Nasogastric Intubation: Insertion Procedures & Technique

When a patient cannot take in enough nutrition orally or cannot eat and drink safely, nasogastric tube feeding maintains their nutritional status. NG tubes are especially useful in dysphagia, where patients struggle to meet needs and risk aspiration.

What is Nasogastric Intubation?

NG intubation inserts a thin plastic tube through the nostril, down the esophagus, and into the stomach. Once placed, you can deliver food and medication or remove stomach contents. NG tubes are typically short and used mainly for suctioning stomach contents and secretions.

Types of Tubes

Tubes passing from the nostrils into the duodenum or jejunum are nasoenteric tubes, medium-length for feeding or long for decompression and aspiration. The two most common GI intubation tubes:

• Levin tube: a single-lumen, multipurpose plastic tube for nasogastric intubation.
• Salem sump tube: a double-lumen tube with a "pigtail" for intermittent or continuous suction.

Indications

• Gastric decompression: connect the tube to suction to relieve pressure, essential in bowel obstruction, paralytic ileus, and post-op stomach or intestinal surgery.
• Aspiration of gastric fluid for lavage or specimen analysis, and in drug overdose or poisoning.
• Feeding and medication administration when oral intake is not possible.
• Prevention of vomiting and aspiration in trauma, and assessment of GI bleeding.

Contraindications

• Recent nasal surgery or severe midface trauma: absolute contraindications, due to the risk of intracranial insertion; use an orogastric tube instead.
• Coagulation abnormality: increased bleeding risk.
• Esophageal varices: increased bleeding and complication risk.
• Recent banding of esophageal varices: elevated risk of damage and bleeding.
• Alkaline ingestion: alkaline substances cause significant esophageal and gastric damage, making intubation hazardous.

Risks and Complications

• Aspiration, the main complication.
• Discomfort, with gagging or vomiting as the tube passes; keep suction ready.
• Trauma to the sinuses, throat, esophagus, or stomach if improperly inserted.
• Wrong placement into the lungs, which lets food and medicine pass and can be fatal.
• Other: abdominal cramping or swelling from oversized feedings, diarrhea, regurgitation, tube obstruction, perforation, and tubes coming out of place.
• Short-term use only. Prolonged use leads to sinusitis, infection, and ulceration of the sinuses, throat, esophagus, or stomach.

Nursing Considerations

• Provide oral and skin care: mouth rinses and water-soluble lubricant on the lips and nostrils to prevent dryness.
• Verify placement by aspirating stomach contents; an X-ray is the most reliable method.
• Wear gloves when handling the tube.
• Use face and eye protection if vomiting risk is high; in trauma, the whole team wears gloves, face and eye protection, and gowns.
• Monitor for complications: nasal irritation, displacement, or infection.
• Ensure patient comfort and educate them on what to expect.
• Document placement verification, maintenance, and any complications.

Inserting a Nasogastric Tube

Supplies and Equipment

• Gloves
• Nasogastric tube
• Water-soluble lubricant (e.g., K-Y jelly)
• Protective towel for the client
• Emesis basin
• Tape for marking placement and securing the tube
• Glass of water (if allowed) and a straw
• Stethoscope
• 60-mL catheter tip syringe
• Rubber band and safety pin
• Suction or tube feeding equipment

A second person may be needed to assist with positioning, holding the water, and encouragement.

Preparation

Patients need little preparation: blow the nose and take a few sips of water (if allowed) beforehand. Once the tube is in the nostril, the patient swallows or drinks water to ease it through the esophagus.

Anesthesia

Some institutions use topical anesthesia to reduce pain and improve success:

• Viscous lidocaine (sniff and swallow method): reduces pain and gagging.
• Nebulization of lidocaine (1% or 4%): through a face mask.
• Anesthetic spray: benzocaine, or tetracaine/benzocaine/butyl aminobenzoate.

Steps in Inserting a Nasogastric Tube

1. Review the order and know the tube's type, size, and purpose. A size 16 or 18 French is widely used for adults; children range from a very small size 5 French to size 12 French for older children.

2. Check the client's identification band to confirm the right client.

3. Gather equipment and set up tube-feeding or suction equipment, confirming it works.

4. Briefly explain the procedure and assess the client's ability to participate. Do not explain too far in advance, since anxiety can interfere; the client needs to relax, swallow, and cooperate.

5. Perform hand hygiene and don non-sterile gloves. Clean technique suffices, since the GI tract is not sterile.

6. Position the client upright or in full Fowler's position with a clean towel over the chest, for swallowing, neck-stomach alignment, and peristalsis.

7. Measure the tubing from the bridge of the nose to the earlobe, then to the point halfway between the end of the sternum and the navel, marking the spot, since each client's terminal insertion point differs.

8. Wipe the face and nose with a wet towel, then wipe the exterior of the nose with an alcohol swab, so the tape holds on clean, non-oily skin and the tube does not shift and cause gagging.

9. Cover the client's eyes with a cloth to protect against alcohol fumes.

10. Examine the nostrils for deformity or obstruction by closing one nostril at a time and having the client breathe through the nose. Insert through the more patent nostril.

11. Lubricate 4 to 8 inches of the tube with water-soluble lubricant. A squirt of Xylocaine jelly in the nostril and a Xylocaine spray to the back of the throat help with discomfort.

12. Flex the head forward, tilt the nose tip upward, and pass the tube gently to the back of the throat, straight back. Flexing the head aids anatomic insertion and makes tracheal passage less likely.

13. Once the tube reaches the nasopharynx, have the client lower the head slightly. Ready the water, emesis basin, and tissues. This follows the anatomic landmarks, and swallowing water aids passage.

14. Instruct the client to swallow as the tube advances to the marked position, breathing through the mouth, so the tube enters the stomach rather than the trachea.

15. If respiratory status changes, the tube coils in the mouth, or the client coughs or turns cyanotic, withdraw the tube immediately. It may be in the trachea.

16. If you feel obstruction, pull out and try the other nostril, letting the client rest a moment.

17. Advance to the marked insertion point and place a temporary piece of tape across the nose and tube to check placement before securing it.

18. Check the back of the throat to confirm the tube is not curled there. If it is, withdraw the entire tube and start again.

19. Check tube placement by at least two, preferably three, of these methods:

• Aspirate stomach contents, which appear cloudy, green, tan, off-white, bloody, or brown. Some small-diameter tubes collapse under suction, making aspiration difficult.
• Check the pH of the aspirate, more accurate than visual inspection. Stomach aspirate generally has a pH range of 0 to 4, commonly less than 4; respiratory aspirate is more alkaline at a pH of 7 or more.
• Inject 30 mL of air into the stomach and listen with the stethoscope for the "whoosh." Small-diameter tubes may make this hard to hear.
• Confirm by x-ray, the only method considered positive.

20. Secure the tube with tape or a commercial holder once stomach placement is confirmed, to prevent peristaltic advancement or accidental removal.

Administering Tube Feeding

Supplies and Equipment

• Gloves
• Feeding pump (if ordered)
• Clamp (optional)
• Feeding solution
• Large catheter tip syringe (30 mL or larger)
• Feeding bag with tubing
• Water and a measuring cup
• Optional: disposable pad, pH indicator strips, water-soluble lubricant, paper towels

Steps in Tube Feeding

1. Prepare the formula:

• Check the expiration date, since outdated formula may be contaminated or less nutritious.
• Shake the can thoroughly to remix settled solution.
• For powdered formula, mix per package instructions, prepare enough for the next 24 hours, refrigerate unused formula, and let it reach room temperature before use. Formula loses value and can be contaminated after 24 hours, and cold formula causes abdominal discomfort.

2. Explain the procedure to gain cooperation.

3. Keep the head of the bed elevated at least 30 to 40 degrees; never feed in the supine position. Semi-Fowler's or full-Fowler's prevents aspiration pneumonia.

4. Check feeding tube placement by:

• Aspirating stomach contents, which confirms placement and shows residual reflecting gastric emptying. Connect the syringe, pull back carefully, determine the residual (clamp the tube to remove the syringe), and return the residual to the stomach, continuing if it does not exceed protocol.
• Injecting 10 to 20 mL of air into the tube (3–5 mL for children) while auscultating over the left upper quadrant; a whoosh or gurgle indicates the stomach, though this is unreliable with small-bore tubes.
• Measuring the pH of aspirated gastric secretions, which should read 1 to 4 (gastric contents are acidic; pleural and intestinal fluid are slightly basic).
• Taking an x-ray or ultrasound, the only method considered positive.

Intermittent or bolus feeding

5. If using a feeding bag: suspend it about 12 to 18 inches above the stomach, clamp the tubing, fill the bag, and prime the tubing to clear air. Connect to the gastric tube, open the clamp, and adjust flow per the order, since fast feeding causes nausea and cramping. As feeding completes, add 30 to 60 mL of water to clear the tube, then clamp and disconnect.

6. If using a syringe: clamp the gastric tube, connect the large syringe (plunger or bulb removed), pour in feeding, raise the syringe 12 to 18 inches above the stomach, and open the clamp. Let it flow slowly, raising and lowering the syringe to control the rate, adding formula until complete, to prevent air entry, nausea, and cramping.

Continuous feeding

7. If using a feeding pump: clamp the setup on a pole, add solution, open the clamp, and prime the tubing. Thread or load the tubing per the manufacturer, connect to the gastric tube, set the prescribed rate and volume, open the clamp, and turn on the pump. Stop the feeding every 4 to 8 hours to assess residual, and flush the tube every 6 to 8 hours.

8. When complete, instill the prescribed water and keep the head elevated 20 to 30 minutes to prevent aspiration.

9. Regularly assess the skin around surgically placed tubes, cleansing with mild soap and water, drying thoroughly, and checking for redness, swelling, pain, or inflammation.

10. Provide mouth care (brushing, mouthwash, moist lips) for hygiene and comfort.

Monitoring a Nasogastric Tube

1. Confirm the order for the NG tube, type of suction, and irrigation direction.

2. Observe drainage: amount, color, consistency, and odor, and hematest for blood. Normal gastric drainage is light yellow to green from bile; bloody drainage may follow gastric surgery but needs close monitoring, and coffee-ground drainage may indicate bleeding.

3. Inspect the suction apparatus: correct setting (continuous or intermittent), range (low, medium, high), and movement of drainage. Loose connections, kinks, or blockages interfere with suction.

4. Assess placement, since the tube can displace into the trachea.

5. Assess comfort: nausea, vomiting, fullness, or pain, which may indicate incorrect suction or blockage.

6. Assess the abdomen for distention and auscultate for bowel sounds. Distention may signal gas or bleeding; bowel sounds indicate returning peristalsis.

7. Assess mobility and respiratory status. Turning and ambulation encourage peristalsis and drainage; the tube may discourage coughing and deep breathing.

8. Observe the nostrils and oral cavity. Cleanse and lubricate the nostrils, change tape as needed, and give mouth care at 2-hr intervals.

9. Monitor overall safety. Secure the tube to the nose and pin it to the gown, keep the call bell in reach, avoid kinks, and keep the client in semi-Fowler's to facilitate drainage and minimize aspiration risk.

10. Monitor the tube and suction at least every 2 hours and irrigate at the ordered interval.

11. Record and measure irrigations and drainage on the intake/output chart. Irrigations are recorded as intake; drainage is measured as output every 8 hours (more often if copious).

12. Replenish supplies and maintain equipment per policy and manufacturer recommendations.

Irrigating a Nasogastric Tube

Regular irrigation maintains patency by clearing formula or debris. Some tubes need normal saline irrigation; others are maintained by airflow. For double-lumen tubes, connect the main lumen to suction and use the short lumen as an airway; if the main lumen blocks, clear it, then inject air through the short lumen.

Supplies and Equipment

• NG tube connected to continuous or intermittent suction
• Irrigation or Toomey syringe and container for solution
• Normal saline for irrigation
• Disposable pad or bath towel
• Disposable gloves (optional)
• Stethoscope
• Clamp

Steps in Irrigating a Nasogastric Tube

1. Check the order and explain the procedure to encourage cooperation.

2. Gather equipment and check expiration dates on the saline and irrigation set.

3. Wash your hands.

4. Assist the client to semi-Fowler's position unless contraindicated, to minimize aspiration risk.

5. Check placement: aspirate gastric contents with an Asepto or Toomey syringe; place 10mL-50ml of air in the syringe and inject while auscultating the epigastric area for the whoosh; and ask the client to speak (difficulty speaking suggests tracheal misplacement).

6. Clamp the suction tubing near the connection, disconnect the NG tube, and lay it on a pad to protect against leakage.

7. Draw up 30 ml of saline (or the ordered amount), which compensates for electrolytes lost through drainage.

8. Place the syringe tip in the tube, hold it upright, and gently insert the solution (or by gravity), without forcing, to avoid air entry and trauma.

9. If you cannot irrigate, reposition the client and retry; check with the physician if repeated attempts fail.

10. Withdraw or aspirate fluid; if no return, inject 20 ml of air and aspirate again to reposition the tube tip.

11. Reconnect to suction and observe movement to confirm patency.

12. Measure and record the irrigating solution and return. Solution instilled is intake; solution returned is output.

13. Rinse equipment if reusing.

14. Wash your hands.

15. Record the procedure, drainage description, and the client's response.

Removing a Nasogastric Tube

Removal assesses whether the patient can tolerate oral feeding. First identify contraindications: a continuing need for the tube for feeding or suction means it should not be removed.

Supplies and Equipment

• Tissues
• Plastic disposable bag
• Bath towel or disposable pad
• Clean disposable glove

Steps in Removing a Nasogastric Tube

1. Check the order for removal.

2. Explain the procedure to the client.

3. Gather equipment.

4. Wash your hands and don a clean glove on the hand that will remove the tube.

5. Discontinue suction, separate the tube, unpin it from the gown, and remove the adhesive tape from the bridge of the nose.

6. Place a towel or pad across the chest and hand the client tissues.

7. Instruct the client to take a deep breath and hold it to prevent aspiration.

8. Clamp the tube with your fingers and quickly, carefully remove it while the client holds their breath, to minimize trauma and prevent drainage.

9. Place the tube and glove in the disposable bag.

10. Reposition the client, offer mouth care, and make them comfortable.

11. Measure the drainage, dispose of equipment per policy, and wash your hands.

12. Record the removal, the client's response, and the drainage measurement, and continue to monitor for discomfort or complications, educating the patient on when to seek help.