Feeding a patient with a nasogastral tube

Authors: Brikez Yu.

Editor: Rednenko V.V.

Equipment for the practical skill:

• simulator with the possibility of installing a nasogastric tube
• medical couch   (chair)
• disinfection table
• manipulation table
• nasogastric tube
• Janet's syringe
• sterile vaseline oil in vials - 25 (30) ml
• the nutritious mixture used for enteral feeding  "Enterolin", heated in a water bath (t 38 - 40 ° C)
• container with boiled water for rinsing the tube after feeding
• sterile dressing (gauze pads)
• container for heating the mixture "Enterolin"
• non steril tray - 2 pcs
• thermometer for water
• non-toxic marker (if there are no insertion depth marks on the tube)
• absorbent sheet
• waterproof sheet
• adhesive tape (plaster)
• clean wipes
• PPE: non-sterile medical gloves; apron
• skin antiseptic
• emergency disinfectant for the external surfaces
• waterproof bag for linen
• medical documentation

 Clinical situation:

• Patient M., 30 years old, after an accident, has multiple fractures of the lower jaw and tissue damages. An active feeding is not possible due to injuries. 
• Feed the patient with a nasogastral tube.

Order of the skill performance:

 The main indications: tumours, especially in the region of head, neck and stomach,jaw injury, comas, mental disorders-psychological absence of appetite, severe depression, swallowing and speech disorder, swelling of the tongue, pharynx, larynx

 The main contra-indications: peptic ulcer disease in the acute stage, acute pancreatitis, severe forms of malabsorbtion, gastrointestinal bleeding, shock, anuria, severe vomiting.

Preparatory stage:

•       Check the integrity of the packages of sterile medical instruments and sterile dressings, the expiration date.
•       Greet the patient, introduce yourself, identify the patient (specify the last name, first name and patronymic of the patient), check the appointment sheet
•       Inform the patient about the procedure, get verbal consent to giving it
•       Put on an apron.
•       Place the mixture bottle "Enterolin"  in a container for heating the mixture 
•       Place the patient in a sitting or half-sitting position using a functional bed (medical couch) or by placing a pillow under the head and neck
•       Cover the patient's chest with protective sheet or towel.
•       Perform hygienic hand antisepsis, put on non-sterile gloves
•       Examine the nasal passages and, if it is necessary, perform a toilet of the nasal cavity: delete of crusts or mucus from a nose using gause pads.
•       Check the temperature of the water with a water thermometer  in the container for heating the bottle with the mixture (temperature 38-40 ° C)  
•       Open the packaging with Janet's syringe, remove Janet's syringe from the packaging, remove the cap (if it is present), put Janet's syringe back into the packaging, and the cap inside container Plastic
•       Open the package with gauze pads
•       Open the vaseline oil bottle.
•       Open steril package with the tube, remove the tube from the package (the distal end of the tube should not touch the outer surface of the package).
•       Take the tube with the first, second and third fingers of your right hand at a distance of 10 cm from the distal end, the same time holding the end of the tube with the connector with your left hand. 
•       Extend the tube lengthwise.
• Bring the tube to the patient and, without touching the patient, measure with the tube the distance corresponding to the depth of the tube insertion into the stomach:
  •     measure the distance from the tragus to the bridge of nose and make the first mark with a non-toxic marker (this distance is approximately 15-18 cm)
  •     measure the distance from the bridge of nose to the belly button , make the second mark

Maine stage:

• Lubricate the nasogastric tube
  • Take the tube in your right hand like a pen, hold on the tube 10 cm from the distal end
  • Take a bottle of vaseline oil in your hand, drain a few drops of oil in a tray. 
  • Apply the distal end of the tube with vaseline oil  above the tray, without touching the tube with the bottle.
• Insert the tube into the stomach
  • Stand to the right of the patient ( in case you are a left-handed person, stand to the left of the patient)
  • Insert the tube through the lower nasal passage to the first mark (15-18 cm), holding it in the right hand, and with the left hand support the patient's head in the forehead area the same time lifting the tip of the nose with the thumb of your left hand.
  • Tilt the patient's head slightly forward
  • Ask the patient to make a few swallowing movements (if he is able to do it)
  • During this movements advance the tube into the esophagus with your right hand
  • Move the tube slowly to the required  distance
    • In case of cough, dyspnoea, cyanosis of the lips, nose, occurs of resistance - remove the tube immediately).
    • If the urge to vomit occurs, make a pause the insertion process of the tube, ask the patient to take a few deep hales and exhales through the nose, then continue inserting the tube until the second mark. 
  • Place the distal (outer) end of the tube inside non steril tray.
• Check the location of the tube inside the stomach:
  • Remove the cap from the tube connector
  • join Janet's syringe with tube connector
  • Pull the plunger of Janet's syringe towards you: if the tube inside stomach cavity, the gastric contents enters the syringe (pay attention  the contents of the stomach  and return it back)
  • Disconnect Janet's syringe from the tube and insert the cap into the tube connector;
• Feed the patient:
  • Take Janet's syringe, fill it with Enterolin  mixture ;
  • Again remove the cap from the tube connector and join Janet's syringe;
  • Inject  the mixture inside the stomach: place the second and third fingers of the left hand on the tube connector, hold the syringe barrel with the first, fourth and fifth fingers of the left hand; with the fingers of your right hand, press the plunger of the syringe;
  • perform feeding process slowly, the same time monitoring the patient's condition;
  • After all volume of food has been injected, disconnect the syringe and insert the cap into the connector;
• Rinse the tube
  • Withdraw 50 ml of warm boiled water into Janet's syringe
  • Again remove the cap from the tube connector, join the syringe with tube connector and inject 50 ml of warm boiled water into the tube to rinsing aim;
  • Disconnect Janet's syringe and close the tube with a cap
  • Place the syringe on the tray
• Fix the tube on the temporal region of the head (or on the dorsum of the nose) with a plaster;
• Place the patient in a comfortable position, create complete rest, provide dynamic observation

Final stage:

•       Take Janet's syringe from the tray and rinsing it in the MI rising container.
•       Place the disconnected Janet syringe and trays in the Disinfection of MI container.
•       Place the Enterolin inside Plastic container
•       Place all MI packages inside Packages container
•       Take off the apron from the patient, place the disposable apron in the container “Disinfection of dressings, PPE”, in case of using a reusable apron, disinfect it by spray metod.
•       Place the absorbent sheet inside waterproof bag for linen
•       Take off the apron from yourself and disinfect it the same way( as patient s apron)
•      Remove gloves, place it inside "Disinfection of dressings, PPE" container
•      Perform a hygienic hand washing.
•      Disinfect manipulation table using spray metod
•      Record the manipulation.