Irrigating a Nasogastric Tube Connected to Suction

Skill 13-9

Irrigating a Nasogastric Tube Connected to Suction

Nasogastric (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. Tubes for decompression typically are attached to suction or the tube may be clamped. 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). The tube must be kept free from obstruction or clogging and is usually irrigated every 4 to 8 hours.

To promote patient safety, NG tube placement must be verified after the initial insertion, before beginning a feeding or instilling medications or liquids, and at regular intervals during continuous feedings (Metheny et al., 2019). This increases the likelihood that the tip of the tube is situated in the stomach or intestine, preventing inadvertent administration of substances into the wrong place. A misplaced tube in the lungs or pulmonary tissue places the patient at risk for aspiration, pneumonia, and even death (AACN, 2020; Metheny et al., 2019). 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 (Irving et al., 2018; Metheny et al., 2019). 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; Anderson, 2018; Dias et al., 2019; Rahimi et al., 2015). An old technique of auscultation of air injected into a tube has been proved unreliable and is not suggested for use (AACN, 2020; Anderson, 2018; Boeykens et al., 2014; Boullata et al., 2017; Irving et al., 2018; Metheny et al., 2019). 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).

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.

Delegation Considerations

The irrigation of an NG tube is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, irrigation of an NG tube may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Water, sterile water, or normal saline solution for irrigation (based on facility policy)
Nonsterile gloves
Additional PPE, as indicated
Irrigation set, including a large syringe (20 to 50 mL)
Clamp
Disposable waterproof pad or bath towel
Emesis basin
Tape measure, or other measuring device
pH test strip (calibrated in units of 0.5 and approved for use with human secretions)
Stethoscope (for abdominal assessment)

Assessment

Assess for signs of respiratory distress; coughing, choking, dyspnea may occur when a tube is inadvertently positioned in the airway (AACN, 2020). 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. If the patient reports any tenderness or nausea or exhibits any rigidity or firmness of the abdomen, confer with the health care team. If the NG tube is attached to suction, assess suction to ensure that it is set at the prescribed pressure. Also, inspect drainage from NG tube, including color, consistency, and amount.

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
Aspiration risk
Risk for impaired gastrointestinal system function

Outcome Identification and Planning

The expected outcome to achieve when irrigating a patient's NG tube is that the tube is successfully irrigated and maintains patency. In addition, the patient will not experience any trauma or injury.

Implementation

Action	Rationale
1. Gather equipment. Verify the prescribed intervention or facility policy and procedure regarding frequency of irrigation, solution type, and amount of irrigant. Check expiration dates on the irrigating solution and irrigation set.	Assembling equipment provides for an organized approach to the task. Verification ensures the patient receives the correct intervention. Facility policy dictates safe interval for reuse of equipment.
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 and why this intervention is needed. Answer any questions, as needed. Perform key assessments as described above.	Explanation facilitates patient engagement. Due to potential changes in a patient's condition, assessment is vital before initiating an intervention.
5. Assemble equipment on the overbed table or other surface within reach.	Organization facilitates performance of the task.
6. Pull the patient's bedside curtain. Raise the bed to a comfortable working position (VHACEOSH, 2016). Assist the patient to 30- to 45-degree position, unless this is contraindicated. Pour the irrigating solution into container.	This provides for privacy. An appropriate working height facilitates comfort and proper body mechanics for the nurse. This position minimizes risk for aspiration. Preparing the irrigation provides for an organized approach to the task.
7. Put on gloves. Place a waterproof pad on the patient's chest, under the connection of the NG tube and suction tubing. Check placement of the NG tube. Refer to Skill 11-2 in Chapter 11.	Gloves prevent contact with body fluids. The waterproof pad protects the patient's clothing and bed linens from accidental leakage of gastric fluid. Checking placement before the instillation of fluid is necessary to prevent accidental instillation into the respiratory tract if the tube has become dislodged.
8. Draw up 30 mL of irrigation solution (or amount indicated in the order or policy) into the irrigation syringe (Figure 1).	This delivers measured amount of irrigant through the tube. Flushing the tube prevents occlusion (Bischoff et al., 2020; Boullata et al., 2017).
9. Clamp the NG tube near the connection site using a clamp, or double the tube on itself. Disconnect the tube from the suction apparatus (Figure 2) and lay it on a disposable pad or towel, or hold both tubes upright in your nondominant hand (Figure 3).	Clamping prevents leakage of gastric fluid.
10. Place tip of the syringe in the tube. If a double-lumen tube is used, make sure that the syringe tip is placed in the drainage port and not in the blue air vent. Hold the syringe upright and gently insert the irrigant (Figure 4) (or allow solution to flow in by gravity if facility policy or prescribed intervention indicates). Do not force solution into the tube.	Gentle insertion of saline solution (or gravity insertion) is less traumatic to gastric mucosa. The blue air vent acts to decrease pressure built up in the stomach when the Salem sump is attached to suction. It is not to be used for irrigation. Flushing the tube prevents occlusion (Bischoff et al., 2020; Boullata et al., 2017).
11. If you are unable to irrigate the tube, reposition the patient and attempt irrigation again. Inject 10 to 20 mL of air and aspirate again. If repeated attempts to irrigate the tube fail, consult with the health care team or follow facility policy.	The tube may be positioned against gastric mucosa, making it difficult to irrigate. Injection of air may reposition the end of the tube.
12. After irrigant has been instilled, hold the end of the NG tube over the irrigation tray or emesis basin. Observe for return flow of NG drainage into the container. Alternatively, you may reconnect the NG tube to suction and observe the return drainage as it drains into the suction container.	Return flow may be collected in an irrigating tray or other available container and measured. This amount will need to be subtracted from the irrigant to record the true NG drainage. A second method involves subtracting the total irrigant from the shift from the total NG drainage emptied over the entire shift to find the true NG drainage. Check facility policy for guidelines.
13. If not already done, reconnect the drainage port to suction, if prescribed.	This allows for continued removal of gastric contents, as prescribed.
14. Inject air into the blue air vent after irrigation is complete. Position the blue air vent above the patient's stomach.	Following irrigation, the blue air vent is injected with air to keep it clear. Positioning the blue air vent above the stomach prevents the stomach contents from leaking from the NG tube.
15. Remove gloves. Perform hand hygiene. Lower the bed and raise the side rails, as necessary. Assist the patient to a position of comfort.	Proper removal of gloves and hand hygiene prevent transmission of microorganisms. Lowering the bed and assisting the patient to a comfortable position promote safety and comfort.
16. Put on gloves. Measure returned solution, if collected outside of the suction apparatus. Rinse equipment if it will be reused. Label equipment with the date, patient's name, room number, and purpose (for NG tube/irrigation).	Gloves prevent contact with blood and body fluids. The irrigant placed in the tube is considered intake; solution returned is recorded as output. Record on the intake and output record. Rinsing promotes cleanliness, infection control, and prepares equipment for the next irrigation.
17. Remove gloves and 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 the NG tube has successfully irrigated and maintained patency, and the patient has not experienced any trauma or injury.

Documentation

Guidelines

Document assessment of the patient's abdomen. Record if the patient's NG tube is clamped or connected to suction, including the type of suction. Document the color and consistency of the NG drainage. Record the solution type and amount used to irrigate the NG tube as well as ease of irrigation or any difficulty related to the procedure. Record the amount of returned irrigant, if collected outside of the suction apparatus. Alternatively, record irrigant amount so it can be subtracted from the total NG drainage amount at the end of the shift. Record the patient's response to the procedure and any pertinent teaching points that were reviewed, such as instructions for the patient to contact the nurse for any feelings of nausea, bloating, or abdominal pain.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Flush solution is meeting a lot of force when plunger is pushed: Inject 20 to 30 mL of free air through the NG tube into the stomach in an attempt to reposition the tube and enable flushing of the tube.
Tube is connected to suction as prescribed, but nothing is draining from the tube: First, check the suction canister to ensure that the suction is working appropriately. Disconnect the NG tube from suction and place your gloved thumb over the end of the suction tubing. If there is suction present, the problem lies in the tube itself. Next, attempt to flush the tube to ensure its patency.
After flushing the tube, the tube is not reconnected to suction as prescribed: Reconnect the tube to suction as soon as the error is noticed. Assess the abdomen for distention and ask the patient if they are experiencing any nausea or any abdominal discomfort. Complete any paperwork per institutional policy, such as a variance report.

Special Considerations

General Considerations

A one-way, antireflux valve may be used in the airflow lumen to prevent reflux of gastric contents through the airflow lumen (refer to Figure 1 in Skill 13-8). When pressure from gastric contents enters the airflow tubing, the valve closes to prevent secretions from exiting the tube. This valve is removed before flushing the lumen with air and then replaced.
Check tube placement before administering any fluids, medications, or feeding, using multiple techniques: x-ray, external length, external verification marking, pH testing, and carbon dioxide monitoring (if available). Consistent inability to withdraw fluid from tube may indicate displacement of the tube from the stomach into the esophagus (AACN, 2020).

Signs of respiratory distress may be absent in patients with an impaired level of consciousness when NG tubes are inadvertently positioned in the airway (AACN, 2020).

Sterile water should be used for tube flushes in immunocompromised or critically ill patients (Allen, 2015; Boullata et al., 2017).
Gastric pH ≥6 is of no benefit in predicting tube location in the GI tract or in ruling out tracheopulmonary placement (Boullata et al., 2017).
Monitoring for carbon dioxide to determine NG tube position and/or dislodgement has been investigated (Hess et al., 2021). This involves the use of a colorimetric end-tidal CO₂ detector to detect the presence of carbon dioxide, which would indicate tube positioning in the patient's airway (Hess et al., 2021). Monitoring for carbon dioxide may be helpful to detect placement of a feeding tube in the tracheobronchial tree (AACN, 2020; Boullata et al., 2017; Hess et al., 2021). However, this technique may be unreliable, as it cannot differentiate placement in the mouth, and carbon dioxide may not be detected when the tube is in the patient's airway if the ports in the tube are occluded (Gilbert & Burns, 2010, as cited in AACN, 2020).

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Skill 13-9