A nasogastric (NG) tube is a pliable single- or double-lumen (inner open space) plastic tube that is hollow and is passed through the nose and into the stomach. Double-lumen tubes are used for gastric decompression (Sigmon & An, 2020) (Figure 1). One larger lumen empties the stomach via suction, and the other provides for a continuous flow of air (acting as a sump) (Sigmon & An, 2020). The airflow lumen controls suction by preventing the drainage lumen from pulling stomach mucosa into the tube's openings and irritating the stomach lining. A one-way antireflux valve may be used in the airflow lumen to prevent reflux of gastric contents through the airflow lumen (Figure 1). When pressure from gastric contents enters the airflow tubing, the valve closes to prevent secretions from exiting the tube.

NG tubes may be used to decompress or drain the stomach of fluid or unwanted stomach contents such as poison or medication and air (Burns & Delgado, 2019) and may be used when conditions are present in which peristalsis is absent. Examples include paralytic ileus and intestinal obstruction by tumor or hernia and adhesive small bowel obstruction (ten Broek et al., 2018). NG tubes may also be used to allow the gastrointestinal tract to rest before or after abdominal surgery to promote healing (Bauldoff et al., 2020). Historically, an NG tube was often used postoperatively as a routine part of care after major abdominal surgery, to rest the intestinal tract and promote healing. Research now shows the routine use of NG tubes after abdominal surgery may serve no beneficial purpose and may actually delay the patient's progress, increasing the time required for flatus to occur and increasing pulmonary complications (Hodin & Bordeianou, 2020; Kantrancha & George, 2014; Sigmon & An, 2020; Venara et al., 2020). Decompression should be reserved for patients with conditions such as a prolonged postoperative ileus or a small bowel obstruction (Hodin & Bordeianou, 2020). Tubes for decompression typically are attached to suction. Suction can be applied intermittently or continuously. When the underlying condition has been resolved and/or the NG tube is no longer indicated, the tube is removed (refer to Skill 13-10).

NG tubes may also be used to administer medications or to provide short-term nutrition, using the stomach as a natural reservoir for food. The use of NG tubes for nutritional purposes is discussed in Chapter 11. Administration of medications via an NG tube is discussed in Chapter 5.

Radiographic examination, measurement of tube length and measurement of tube marking, measurement of aspirate pH, and monitoring of carbon dioxide have been suggested to confirm tube placement in the stomach. The use of two or more of these techniques in conjunction with each other increases the likelihood of correct tube placement (AACN, 2020; Anderson, 2019; Dias et al., 2019; Irving et al., 2018; Methany et al., 2019; Rahimi et al., 2015). Recommendations for use of visual inspection of gastric aspirate are conflicting; this method should be used cautiously if part of policy and procedure guidelines and with consideration to the potential for inaccuracy (AACN, 2020; Dias et al., 2019; Mak & Tam, 2020; Metheny et al., 2019). When bedside methods to check placement suggest the tube has been displaced, a radiograph should be requested to determine the tube's location (AACN, 2020). An old technique of auscultation of air injected into a tube has been proved unreliable and should not be used (AACN, 2020; Boeykens et al., 2014; Boullata et al., 2017; Irving et al., 2018; Metheny et al., 2019). A detailed discussion of each of these methods to confirm placement is provided in Chapter 11, Nutrition.

Assessment

Assess the patency of the patient's nares by asking the patient to occlude one nostril and breathe normally through the other. Select the nostril through which air passes more easily. Also, assess the patient's history for any recent facial trauma, polyps, blockages, or surgeries. Patients with facial fractures or facial surgeries present a higher risk for misplacement of the tube into the brain. Many facilities require a health care provider to place NG tubes in these patients. Inspect the abdomen for distention and firmness; auscultate for bowel sounds or peristalsis and palpate the abdomen for distention and tenderness. If the abdomen is distended, consider measuring the abdominal girth at the umbilicus to establish a baseline.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

• Impaired gastrointestinal system function
• Knowledge deficiency
• Risk for impaired gastrointestinal system function

Outcome Identification and Planning

The expected outcome to achieve when inserting an NG tube is that the tube is passed into the patient's stomach without any complications. Other outcomes may include that the patient exhibits no signs and symptoms of aspiration, rates pain as decreased from prior to insertion, and verbalizes an understanding of the reason for NG tube insertion.

Implementation

Action	Rationale
1. Verify the prescribed intervention for insertion of an NG tube. Gather equipment, including selection of the appropriate NG tube.	This ensures the patient receives the correct treatment. Assembling equipment provides for an organized approach to the task. NG tubes should be radiopaque, contain clearly visible markings for measurement, and may have multiple ports for aspiration.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Explain the procedure to the patient, including the rationale for why the tube is needed. Discuss the associated discomforts that may be experienced and possible interventions that may allay this discomfort. Answer any questions, as needed.	Explanation facilitates patient engagement and reduces anxiety.
5. Assemble equipment on the overbed table or other surface within reach.	Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
6. Close the patient's bedside curtain or door. Raise the bed to a comfortable working position (VHACEOSH, 2016). Assist the patient to high-Fowler position or elevate the head of the bed 45 degrees if the patient is unable to maintain an upright position. Drape their chest with a bath towel or disposable pad. Have an emesis basin and tissues within reach.	Closing the curtains or the door provides for patient privacy. Having the bed at the proper height prevents back and muscle strain. The upright position is more natural for swallowing and reduces the risk for aspiration if the patient should vomit. Passage of the tube may stimulate gagging and tearing of the eyes.
7. Refer to facility policy regarding method(s) to determine insertion length. Measure the distance to insert the tube by placing the tube tip at the patient's nostril and extending it to the tip of the earlobe and then to the point midway between the xiphoid process and umbilicus. Alternatively, measure from the xiphisternum (xiphoid process) to the earlobe, to the nose and add 10 cm (Fan et al., 2019). Refer to facility policy. Mark the tube with an indelible marker.	The NEMU (nose-ear-mid-umbilicus) has been suggested as an accurate method of measurement in infants and children (Ellett et al., 2012; Irving et al., 2018). Another method, the xiphisternum-earlobe-nose +10 cm, has been suggested as the best estimate for the length of NG tube required (Fan et al., 2019). Correct positioning results in tip positioning between 3 and 10 cm under the lower esophageal sphincter (Torsy et al., 2018). Determination of NG tube insertion length is controversial, and recommendations are conflicting; most evidence for practice identifies the need for more research to determine more accurate and reliable ways to determine tube insertion depth (Boeykens, 2018; Fan et al., 2019; Mak & Tam, 2020; Parker et al., 2018; Taylor, 2020; Torsy et al., 2018).
8. Put on gloves. Lubricate the tip of the tube (at least 2 to 4 inches) with water-soluble lubricant. Apply topical anesthetic to the nostril and oropharynx, as appropriate.	Lubrication reduces friction and facilitates passage of the tube into the stomach. Water-soluble lubricant will not cause pneumonia if the tube accidentally enters the lungs. Topical anesthetics act as local anesthetics, reducing discomfort. Consult the health care team for an order for a topical anesthetic, such as lidocaine gel or spray, if needed.
9. After selecting the appropriate nostril, ask the patient to flex their head slightly back against the pillow. Gently insert the tube into the nostril while directing the tube upward and backward along the floor of the nose (Figure 2). The patient may gag when the tube reaches the pharynx. Provide tissues for tearing or watering of the eyes. Offer comfort and reassurance to the patient.	Following the normal contour of the nasal passage while inserting the tube reduces irritation and the likelihood of mucosal injury. The tube stimulates the gag reflex readily. Tears are a natural response as the tube passes into the nasopharynx. Many patients report that gagging and throat discomfort can be more painful than the tube passing through the nostrils.
10. When the pharynx is reached, instruct the patient to touch their chin to their chest. Encourage the patient to sip water through a straw or swallow (Figure 3). Advance the tube in a downward and backward direction when the patient swallows. Stop when the patient breathes. If gagging and coughing persist, stop advancing the tube and check placement of the tube with a tongue blade and flashlight. If the tube is curled, straighten the tube and attempt to advance it again. Keep advancing the tube until the pen marking is reached. Do not use force. Rotate the tube if it meets resistance.	Bringing the head forward helps close the trachea and open the esophagus. Swallowing helps advance the tube, causes the epiglottis to cover the opening of the trachea, and helps to eliminate gagging and coughing. Excessive coughing and gagging may occur if the tube has curled in the back of the throat. Forcing the tube may injure mucous membranes.
11. Discontinue the procedure and remove the tube if there are signs of distress, such as gasping, coughing, cyanosis, and inability to speak or hum.	The tube is in the airway if the patient shows signs of distress and cannot speak or hum. If, after three attempts, NG insertion is unsuccessful, another nurse may try, or the patient should be referred to another health care professional.
12. Secure the tube loosely to the nose or cheek with tape until placement is verified. Confirm placement of the NG tube in the patient's stomach using at least two methods. Refer to Skill 11-2 in Chapter 11.	Verify correct placement of the NG tube after the initial insertion, before beginning a feeding or instilling medications or liquids, and at regular intervals during continuous feedings (Metheny et al., 2019). A misplaced tube in the lungs or pulmonary tissue places the patient at risk for aspiration, pneumonia, and even death (Lamont et al., 2011, as cited in Anderson, 2018). With the exception of radiographic examination, which is usually done immediately after insertion to verify initial tube placement, the use of two or more techniques in conjunction with each other increases the likelihood of correct tube placement (AACN, 2020; Anderson, 2019; Anderson, 2018; Dias et al., 2019; Rahimi et al., 2015).
13. After confirmation of tube placement, secure the tube. Apply a skin barrier to the tip and end of the nose and allow it to dry. Remove gloves and secure the tube with a commercially prepared securement device (Figure 4) (follow the manufacturer's directions) or tape it to the patient's nose. To secure with tape:	Securing the tube prevents migration of the tube inward and outward. The skin barrier improves adhesion and protects skin. Constant pressure of the tube against the skin and mucous membranes may cause pressure injury (Powers, 2019).
a. Cut a 4-inch piece of tape and split the bottom 2 inches (Figure 5) or use packaged nose tape for NG tubes.
b. Place the unsplit end over the bridge of the patient's nose (Figure 6).
c. Wrap the split ends under and around the NG tube (Figure 7). Be careful not to pull the tube too tightly against the nose (Powers, 2019).
14. Put on gloves. Clamp the tube and remove the syringe. Cap or attach the tube to suction (Figure 8), according to the prescribed interventions. Remove gloves. Perform hand hygiene.	Gloves prevent contact with blood and body fluids and transfer of microorganisms. Suction provides for decompression of the stomach and drainage of gastric contents. Removing gloves properly and using hand hygiene reduces the risk for infection transmission and contamination of other items.
15. Measure the length of the exposed tube. Reinforce the marking on the tube at the nostril with indelible ink. Ask the patient to turn their head to the side opposite the nostril in which the tube is inserted. Secure the tube to the patient's gown by using rubber band or tape and a safety pin. For additional support, tape the tube onto the patient's cheek using a piece of tape. Secure the vent of the double-lumen tube above stomach level. Attach the vent at shoulder level (Figure 9).	The tube should be marked with an indelible marker at the nostril. This marking should be assessed each time the tube is used to ensure the tube has not become displaced. Tube length should be checked and compared with this initial measurement, in conjunction with pH measurement and visual assessment of aspirate, at regular intervals. An increase in the length of the exposed tube may indicate dislodgement (AACN, 2020; Boullata et al., 2017). Securing prevents tension and tugging on the tube. Turning the head ensures adequate slack in the tubing to prevent tension when the patient turns the head. Securing the double-lumen tube above stomach level prevents seepage of gastric contents and keeps the lumen clear for venting air.
16. Put on gloves. Assist with or provide oral hygiene at 2- to 4-hour intervals. Lubricate the lips generously and clean nares and lubricate, as needed. Offer analgesic throat lozenges or anesthetic spray for throat irritation, if needed.	Gloves prevent contact with blood and body fluids and transfer of microorganisms. Oral hygiene keeps the mouth clean and moist, promotes comfort, and reduces thirst.
17. Remove and reapply the NG tube securement device every 24 hours; assess, clean, and apply a skin barrier to the skin beneath or in contact with the NG tube prior to replacement. Reposition the tube to alleviate pressure. Provide nares hygiene as needed (Schroeder & Sitzer, 2019).	Pressure from the tube can create pressure damage; these actions help prevent development of pressure injury (Baranoski & Ayello, 2020; EPUAP, NPIAP, & PPPIA, 2019; Schroeder & Sitzer, 2019).
18. Remove equipment and return the patient to a position of comfort. Remove gloves. Perform hand hygiene. Raise the side rail and lower the bed.	Positioning promotes patient comfort and safety. Removing gloves properly and using hand hygiene reduces the risk for infection transmission and contamination of other items.
19. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.

Evaluation

The expected outcomes have been met when the tube has been passed into the patient's stomach without any complications, and the patient has exhibited no signs and symptoms of aspiration, has rated pain as decreased from prior to insertion, and has verbalized an understanding of the reason for NG tube insertion.