indicator strips (NPSA 2005, C; Rollins 1997). When aspirating fluid for pH testing, wait at least 1 hour after a feed or medication has been administered (either orally or via the tube). Before aspirating, flush the tube with 20 mL of air to clear other substances (Metheny et al. 1993). A pH level of 5.5 is unlikely to be pulmonary aspirates and it is considered appropriate to proceed to feed through the tube (Metheny and Meert 2004, NPSA 2005). Indicator strips should have gradations of 0.5 or paper with a range of 0–6 or 1–11 to distinguish between gastric acid and bronchial secretions (NPSA 2005, C).
To prove an accurate test result because the feed or medication may raise the pH of the stomach.
If a pH of 6.0 or above is obtained or there is doubt over the result in the range of pH 5–6 then feeding must not commence. The nasogastric tube may need to be repositioned or checked with an X-ray. There is an increased risk of the nasogastric tube being incorrectly placed (NPSA 2005, C).
15 The following methods must not be used to test the position of a nasogastric feeding tube: auscultation (introducing air into the nasogastric tube and checking for a bubbling sound via a stethoscope, also known as the ‘whoosh test’), use of litmus paper or absence of respiratory distress.
These tests are not accurate or reliable as a method of checking the position of a nasogastric tube as they have been shown to give false-positive results (Metheny and Meert 2004, E; NPSA 2005, C).
16 Document the tip position in the patient’s notes.
To record the position (NMC 2009, C).
Action Figure 4a Measuring for a nasogastric tube: measure from patient’s ear lobe to bridge of nose.
Action Figure 4b Measuring for a nasogastric tube: measure from ear lobe to bottom of xiphisternum.
Procedure guideline 8.11 Nasogastric intubation with tubes without using an introducer, for example, a Ryle’s tube
Essential equipment
Clinically clean tray
Nasogastric tube that has been stored in a deep freeze for at least half an hour before the procedure is to begin, to ensure a rigid tube that will allow for easy passage
Receiver
Topical gauze
Lubricating jelly
Hypoallergenic tape
Indicator strips with pH range of 0–6 or 1–11 with gradations of 0.5
50 mL enteral syringe
Spigot
Glass of water
Preprocedure
Action Rationale
1 Explain and discuss the procedure with the patient.
To ensure that the patient understands the procedure and gives their 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