Teaching special procedural skills like Nasogastric (NG) tube insertion through a lecture/discussion model with practical session is expected to groom advanced providers in intubation. Any health care provider authorized to perform the skill of nasogastric tube insertion will be fully trained in intubation procedure after undergoing this training program, and can groom others as well.
Teaching Objective
“Clinical education is a term denoting the practice of assisting a student to acquire the required knowledge, skills and attitude in practice settings” and “the traditional model and likely the most common technique for procedural instruction is the “see one, do one, teach one” method.” (Rose & Best, 2005. p.3; & Saem medical student educators handbook, (n.d), p.3). It implies that the supervising tutor demonstrates the procedure using proper technique, which is followed and performed by the student under supervision, and finally the student takes on the role of teacher for the next learner. The objective of this teaching module is training nasogastric (NG) tube insertion through a lecture/discussion model with practical session.
Student emergency medical technicians (EMT) certified to perform endotracheal intubation are enrolled in this teaching plan of pre-hospital nasogastric tube insertion. A lecture/discussion model with practical skill session, open question and answer session, and testing of the teaching outcome using a manikin is narrated here. The teaching intention is that on completion of the intubation training program the providers are able to understand the indications and contraindications of placing a NG tube, describe procedure of placing it, and demonstrate their skill using an intubation manikin.
An introduction to nasogastric tube
“A nasogastric tube is a thin, pliable plastic tube that can be inserted into a client’s nose and advanced into the stomach.” Nasogastric intubation is ordered when there is “gastric decompression, gastric lavage, or gastric feeding” (Craven & Himle, 2006, p.1139). Gastric decompression is indicated for a bowel obstruction, and when surgery is performed on the stomach or intestine. Gastric lavage means irrigation of the stomach for swift removal of accidental poisoning or drug overdose. Nasogastric tube insertion helps access stomach, and enables to “drain gastric contents, decompress the stomach, obtain a specimen of the gastric content, or introduce a passage into the GI tract” (Nasogastric tube insertion, removing). Most common types of enteral feeding tubes are wide bore gastric tube like ‘Salem Sump’ tube, fine bore gastric tubes, fine bore jejunal feeding tube, double lumen tubes, and gastrostomy tubes.
Contra indications and complications
“Nasogastric tubes are contraindicated in patients with a fractured base of skull because of the risk of intracranial penetration.” (Types of enteral feeding tubes: Wide bore gastric tubes, 2004). Primary complications of nasogastric insertions include “aspiration and tissue trauma” and can induce gagging or vomiting.” (Nasogastric tube insertion, 2003). Precautions to be taken while NG tube insertion includes: never clamp tube for longer periods; use normal saline for lavage procedures; do not use the vent tube (blue pigtail) for installation or removal of solutions.
The procedure
First assemble all the supplies and equipments required for the procedure, such as: personal protective equipments, appropriate nasogastric tube; water-soluble lubricant, preferably 2% Xylocaine jelly, low powered suction device, clean gloves, stethoscope, adhesive tape, safety pin, pH indicator strips, and glass of water. Wash hands and wear gloves before tube insertion. Identify client and explain the purpose and procedure, for reducing anxiety and to enable therapy acceptance. Help the patient into high Fowler’s position, position the patient upright, with head tilted forward for optimal neck/stomach alignment. Examine nostrils for deformity or obstructions to determine best side for insertion. Inspect NG tube for defects, and determine length of nasogastric tube to be inserted. By measuring the distance of the tube from bridge of nose to the earlobe, then to the xiphistenum total length of the tube can be determined. Mark tube with tape or note the black marking on the tube. Curve end of the tube and lubricate first 2-4 inches of tip (distal tip of tube) with a water soluble lubricant, such as 2% Xylocaine jelly. Vaseline should not be used to lubricate the tube. Gently insert tube along the floor of the nose advancing towards nasopharynx. Once tube is in the nasopharynx the client should be encouraged to swallow the tube, and advance the tube as patient swallows. Care must be taken to ensure that the tube has not passed through the windpipe and down into the lungs. Patient should also be encouraged to breath through mouth while inserting the tube. If the patient shows respiratory changes or coughs, or the tube coils in the mouth the tube should be withdrawn immediately.
On successful passage of tube to the predetermined length, confirm its position inside the stomach. Methods used are by listening to air introduction over the stomach with a stethoscope and checking the aspirate for pH level. By attaching a syringe to the free end of the tube and aspirating sample draw aspirate and check with pH paper to ensure that the contents are acidic. The pH level below 6 confirms that the tube has reached its intended position. The second method is injecting air into the tube and listening over the stomach with a stethoscope. Universal body fluid precaution should be observed to ensure that aspirate does not exceed intake. When difficulty is encountered while aspirating, inject 10cc of air into the blue air inlet to clear it. In case of any doubt about the tube placement, obtain an x-ray before instilling any feeding or medications. Secure the tube with tape to bridge of the nose and anchor it to the client’s gown with tape and a safety pin. Now the patient is ready to introduce medications as needed, and it is essential to occasionally reassess placement. Using a checklist of procedures being performed and documenting the reasons for insertion and allied details ensure that all the insertion parameters have been met. After the lecture session, clear written instruction about suction, aspiration, and recording of observations will be given to the trainees.
Testing skills to assess teaching outcome
Using askillsical airway manikin students’ skill are tested. The examiner shall allow candidates to familiarize with the equipment and clear any doubts before examination. Immediately after narrating examination instructions candidates shall begin the test. Record start time and test time should be five minutes. The grading criteria is based on important stages of tube insertion, like: preparing and assembling of equipments; explaining procedure to the patient; raising head of bed and positioning patients, selecting appropriate tube size; lubricating and curving of tube; caution in inserting the tube; verifying tube placement; applying suction at lowest possible setting; stomach content removal; introducing medication; and securing the tube in place. Standard assessment form containing all these parameters, along with student information and space for documenting comments of examiner will monitor proficiency in inserting nasogastric tube. This module can prepare, train, and test skills of new entrants and make health care delivery more quality oriented and error free.
References
- Craven, R.uth, F., & Hirnle, Constance, J. (2006). Fundamentals of nursing human health and function. Lippincot Williams & Wilkins. 1139. Web.
- Nasogastric tube insertion and lavage. (n.d.).
- Nasogastric tube insertion. (2003). University o Ottawa.
- Rose, Miranda., & Best, Dawn. (2005). Transforming practice through clinical education professional supervision and mentoring. Elsevier Health Sciences. 3. Web.
- Saem medical student educators handbook Saem undergraduate education committee. (n.d.). 3.
- Types of enteral feeding tubes: Wide bore gastric tubes. (2004). Module: Insertion of Nasogastric Tubes. 3.