 Common types of tubes used in the clinical

setting
 Assessment points related to the specific type

of tube
 Procedures for insertion of a particular tube
 Standard (universal) precautions
 Handling infectious materials
 Verifying correct placement and procedures
for administering medications or feedings, if
appropriate
 Interventions related to the care of the client
 Interventions associated with complications

or emergencies that may occur

 Client/family education regarding care at

home
 DESCRIPTION
◦ Short tubes used to intubate the stomach
◦ Inserted from the nose to the stomach
 LEVINE
◦ Single-lumen nasogastric tube
◦ Used to remove gastric contents via intermittent
suction or to provide tube feedings
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for
clinical practice, ed 2, Philadelphia: W.B. Saunders.
 SALEM SUMP
◦ Double-lumen nasogastric tube with an air vent
◦ Used for decompression with continuous suction
◦ Air vent is not to be clamped and is to be kept
above the level of the stomach
◦ If leakage occurs through the air vent, instill 30 ml
of air into the air vent and irrigate the main lumen
with normal saline (NS)
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical
practice, ed 2, Philadelphia: W.B. Saunders.
 Place the client in high-Fowler’s position
 Measure from tip of nose to earlobe to
xiphoid process to determine the length of
insertion and mark with tape
 Lubricate tube about 3 inches with a water-
soluble jelly only (oil-soluble is not used), to
prevent the development of pneumonia if the
tube accidentally slips into the bronchus
 Instruct the client to bend the head forward,
which closes the epiglottis and opens the
esophagus
 Insert into nostril, advance backward and
through the nasopharynx
 Have the client take a sip of water and

advance tube as the client swallows

 Do not force the tube
 If the client experiences any respiratory

distress (coughing or choking) during

insertion, pull back on the tube and wait until
the distress subsides
 Advance until taped mark is reached; tape in
place when correct placement is confirmed
 If feedings are prescribed, x-ray confirmation

should be done prior to initiating feedings

 When gastrointestinal (GI) tubes are attached

to suction, suction may be continuous or

intermittent, with a pressure not exceeding
25 mmHg as prescribed by the physician
From Perry, A. & Potter, P. (2002). Clinical nursing skills and techniques, ed 5, St Louis: Mosby.
 The most reliable method to determine placement is
by x-ray
 Assess placement every 4 hours and before
administering feedings or medications
 Assess placement by aspirating gastric contents and
measuring the pH, which should be 4 or less (pH
values greater than 6 indicate intestinal placement)
 Inserting 5 to 10 ml of air into the NG tube and
listening for the rush of air over the stomach with a
stethoscope is an alternative method for assessing
placement, but is not as reliable as an x-ray or
checking gastric pH
 Check residual volumes every 4 hours, before
each feeding, and before giving medications
 Aspirate all stomach contents (residual) and

measure amount
 Reinstill residual feeding to prevent excessive

fluid and electrolyte losses unless the

residual volume appears abnormal
 Performed every 4 hours to check the patency
of the tube
 Assess placement before irrigating
 Gently instill 30 to 50 ml of water or normal

saline (NS) (depending on agency policy) with

an irrigation syringe
 Pull back on the syringe plunger to withdraw

the fluid to check patency; repeat if tube

remains sluggish
 Ask the client to take a deep breath and hold
 Remove the tube slowly and evenly over the

course of 3 to 6 seconds (coil the tube

around the hand as it is being removed)
 TUBES
◦ Nasogastric
◦ Nasoduodenal or nasojejunal
◦ Gastrostomy
◦ Jejunostomy
From Perry, A. & Potter, P. (2002). Clinical nursing skills and techniques, ed 5, St Louis: Mosby.
From Perry, A. & Potter, P. (2002). Clinical nursing skills and techniques, ed 5, St Louis: Mosby.
 TYPES OF FEEDINGS
◦ Bolus
◦ Continuous
◦ Cyclical
 BOLUS
◦ Resembles normal meal feeding patterns
◦ Can be administered via a syringe or via an
intermittent feeding
◦ With an intermittent feeding, approximately 300 to
400 ml of formula is administered over a 30- to
60-minute period every 3 to 6 hours
From Perry, A. & Potter, P. (2002). Clinical nursing skills and techniques, ed 5, St Louis: Mosby.
 CONTINUOUS
◦ Administered continuously for 24 hours
◦ An infusion pump regulates the flow
 CYCLICAL
◦ Administered either in the daytime or nighttime for
8 to 16 hours
◦ An infusion pump regulates the flow
◦ Feedings at night allow for more freedom during
the day
From Perry, A. & Potter, P. (2002). Clinical nursing skills and techniques, ed 5, St Louis: Mosby.
 Position the client in high-Fowler’s and on the
right side if comatose
 Warm feeding to room temperature to prevent
diarrhea and cramps
 Aspirate all stomach contents (residual),
measure the amount, and return the contents to
the stomach to prevent electrolyte imbalances
 Check physician’s order and agency policy
regarding residual amounts; usually if the
residual is less than 100 to 150 ml, feeding is
administered; if greater than 150 ml, hold the
feeding
 Assess tube placement by aspirating gastric
contents and measuring the pH (should be 4
or less)
 Assess bowel sounds; hold feeding and notify
the physician if bowel sounds are absent
 Use a feeding pump for continuous or cyclical
feedings
 For bolus feeding, leave the client in a high-
Fowler’s position for 30 minutes after feeding
 For a continuous or cyclical feedings, keep the
client in a semi-Fowler’s position at all times
 Change the feeding container and tubing
every 24 hours
 Do not hang more solution than will be

required for a 4-hour period to prevent

bacterial growth
 Check the expiration date on the formula

prior to administering
 Shake the formula well prior to inserting into

container
 Always assess placement of the tube prior to
feeding
 Always assess bowel sounds; do not

administer any feedings if bowel sounds are

absent
 If an obstruction occurs, try flushing with

water, saline, cranberry juice, ginger ale, or

cola, if not contraindicated, after checking
placement
 Add a drop of methyline blue to the feeding,
particularly with clients who have endotracheal
or tracheal tubes; suspect tracheoesophageal
fistula when blue gastric contents appear in
tracheal excretion and if this is noted, notify
the physician immediately
 Administer feeding at prescribed rate, or via
gravity flow (intermittent, bolus feedings) with a
60-ml syringe with the plunger removed
 Gently flush with 30 to 50 ml of water or
normal saline (depending on agency policy)
with the irrigation syringe after the feeding
 Aspiration
 Vomiting
 Diarrhea
 Clogged tube
 Verify tube placement
 Do not administer feeding if residual is

greater than 150 ml

 Keep the head of the bed elevated
 If aspiration occurs, suction as needed,

assess respiratory rate, auscultate lung

sounds, monitor temperature for aspiration
pneumonia, and prepare to obtain chest
radiograph
 Administer feedings slowly, and for bolus
feedings, make the feeding last for 30
minutes
 Do not allow feeding to run dry
 Do not allow air to enter the tubing
 Administer feeding at room temperature
 Elevate the head of the bed
 Administer antiemetics as prescribed
 If client vomits, place in side-lying position
 Use fiber-containing feedings
 Administer feeding slowly and at room

temperature
 Use liquid forms of medication, if possible
 Flush the tube with 30 to 50 ml of water or

NS (depending on agency policy) before and

after medication administration and before
and after bolus feeding
 Flush with water every 4 hours for continuous

feeding
 Crush medications or use elixir forms of
medications; assure that the medication
ordered can be crushed or that the capsule
can be opened
 Dissolve crushed medication or capsule

contents in 5 to 10 ml of water
 Check placement and residual prior to

instilling medications
 Draw up the medication into a catheter tip
syringe, clear excess air, and insert
medication into the tube
 Flush with 30 to 50 ml of water or NS

(depending on agency policy)

 Clamp the tube for 30 to 60 minutes

(depending on medication and agency policy)

 DESCRIPTION
◦ Passed nasally into the small intestine
◦ Used to decompress the bowel or to remove
intestinal contents
◦ Enters the small intestine through the pyloric
sphincter because of the weight of a small bag of
mercury at the end
 Cantor and Harris tube
 Miller-Abbott tube
 Single-lumen tube with a reservoir for 5 to 10
ml of mercury located at its tip, below the
level of the drainage holes
 Mercury is inserted before the tube is passed

through the nose, making the procedure

uncomfortable
 The Harris tube is also used for lavage and

suction
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical
practice, ed 2, Philadelphia: W.B. Saunders.
 A double-lumen tube
 One lumen is for the instillation of mercury

once the tube is in the stomach, and the

other is for irrigation or drainage
From Monahan, F. & Neighbors, M. (1998) Medical-surgical nursing: Foundations for clinical
practice, ed 2, Philadelphia: W.B. Saunders.
 IMPLEMENTATION
◦ Assess physician’s orders and agency policy for
advancement and removal of tube
◦ Position client on the right side to facilitate passage
of the mercury weights within the tube through the
pylorus of the stomach and into the small intestine
◦ Do not secure the tube to the face with tape until it
has reached final placement (may take several
hours) in the intestines
◦ X-ray is performed to verify desired placement
 IMPLEMENTATION
◦ Monitor drainage from the tube
◦ If the tube becomes blocked, notify the physician; a
small amount of air injected into the lumen may be
prescribed to clear the tube
◦ Assess the abdomen and measure abdominal girth
 IMPLEMENTATION
◦ To remove the tube, the mercury and air are
removed from the balloon portion of the tube with
a 5-ml syringe; the tube is gradually removed (6
inches every hour) as prescribed by the physician
◦ Dispose the mercury in the appropriate manner as
per agency policy
 DESCRIPTION
◦ Used to apply pressure against esophageal veins to
control bleeding
◦ Not used if the client has ulceration or necrosis of
the esophagus or had previous esophageal surgery
 TYPES
◦ Sengstaken-Blakemore tube
◦ Minnesota tube
 Triple-lumen gastric tube with an inflatable
esophageal balloon, an inflatable gastric
balloon, and a gastric aspiration lumen
 The gastric balloon applies pressure at the
cardioesophageal junction to directly compress
gastric varices and to decrease blood flow to
esophageal varices; traction is applied to
maintain the gastric balloon in place
 The esophageal balloon directly compresses
esophageal varices
 If bleeding is not stopped with inflation of the
gastric balloon, the esophageal balloon is
inflated to 25 to 45 mmHg
 An x-ray of upper abdomen and chest
confirms placement
 Gastric contents are aspirated by gastric
lavage or intermittent suction via the gastric
aspiration port
 A nasogastric tube is also inserted in the
opposite naris to collect secretions that
accumulate above the esophageal balloon
From Monahan, F. & Neighbors, M. (1998), Medical-surgical nursing: Foundations for
clinical practice, ed 2, Philadelphia: W.B. Saunders.
 Four-lumen gastric tube
 A modified Sengstaken-Blakemore tube with

an additional lumen for aspirating

esophagopharyngeal secretions
 IMPLEMENTATION
◦ Check patency and integrity of all balloons prior to
insertion
◦ Label each lumen
◦ Place the client in the upright or Fowler’s position
for insertion
◦ Prepare for x-ray immediately after insertion to
verify placement
◦ Maintain head elevation once the tube is in place
 IMPLEMENTATION
◦ Double-clamp the balloon ports to prevent air leaks
◦ Keep scissors at the bedside at all times; monitor
for respiratory distress and if it occurs, cut tubes to
deflate balloons
◦ Release esophageal pressure as prescribed and per
agency policy to prevent ulceration or necrosis of
the esophagus
 IMPLEMENTATION
◦ Monitor for increased bloody drainage, which may
indicate persistent bleeding
◦ Monitor for signs of esophageal rupture, which
includes a drop in blood pressure, increased heart
rate, or back and upper abdominal pain
◦ Esophageal rupture is an emergency and must be
reported to the physician immediately
 DESCRIPTION
◦ Used to remove toxic substances from the stomach
 LAVACUATOR
◦ An orogastric tube with a large suction lumen and a
smaller lavage/vent lumen that provides continuous
suction
◦ Irrigation solution enters the lavage lumen while
stomach contents are removed through the suction
lumen
 EWALD’S
◦ Reusable single-lumen large tube used for rapid
one-time irrigation and evacuation
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for
clinical practice, ed 2, Philadelphia: W.B. Saunders.