Clinical skill module

BY Dr : Aisan Madih Hama

Department of internal medicine

College of medicine
University of Sulaimani
NASOGASTRIC TUBE PLACEMENT

Nasogastric intubation is a
medical process involving the
insertion of a plastic tube
through the nose, down the
esophagus, and down into the
stomach.
 INDICATIONS
Diagnostic indications for Therapeutic indications for
NG intubation: NGT intubaation:

• Evaluation of upper gastrointestinal • Gastric decompression.

Bleeding. • Relief of symptoms and bowel rest
• Aspiration of gastric uid in the setting of small-bowel
content. obstruction.
• Identi cation of the esophagus and • Aspiration of gastric content from
stomach on a chest radiograph. recent ingestion of toxic material.
• Administration of medication.
• Administration of radiographic • Feeding.
contrast to the GIT tract. • Bowel irrigation.

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Contraindications
◦ Absolute contraindications:
◦ Mid face trauma
◦ Recent nasal surgery
◦ Relative contraindications:
◦ Coagulation abnormalities
◦ Recent alkaline ingestion (due to risk of oesophageal
rupture)
◦ Oesophageal varices (untreated or recently banded/
cauterised)
◦ Oesophageal strictures
◦ In the presence of relative contraindications, the advantages
and disadvantages of NG placement will have to be judged
against the reason for tubing and the patient’s condition.
Equipment
• Sterile gloves.
• Kidney bowl.
• Gauze.
• Lubricant jelly.
• NG tube.
• 10 mL syringe.
• Litmus paper.
• Medical adhesive tape.
• Drainage bag.
• Gloves.
• Glass of water with straw.
PRACTICAL PROCEDURE
• Explain the procedure to the patient and obtain consent.
• Wash your hands and wear sterile gloves.
• Ensure that the end of the NG tube will it the drainage bag to be used.
• The patient should be in an upright position, the head supported with pillows
if needed to ensure that it is not tilting backwards.
• Check the patency of the nostrils; ask the patient to blow their nose if
needed.
• Lubricate the NG tube tip and the irst 10 cm.
• Slowly insert the NG tube into a nostril using a rotating motion and advance it
horizontally along the base of the nasal cavity until it reaches the posterior
pharynx (and hence usually induces the gag re lex).
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• Ask the patient to swallow water repeatedly through a
straw whilst advancing the NG tube during the swallow.
In this manner the patient e ectively swallows the tube
into the oesophagus.
• Advance the NG tube down the oesophagus and into
the stomach.
• Ensure the NG tube is sitting in the stomach:
Gently aspirate stomach contents with a syringe and
test with litmus paper (if in The stomach PH should be
less than 4 ).
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 • Attach the drainage bag.
• Secure the NG tube around the patient’s nose with
micropore tape taking care not
to exert too much pressure on the nares adjacent to the
NG tube.
• Document the date and time of NG tube insertion.
Document the type of tube
inserted, the batch number, any complications or
di iculties in insertion and how The correct position of
the was con irmed.
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POST-PROCEDURE INVESTIGATION
• If you are in any way unsure about the position of the NG tube, obtain a
chest X-ray. The NG tube tip has a radio opaque line at the end and can
therefore be seen. However, this X-ray con irmation is valid only at the time
of the X-ray.

• The NG tube should not be used until positive evidence of its placement
has been obtained (pH or chest X-ray).

• Syringing air down the NG tube whist auscultating the epigastrium is an

unreliable method of checking tube position due to transmitted lung
sounds.
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COMPLICATIONS
• Failure to pass the NG tube.
• Epistaxis.
• NG tube passed into trachea.
• Oesophageal, pharyngeal or gastric perforation.
• NG tube in duodenum – should this be con irmed on chest
X-ray pull the tube back
approximately 5 cm.
• Oesophagitis and stricture formation secondary to
oesophageal in lammation.
• Retropharyngeal or nasopharyngeal necrosis.
• Sinusitis from NG tube in situ for a prolonged period of time.
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paracentesis
• paracentesis
• Abdominal paracentesis (drainage)
A drain is inserted into the abdominal cavity allowing
drainage of large amounts of ascitic luid for therapeutic
purposes.

• Ascitic tap
A needle is inserted through the abdominal wall and
withdraw a small amount of luid for diagnostic purposes.
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indications
• Diagnostic paracentesis
• Inpatients who have peritoneal luid that is new or of
uncertain etiology.
• Inpatients with ascites and symptoms such as fever or
increased pain that suggest possible infection of the ascitic luid
(eg, spontaneous bacterial peritonitis ) and refractory ascites.

• Therapeutic paracentesis
• To alleviate symptoms(Respiratory compromise),usually
dyspnea or pain caused by large-volume ascites.
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contraindications
• Absolute
• Severe, uncorrectable disorders of blood coagulation.
• Intestinal obstruction with bowel distention.
• An infected abdominal wall.

• Relative
• Poor patient cooperation.
• Surgical scarring.
• Large intra-abdominal mass, or 2nd or 3rd trimester pregnancy.
• Severe portal hypertension with abdominal collateral circulation.
Equipment Required
• Sterile pack (gloves, cotton, container) .
• 10ml syringe
• 20ml syringe
• Green needle
• Orange needle
• 5-10ml 1% lidocaine solution.
• Antiseptic solution, (Bananno abdominal catheter pack (catheter, sleeve,
puncture needle, adaptor clamp) • Catheter bag. • Catheter bag stand. •
Scalpel) for paracentesis.
• Microbiology culture bottles
• 2 sterile collection bottles
• Biochemistry tube(glucose).
• Hematology tube.
 Procedure
• Introduce yourself , con irm patient’s identity, explain the procedure,
obtain verbal consent.
• Ensure that the patient has emptied their bladder.
• Position the patient lying supine or in the lateral decubitus position
leaving the right side available undress exposing the abdomen.
• Percuss the abdomen for ascetic dullness.
• Mark a suitable site of the right iliac fossa with in the area of dullness.
• Clean the area with antiseptic solution and put on sterile gloves.
• Inject local anaesthetic, to skin and subcutaneous tissue via needle
and 10ml syringe and wait for 1min for it to take e ect.
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• Attach the Green needle to 20ml syringe and insert into the
abdomen, perpendicular to skin. Advance the needle until luid
is withdrawn.
• Aspirate as much as possible
• Remove the needle and apply a suitable sterile dressing.
• Put 4ml of luid in each bottle and send to Lab for:
Biochemistry-standard collection bottle (albumin, LDH,
amylase)
Biochemistry-accurate glucose collection tube (glucose).
Cytology.
Haematology (total and di erential white cell count)
Microbiology (MC &S)
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Prepare the catheter kit- straighten the catheter using the plastic covering sheath provided.
• Take the needle in the pack and pass through the sheath until the needle protrudes from the
catheter tip.
• Close o the rubber bung at the end of the catheter. • Make a small incision in the skin using the
scalpel.
• Grasp the catheter needle 4’ above the distal end and, with a irm thrust, push the needle
through the abdominal wall to 3cm deep.
• Withdraw needle from the catheter hub and advance catheter until the suture disc is reaches the
skin.
• Remove the needle, connect adaptor-clamp to the catheter hub and securely attach the rubber
portion of the clamp into a standard drainage catheter bag.
• Suture the catheter into the abdominal wall carefully and tape to ensure the catheter won’t fall
out.
• Ensure the clamp is open to allow luid to drain
In cirrhotic patients-every 3L of ascitic luid drain need to be replace by infusing human
albumin solution(HAS).
Usually catheters are not left in place for >24hrs.
• Document all the procedure in patient’s note.
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 positioning

• Have the patient sit in bed with the

head elevated 45 to 90°. If
choosing a needle insertion site in
the left lower quadrant, partially
roll the patient onto his or her left
side to allow the luid to pool in the
area.
• Alternatively, position the patient in
a lateral decubitus position. In this
position, the air- illed bowel loops
loat up.
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complications
• Hemorrhage
• Prolongedleakageofascitic luidthroughtheneedle
puncture site
• Infection
• Bowel perforation
• hypotension
• possiblytransienthyponatremiaandincreasedcreatinine
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THANK YOU