Skills Module 3.0: Nasogastric Tube Posttest

Nasogastric tube (NGT) insertion is a common yet critical procedure performed in various healthcare settings. Mastering the post-test for Skills Module 3.0 on NGT insertion demonstrates proficiency in the practical aspects, safety protocols, and patient care involved. This comprehensive guide will navigate you through the key elements of NGT insertion, management, and troubleshooting, ensuring you're well-prepared for the post-test and, more importantly, for real-world clinical scenarios.

Understanding the Nasogastric Tube

An NGT is a flexible tube inserted through the nose, down the esophagus, and into the stomach. Its primary purposes include:

• Gastric Decompression: Removing air and fluids from the stomach to relieve pressure, often used in cases of bowel obstruction or ileus.
• Feeding: Providing nutritional support to patients who cannot eat orally, such as those recovering from surgery, stroke, or suffering from dysphagia.
• Medication Administration: Delivering medications directly into the stomach.
• Gastric Lavage: Washing out the stomach to remove toxins or blood, typically in cases of poisoning or gastrointestinal bleeding.

Pre-Procedure Preparation: A Crucial First Step

Before initiating NGT insertion, thorough preparation is paramount. This phase not only ensures patient safety and comfort but also optimizes the success of the procedure.

1. Patient Assessment and Education

• Review the patient's medical history: Identify any contraindications for NGT insertion, such as facial fractures, esophageal strictures, recent nasal surgery, or coagulopathies.
• Assess the patient's level of consciousness and ability to cooperate: This will influence the insertion technique and the level of assistance required.
• Explain the procedure to the patient: Describe the steps involved, the purpose of the NGT, and the expected sensations. This helps reduce anxiety and promotes cooperation.
• Obtain informed consent: Ensure the patient (or their legal representative) understands the procedure and its potential risks and benefits. Document the consent in the patient's medical record.

2. Gathering Equipment

Having all necessary equipment readily available streamlines the procedure and minimizes delays. Essential items include:

• Nasogastric tube: Choose the appropriate size and type based on the patient's age, size, and the purpose of the tube.
• Water-soluble lubricant: Facilitates smooth insertion and reduces friction.
• Gloves: Maintain sterile technique and protect against infection.
• Personal Protective Equipment (PPE): Gown and mask to protect against bodily fluids.
• Emesis basin: To collect any vomitus during the procedure.
• Cup of water with a straw (if appropriate): Swallowing helps advance the tube into the esophagus.
• Suction equipment: To clear the airway if the patient aspirates.
• Stethoscope: To auscultate for air insufflation into the stomach.
• pH indicator strips: To verify the acidity of the gastric aspirate.
• Syringe (50-60 mL): To aspirate gastric contents and flush the tube.
• Tape or commercial NGT fixation device: To secure the tube to the patient's nose.
• Safety pin and rubber band: To secure the NGT to the patient's gown.
• Towel or absorbent pad: To protect the patient's clothing and bedding.

3. Patient Positioning

Proper positioning is crucial for facilitating NGT insertion and minimizing the risk of complications.

• High Fowler's position (if tolerated): Elevating the head of the bed to 45-90 degrees reduces the risk of aspiration.
• If high Fowler's is not possible: Position the patient in a semi-Fowler's position (30-45 degrees) or in a lateral decubitus position (lying on their side).

Step-by-Step NGT Insertion Technique

Following a systematic approach to NGT insertion ensures accuracy and minimizes patient discomfort.

1. Determine the Length of Insertion

Accurately measuring the length of the NGT to be inserted is essential to ensure proper placement in the stomach. Use the NEX measurement technique:

• Nose to Ear Lobe to Xiphoid process: Measure the distance from the tip of the patient's nose to the earlobe and then from the earlobe to the xiphoid process (the bony prominence at the bottom of the sternum).
• Mark the tube: Use a piece of tape or a permanent marker to indicate the measured length on the NGT.

2. Prepare the Tube

• Lubricate the distal end of the NGT: Apply a generous amount of water-soluble lubricant to the first 2-4 inches of the tube. This will ease insertion and minimize trauma to the nasal passages and esophagus.

3. Insertion

• Gently insert the NGT into the nostril: Instruct the patient to tilt their head back slightly.
• Advance the tube along the floor of the nasal passage: Avoid forcing the tube if resistance is encountered.
• Once the tube reaches the nasopharynx: Instruct the patient to flex their head forward, tucking their chin to their chest. This closes off the trachea and opens the esophagus.
• Instruct the patient to swallow: As the patient swallows, advance the tube 1-2 inches with each swallow. Offer sips of water through a straw to facilitate swallowing (if the patient is able to swallow safely).
• Advance the tube to the marked point: Continue advancing the tube until the marked point reaches the nostril.

4. Troubleshooting

• If the patient coughs, gags, or experiences respiratory distress: Stop advancing the tube and check for proper placement. The tube may have entered the trachea. Gently pull back on the tube and try again, ensuring the patient's head is flexed forward.
• If resistance is encountered: Do not force the tube. Rotate the tube slightly and try again. If resistance persists, remove the tube and try the other nostril. Consider using a smaller-diameter tube.

Post-Insertion Confirmation: Ensuring Correct Placement

Verifying correct NGT placement is crucial before initiating feeding, medication administration, or gastric decompression. Several methods are used to confirm placement:

1. Auscultation

• Inject 10-20 mL of air into the NGT: Using a syringe, inject air into the tube while listening with a stethoscope over the epigastric region (the upper central abdomen).
• Listen for a whooshing sound: A whooshing sound indicates that the air has entered the stomach. However, auscultation is not a reliable method for confirming NGT placement and should not be used as the sole method.

2. pH Testing of Gastric Aspirate

• Aspirate a small amount of gastric fluid: Using a syringe, aspirate 5-10 mL of fluid from the NGT.
• Test the pH of the aspirate: Apply a drop of the aspirate to a pH indicator strip.
• Interpret the results: A pH of 5.5 or less generally indicates gastric placement. However, medications such as antacids can raise the pH of gastric contents.

3. Radiographic Confirmation (X-ray)

• Obtain a chest X-ray: This is the gold standard for confirming NGT placement. The X-ray will show the position of the NGT in relation to the stomach.
• Verify placement with a radiologist: A radiologist should interpret the X-ray to confirm that the tip of the NGT is located in the stomach or duodenum.

Important Note: Always confirm NGT placement using radiographic confirmation before initiating feeding or medication administration.

NGT Management and Maintenance

Once the NGT is in place, ongoing management and maintenance are essential to prevent complications and ensure optimal patient outcomes.

1. Secure the NGT

• Use tape or a commercial NGT fixation device: Secure the NGT to the patient's nose to prevent dislodgement.
• Avoid putting pressure on the nares: Reposition the tape or device as needed to prevent skin breakdown.
• Secure the NGT to the patient's gown: Use a safety pin and rubber band to attach the NGT to the patient's gown, providing additional security and preventing accidental pulling.

2. Maintain Patency

• Flush the NGT regularly: Flush the tube with 30-60 mL of water every 4-6 hours and after each medication administration or feeding. This helps prevent clogging.
• Use warm water if the tube becomes clogged: Gently flush the tube with warm water using a syringe. Avoid using excessive force, which can damage the tube.
• Consider using pancreatic enzyme solutions: If warm water is ineffective, consider using a pancreatic enzyme solution to dissolve the clog. Follow the manufacturer's instructions carefully.

3. Oral and Nasal Care

• Provide frequent oral hygiene: Encourage the patient to brush their teeth and use mouthwash regularly. This helps prevent oral infections and promotes comfort.
• Clean the nares regularly: Use a cotton swab moistened with saline to clean the nares around the NGT. This helps prevent skin breakdown and infection.
• Apply a water-soluble lubricant to the nares: This helps prevent dryness and irritation.

4. Monitoring and Documentation

• Monitor the patient for complications: Assess for signs and symptoms of aspiration, skin breakdown, infection, and electrolyte imbalances.
• Document the following:
  • Date and time of NGT insertion
  • Size and type of NGT
  • Nare used for insertion
  • Length of tube inserted
  • Method of placement confirmation
  • Patient's tolerance of the procedure
  • Any complications encountered
  • Frequency of flushing
  • Volume and type of flush solution
  • Assessment findings

Potential Complications and Troubleshooting

While NGT insertion is generally safe, potential complications can arise. Being aware of these complications and knowing how to manage them is crucial.

1. Aspiration

• Signs and symptoms: Coughing, choking, wheezing, respiratory distress, pneumonia.
• Prevention: Position the patient in high Fowler's position during and after NGT insertion and feeding. Verify NGT placement before initiating feeding or medication administration. Check gastric residual volume before each feeding.
• Management: Stop the feeding immediately. Suction the airway. Administer oxygen. Monitor the patient's respiratory status. Obtain a chest X-ray.

2. Nasal and Esophageal Irritation

• Signs and symptoms: Nasal pain, sore throat, hoarseness, bleeding.
• Prevention: Use a well-lubricated NGT. Avoid using excessive force during insertion. Provide frequent oral and nasal care.
• Management: Apply a water-soluble lubricant to the nares. Offer throat lozenges or gargle with warm saline. Consider using a smaller-diameter NGT.

3. Skin Breakdown

• Signs and symptoms: Redness, irritation, blistering around the nares.
• Prevention: Reposition the tape or fixation device regularly. Use skin protectants.
• Management: Clean the area with mild soap and water. Apply a barrier cream. Consider using a different type of fixation device.

4. Clogged Tube

• Signs and symptoms: Inability to flush the NGT, decreased gastric output.
• Prevention: Flush the NGT regularly with water.
• Management: Attempt to flush the tube with warm water. Consider using a pancreatic enzyme solution. If these measures are ineffective, the NGT may need to be replaced.

5. Electrolyte Imbalances

• Signs and symptoms: Weakness, fatigue, muscle cramps, confusion, arrhythmias.
• Prevention: Monitor electrolyte levels regularly. Replace electrolytes as needed.
• Management: Administer electrolyte supplements as prescribed. Adjust the feeding regimen.

NGT Removal

When the NGT is no longer needed, it should be removed carefully to minimize patient discomfort and prevent complications.

1. Preparation

• Explain the procedure to the patient: Describe the steps involved and reassure the patient.
• Gather equipment: Gloves, tissues, emesis basin.
• Position the patient: Semi-Fowler's position.

2. Removal

• Disconnect the NGT from the suction or feeding tube: Ensure the tube is free from any attachments.
• Flush the NGT with 10-20 mL of air: This clears the tube of any remaining fluid.
• Instruct the patient to take a deep breath and hold it: This helps prevent aspiration.
• Gently and slowly remove the NGT: Pull the tube out smoothly and steadily.
• Provide the patient with tissues: To wipe their nose.
• Assess the patient: For any signs of discomfort or complications.

3. Post-Removal Care

• Provide oral hygiene: Encourage the patient to rinse their mouth.
• Monitor the patient: For any signs of nasal bleeding, sore throat, or respiratory distress.
• Document the removal: In the patient's medical record.

Key Considerations for the Skills Module 3.0 Post-Test

The Skills Module 3.0 post-test on NGT insertion will likely assess your knowledge and skills in the following areas:

• Indications and contraindications for NGT insertion: Understand when NGT insertion is appropriate and when it is not.
• Proper technique for NGT insertion: Demonstrate the ability to insert an NGT safely and effectively.
• Methods for confirming NGT placement: Know the different methods for verifying NGT placement and their limitations.
• NGT management and maintenance: Understand how to care for an NGT and prevent complications.
• Troubleshooting potential complications: Be able to identify and manage common complications associated with NGT insertion.
• Documentation: Know what information to document in the patient's medical record.

Frequently Asked Questions (FAQ)

• What size NGT should I use? The size of the NGT depends on the patient's age, size, and the purpose of the tube. Smaller-diameter tubes are generally used for infants and children, while larger-diameter tubes are used for adults.
• What do I do if I encounter resistance during NGT insertion? Do not force the tube. Rotate the tube slightly and try again. If resistance persists, remove the tube and try the other nostril. Consider using a smaller-diameter tube.
• How often should I flush the NGT? Flush the NGT with 30-60 mL of water every 4-6 hours and after each medication administration or feeding.
• How do I know if the NGT is clogged? You will be unable to flush the NGT, and the gastric output will decrease.
• What is the gold standard for confirming NGT placement? Radiographic confirmation (X-ray) is the gold standard for confirming NGT placement.

Conclusion

Mastering NGT insertion and management requires a combination of theoretical knowledge and practical skills. By understanding the indications, contraindications, insertion technique, methods for confirming placement, and potential complications, you can provide safe and effective care to patients requiring NGTs. This comprehensive guide provides a solid foundation for success in the Skills Module 3.0 post-test and, more importantly, in your clinical practice. Remember to always prioritize patient safety, follow established protocols, and seek guidance from experienced healthcare professionals when needed.