Insertion and care of fine bore nasogastric tubes for enteral feeding and medication in adults (G081)

Nasogastric (NG) feeding may be indicated for patients who are unable to meet their nutritional requirements by mouth, but have a functioning gastrointestinal tract. This may be because they are unable to take any nutrition orally, or may need additional nutrition to improve an inadequate oral intake¹.

In those patients requiring short term enteral nutritional support, a fine bore NG tube, which is inserted through the nose into the stomach, is the most common method of achieving this support. However, NG feeding may not offer the best solution for every patient.  For those with a history of aspiration, gastric malignancy or delayed gastric emptying, a naso-intestinal tube, which extends into the duodenum or proximal jejunum, thereby bypassing the stomach, may be appropriate. For those requiring prolonged artificial feeding (longer than 4 weeks), percutaneous endoscopic gastrostomy (PEG) should be considered^2,3.

The decision to embark on nasogastric feeding must be made by the multidisciplinary team following nutritional screening and assessment. The rationale for the decision to place a nasogastric tube must be made following careful assessment of the risk and benefits by at least two competent health care professionals ^4,5,6, including the consultant responsible for the patients care and should be documented in patient’s notes⁷. Informed consent must be sought from the patient. Where a patient lacks the capacity to make this decision, then medical staff should consider treatment under the Adults with Incapacity (Scotland) Act 2000 involving the appointed Power of Attorney (POA) if appropriate. Consent should be documented within the patient’s medical and nursing notes.

Type of NG tube

Fine bore nasogastric tubes may be made from a variety of materials and come in a range of sizes in terms of French gauge and length. All tubes are single use and must not be reused under any circumstances⁸ and must be radio opaque for X-ray visualisation as required⁹. The Dietetic department will supply the appropriate nasogastric tube for the majority of patients.

Polyvinyl chloride (PVC) tubes are designed for short term use, 7-10 days maximum. These tubes contain chemical plasticisers designed to keep the tube material soft and flexible. Over time, these plasticisers are bleached out of the tube, making it brittle and increasing the risk of complications. They should not be left in situ for longer than the recommended period.

Polyurethane or silicone elastomer tubes are designed for longer term use, up to 8 weeks. They remain soft and flexible over prolonged periods and are more cost effective.

In adults fine bore NG tubes can be left in situ for as per manufacturer’s instructions, however should be reviewed after 28 days to allow multidisciplinary team discussion and decision making prior to removal date.

Size of tube

Enteral feeding can be delivered via a 6Fr to 12Fr. This small lumen still allows administration of fibre containing feed and can be aspirated with a 50ml syringe. Larger lumens are seen as being less comfortable in situ and patients are less inclined to eat/drink during the day, where clinically allowed.  Guidewires allow the tube to be aspirated with the wire in situ. The tube should connect securely with compatible enteral giving sets and syringes.

Type of syringe

In line with National Patient Safety Agency (NPSA) 2007 recommendations, only syringes labelled ‘enteral’ (purple in colour) should be used with enteral feeding systems. These syringes are incompatible with IV systems, reducing the risk of ‘wrong route’ error.

Fine bore NG tubes should only be passed by medical or nursing staff who have been appropriately trained and have up to date knowledge on:

• the type of tube to be inserted
• the procedure for insertion
• the management of tube post insertion
• potential complications.

In general, medical staff are responsible for the insertion of fine bore NG tubes in patients who have:

• maxillofacial disorders or surgery
• laryngectomy
• any disorder of the oesophagus.

Nursing staff working within the above speciality areas and who have been trained and are competent, may pass NG tubes on the above group of patients after consultation with medical staff.

This is a clean procedure, not sterile.

If, at any time during the procedure, the patient experiences respiratory distress, withdraw tube immediately.

1. Informed consent – a full verbal explanation of the intended procedure should be given to the patient. The patient should be given time to consider the information before being required to give consent¹⁰.
2. Following explanation of the planned procedure, establish their understanding of the underlying rationale and procedures relating to nasogastric tube insertion.
3. Check packaging for any special instructions.
4. Ensure privacy.
5. Position patient – neck neither extended nor flexed with trunk symmetrical. Unconscious patient should be in the lateral position.
6. Agree signal to stop procedure to reduce sense of personal threat.
7. Select nostril, checking preference with patient if possible. Perform nasal hygiene and check for obstruction.
8. Wash hands and don plastic apron and gloves.
9. Use the N.E.X. method (see picture). This is the length from Nose to, Ear then Xithiphi sternum. Measure and then add on two centimetres. This gives an estimate of the length of tube required.
   Image courtesy of Peter Lamb
10. Check the tube, ensuring guide wire does not protrude and is locked into position.
11. Lubricate tube as per manufacturer’s instructions.
12. Commence passage of tube in selected nostril: slide gently backwards and inwards (approx 10cm) along the floor of the nose to the back of the throat. Never force tube.
13. If obstruction felt, withdraw slightly and advance at different angle, gentle rotation of tube may help. Alternatively, use other nostril.
14. To facilitate passage of the tube into the oesophagus, encourage natural swallow. A sip of water may be given unless contraindicated. This stimulates peristalsis, prevents gagging and causes epiglottis to close reducing the risk of tracheal intubation.
15. Tilt chin downwards.
16. Continue to advance tube, checking the tube is not coiled in throat/mouth.
17. Advance tube until the pre measured length reaches nostril then mark the tube with indelible pen to identify the limit mark. The limit mark and should always be visible at the nostril once the tube is inserted.
18. Secure tube with tape supplied, as shown by manufacturers, across bridge of nose and secured to the tube, not the patients nostril (prevents friction)^7,11.
19. Document procedure in patients nursing notes including how consent was obtained, patient’s tolerability to procedure and number of insertion attempts taken.

The NPSA¹² recommended that only the following two methods be used to confirm the position of a fine bore NG tube:

1. Measuring the pH of aspirate using pH indicator strips; or
2. Chest x-ray reported by a competent clinician (in NHS AA this is a consultant radiologist)

No other methods should ever be used to confirm the position of a fine bore nasogastric tube in the stomach following initial insertion¹².

1. Nasogastric tubes must not be flushed, nor any liquids, including feed introduced until placement of the tip of the tube is confirmed to be in the stomach by pH testing or chest x-ray¹³.
2. Keep the guidewire in position until placement confirmed.
3. Using a 50ml syringe aspirate 0.5-1ml of liquid from the stomach. Using pH indicator strip (not pH paper) place a few drops of aspirate onto it. Match the colour of the strips with the colour code on the pH box to identify the pH of the stomach content. pH indicator strips should be read under good lighting^7,14. This reduces the risk significantly of a pH interpretation error.
   1. pH 5.5 or below indicates location of nasogastric tube is in the stomach and it is safe to commence use of the NG tube.
   2. pH greater than 5.5 indicates that the nasogastric tube may not be in stomach and it is not safe to use. A chest x-ray is now required to check the tube position.
4. If it is not possible to obtain aspirate for checking pH, provide reassurance to the patient and explain the process involved.
5. Leave the patient for 15-30 minutes and attempt to aspirate again¹³. If patient is clinically allowed, give a drink at least 15 minutes before attempting the aspirate.
6. If no aspirate obtained change position of patient onto their left side. Attempt to aspirate.
7. If no aspirate obtained, use a 50ml syringe to insufflate 10ml of air through the nasogastric tube. This allows any debris to be expelled from tube end or to alter the position of the tube within the stomach and then attempt slowly to aspirate gastric contents. If gastric aspirate is not obtained on first attempt this can be repeated on a further 2 occasions.
8. Give mouth care to patients who are nil by mouth (stimulates gastric secretions of acid)¹⁵. Attempt to aspirate.
9. If no aspirate obtained and this is the initial tube placement then advance or withdraw nasogastric tube 3-5cm and attempt to aspirate.
10. If no aspirate obtained finally remove guidewire and attempt to aspirate.
11. If still no aspirate, it should now be assumed that the NG feeding tube is in the wrong place and either;
    1. A chest x-ray is required to confirm the tube position; or
    2. If clinically indicated the NG tube is removed and a new tube is inserted as above.

If the pH is greater than 5.5 on placement, or there is no aspirate, it should always be assumed that the NG feeding tube may be in the wrong place and that a chest X-ray is required to determine the tubes position.

Therefore fine bore NG tube position must be confirmed by chest X-ray in the following cases:

• if aspirate cannot be obtained; or
• pH of aspirate is >5.5.

In addition, it is recommended that fine bore NG tube position be confirmed by chest X-ray for;

• all patients in high risk groups e.g. intubated patients
• when duodenal/jejunal placement is desired.

Process for confirming fine bore NG tube position by chest X-ray

1. Chest x-rays to check tube placement must be requested by a qualified professional (doctor or ANP).
2. Chest X-ray confirmation of the position of tube must be made by a consultant radiologist.
   1. Chest X-rays should not be interpreted for this reason by other staff groups.
   2. This step reduces the risk significantly of an X-ray interpretation error when checking tube position.
   3. This should be done within an hour of x-ray being carried out.
   4. To facilitate this chest X-rays requested for tube position confirmation should be carried out between 9-5pm (any day of the week).
   5. In practice this means waiting until the following morning to perform a check X-ray if the tube was inserted after 5pm and the pH check has failed.
3. If the chest X-ray confirms the NG tube is correctly placed in the stomach, the confirmation should be documented by the medical team on the ‘confirmation of position record sheet’ (see Appendix 1). The NG tube can now be used.
4. If the chest X-ray confirms the NG tube is not correctly placed, it should be removed and consideration given to insertion of a new NG tube.

When the tube position has been confirmed by pH or chest X-ray as above;

1. Secure the tube by taping it to the patient’s cheek using nasal fixation tape in a manner, which keeps the tube out of the patient’s visual field and avoids friction.
2. A number should be visible at the patient’s nostril - this is now marked with indelible pen. This will be the limit mark used for all subsequent checking of the tube position.
3. Record the date and time of the procedure, the technique used to confirm the tube position along with the length of the tube, lot number and confirm that the limit mark is identified on confirmation of position record sheet (see Appendix 1).
4. The NG tube can now be used.

1. The nasal ‘bridle’ is a retention device available for use within NHS Ayrshire and Arran.
2. Only nursing/medical staff that have had training and subsequent supervised practice should place nasal retention devices.
3. The nasal retention device is placed by passing two catheter-mounted magnets, one either side of the nasal septum, which then meet and lock securely in the nasopharyngeal space. This allows the attached umbilical tape to be looped around the vomer bone at the rear of the septum, leaving a tail exiting from each nostril. A simple clip then securely grips the tape and fine bore NG tube together – without occluding the lumen of the NG tube.  The tube is then attached to the cheek with tape and looped over the ear.
4. The bridle can stay in place for 30 days or can be risk assessed to stay in as long as the NG tube.
5. The bridle does help to reduce the risk of unintentional or intentional removal of an NG but does not prevent it completely. The tube can still be coughed or vomited out of the stomach. It is therefore essential to check pH before using the NG tube as described below.
6. The bridle is suitable for all patients with NG tubes in situ, it is particularly useful for:
   1. Confused patients who repeatedly remove fine bore tubes.
   2. Patients who need to retain the NG/naso-intestinal tube when replacement would be a high risk procedure.
   3. Patients being discharged in to the community.
7. Nasal retention devices are contraindicated where:
   1. The patient refuses placement.
   2. The patient has severe trauma to the nose/face.
   3. The patient has an International Normalised Ratio (INR) greater than 1.3.

1. Check the bottle/bag of feed is of correct specification according to the dietetic recommendations.
2. Check that the patient’s personal identifiers correspond with dietetic instruction and that correct feed is selected and expiry date checked.
3. The feeding pump should have a continuous electricity supply, but can function on a battery. Feeding pumps should be regularly checked by Medical Physics.
4. Ensure that the feed is correctly primed through the giving set, the giving set is correctly positioned and the feeding pump is connected to the NG tube.
5. Ensure that the pump is set at the correct rate according to the enteral feeding regimen chart. Record and sign appropriately in the enteral feeding monitoring chart.
6. The patient should be observed hourly for the first 4 hours after commencing feed as this is when the patient is most likely to experience any adverse reaction to the feed or signs of aspiration. Where possible, the patient should be asked to inform staff of any nausea, bloating, abdominal pain, sweating, light-headedness or palpitations.
7. The feed, rate and volume should be checked two hourly to ensure feed continues to run at prescribed rate.
8. Any feeding pump alarms should be attended to immediately.
9. All feeds should be administered at room temperature.
10. The total ‘hanging time’ of a sterile feed must not exceed 24 hours.
11. The giving set should be renewed every 24 hours or if disconnected for any reason.
12. A closure cap should be placed on the end of NG tube when feeding not in progress.
13. Record all feed/water administered in feed recording chart or fluid balance chart.
14. Infection Control Guidelines on Enteral Feeding must be adhered to at all times.

1. Refer to Code of Practice for the Control of Medicines.
2. Refer to Enteral Feeding Guideline.
3. The appropriate administration of a drug via a nasogastric tube should be checked with the ward clinical pharmacist or Medicine Information.
4. The vast majority of drugs are unlicensed when administered via a naso-gastric tube.

Fine bore NG tubes can move out of the stomach after any of the following;

• an episode of retching, coughing or vomiting
• an episode of oropharyngeal suctioning
• during routine use of the tube.

It is therefore essential that tube position is confirmed on the following occasions;

• at least once daily during continuous feeds
• prior to commencing every feed or water given
• prior to administration of medicines
• after an episode of retching/coughing/vomiting
• after each episode of oropharyngeal suctioning
• if displacement of the tube is suspected i.e. limit mark has moved or external length has changed
• the patient develops new or unexplained respiratory symptoms or if oxygen saturation decreases.

Methods for subsequent checking of the position of the fine bore NG tube

1. pH testing
   1. Where feed/medication has already passed through the tube, a minimum of an hour delay, without any further feeding, should be instigated prior to testing of gastric aspirate using the correct pH strips wherever aspirate can be obtained.
   2. It is essential to inject 5ml of air down the NG tube to dry the tube prior to carrying out the pH test to ensure the tube is clear of any residual water from previous flushing.
   3. Where the pH result is consistently greater than 5.5 or gastric aspirate is unable to be obtained this must be discussed with the multi-professional team regarding appropriate action to be taken. Outcome and rationale for decision must be documented within the patient’s records.
2. limit mark
   1. This is the mark put on the tube at insertion (see above) and is recorded on the ‘Confirmation of Position’ record (see Appendix 1).

In some situations, such as when patients are fed continuously, when they are treated with acid reducing medication, and when medications are frequently given down nasogastric tubes, it may not be possible to obtain aspirate with a pH between 1 and 5.5, and daily chest X-rays are not practical or safe. Therefore, in circumstances where the initial placement was appropriately confirmed, the only practical method of determining if the tube remains correctly placed prior to each administration of medications or feed may be through external observation of the tube. Where local guidance permits, this should include confirmation that the length of the external tube remains identical to that recorded initially in the patient’s notes, and that fixation tapes or plasters have not moved or worked loose.

If in any doubt of the position of the tube, it should be checked by chest x-ray (see above) or removed and a new tube re-passed. A NG tube can be x-rayed once the guide wire has been removed and position confirmed by consultant radiologist and documented by medical team.

Regular flushing of fine bore NG tubes will help to reduce the risk of blockage. 

The NG tube should be flushed with at least 20mls water or an amount as recommended by the dietician, at the following junctures;

1. Prior to commencing feed
2. On completion of feed
3. Following the administration of medicines through tube
4. If the feeding tube has been disconnected
5. If an orogastric, nasogastric, nasojejunal feeding tube is not being used for feeding it should be flushed 6 hourly to keep the tube patent.

Tap water is used for most patients, though those who are immune compromised or have naso-intestinal tubes use sterile water or if at home, cooled boiled water.

Prevention of tube blockage is crucial. This is attained by:

1. Feeding as per protocol
2. Remembering to flush tube as described above
3. Ensuring you check medications with Pharmacy or appropriate guidelines regarding compatibility.

If the tube becomes blocked:

1. Flush with 25-30ml of warm water
2. If this fails flush with 25-30ml of carbonated water
3. If this fails try Clog Zapper^TM
4. If this fails consider removing tube and re-passing a new tube
5. Never try to unblock a NG tube by reinserting the guidewire.

To optimise patient comfort, safety and effectiveness of enteral feeding the following interventions should be carried out:

1. Routine bloods – Urea and Electrolytes - to be taken as a baseline.
2. If the patient is allowed to take some oral diet and fluids, the normal oral hygiene associated with cleaning teeth after meals should be sufficient.
3. If the patient is not able to take any oral diet and fluids, extra vigilance is essential to keep the mouth clean, moist and free from infection. In this instance nursing staff should carry out oral hygiene 1-2 hourly. Teeth/dentures should be cleaned twice daily and a water-based lubricant should be applied to the lips as needed.
4. To prevent oral mucosa drying out, encourage patient to breathe through the nose rather than the mouth. Some patients may benefit from saliva substitute.
5. Some patients may be unable to swallow their saliva and may have problems with drooling, resulting in sore skin around the mouth. Ensure these patients have an extra supply of soft tissues to remove the excess saliva.
6. Daily inspection of the skin and nasal mucosa in contact with the tube is essential to detect any signs of pressure damage caused by the tube. If any pressure damage is suspected, the fixation position of the tube must be adjusted.
7. Ensure Malnutrition Universal Screening Tool (MUST) is completed and care plan is in place.
8. Observe for changes in bowel function using Bristol Stool Chart.
9. Care should be taken not to dislodge the tube while performing activities of daily living.
10. Provide regular reassurance and ensure the patient is aware of the significance of the artificial feeding. Encourage the patient to discuss any fears or concerns they may have about the method of feeding.
11. Weigh the patient at the start of feeding and weekly thereafter, or as requested by dietician.

Biochemical

Check blood biochemistry and glucose on a daily basis until feed is at established rate and then weekly to ensure patient remains metabolically stable. Hyperglycaemia can occur in a minority of enterally fed patients¹⁵. Refer to medical staff and dietician if any concerns.

Microbiological

Potential for contamination of feed or equipment and compliance with the Infection Control Guideline for Enteral Feeding (section 25) is essential.

Aspiration

This can be a life threatening complication. Symptoms may be overt with sudden onset of respiratory distress, or may be insidious in nature. The patient may not be diagnosed until pyrexia, tachypnoea, hypoxaemia, hypercapnia and/or pulmonary changes are evident on X-ray, without any other obvious cause. Aspiration can occur due to displacement of the NG tube or due to rapid infusion of feed, causing gastric overloading and delayed gastric emptying, with subsequent reflux of feed.

To reduce the risk of aspiration to as low as possible it is essential that the position of the NG tube is confirmed at the following junctures:

1. at least once daily during continuous feeds
2. prior to commencing every feed or water given
3. prior to administration of medicines
4. after an episode of retching/coughing/vomiting
5. after each episode of oropharyngeal suctioning
6. if displacement of the tube is suspected i.e. limit mark has moved or external length has changed
7. the patient develops new or unexplained respiratory symptoms or if oxygen saturation decreases.

Patients being fed via a naso-gastric tube should have their head and shoulders elevated to at least 30 degrees during feeding and for at least one hour afterwards. This facilitates gravitational drainage of feed from the stomach and prevents reflux into the oesophagus.

If aspiration is suspected:

1. Stop the feed
2. Refer to medical staff who will request an urgent chest X-ray and assess for further treatment
3. If the NG tube has been displaced from the stomach it should be removed not repositioned.

Bloating and vomiting

Start the feed slowly and gradually build up to the prescribed volume. Once the feed is established, determine whether bloating or nausea occurs and consider anti-emetic or gastric motility agents. If vomiting occurs, the tube position should be checked and the dietician notified.

Diarrhoea

Do not automatically assume diarrhoea is due to the feed. Maintain feed rate until:

1. Diagnosis is established.
2. Review medical history, especially for evidence of pre-existing bowel disorders.
3. Review recent and current drug therapy, particularly antibiotics, elixirs and laxatives.
4. Review fibre intake, especially in long-term tube fed patients.
5. Review history of recent enteral intake.
6. Take stool sample for analysis.
7. Review techniques and procedures for handling of equipment and feed administration.

It may be necessary to give intravenous fluids and/or additional water to maintain hydration status.

Constipation

• Possibly due to immobility, dehydration
• Consider fibre-contain feed
• Ensure adequate hydration and accurate fluid balance
• Review drugs which may be reducing GI motility
• Encourage mobilisation where possible.

Continuous feeding in the Intensive Care Unit (ICU)

Wide bore nasogastric tubes are initially inserted for the purpose of gastric decompression rather than for enteral feeding. Once decompression is no longer required, enteral feeding is often established through the wide bore tube. This mostly happens within the ‘high care areas’ such as ICU. The main difference between a wide bore and fine bore nasal gastric tube is that the wide bore tube has an airway lumen, which can be occluded with a valve or spigot when feed is in progress, but must be open to the air when the tube is being aspirated. The purpose of the airway lumen is to prevent trauma to the mucosa from being sucked into the side holes of the tube when aspirating. When the wide bore tubes are being used for enteral feeding they are managed in the same way as a fine bore feeding tube.  It would be preferable however that on leaving a high care area or when deemed possible the wide bore should be changed to fine bore tube.

When patients are prescribed a 24 hr feeding regimen in ICU, the tube position must be checked at least once a day. NPSA¹⁴ recommend that at least one hour has elapsed since the stopping of the feed before testing; this allows time for the pH of the stomach content to fall. If for any reason, it is not appropriate to stop the feed for this length of time, then a decision has to be made in relation to the management of these patients.

In circumstances where the initial tube placement was confirmed and there is no reason to suspect displacement (i.e. no vomiting, retching or coughing spasms and no unexplained respiratory symptoms) the only practical method of determining if the tube remains in the correct position is measuring the external length. Tube length should be recorded on a daily basis and prior to administration of any liquid via nasogastric tube on the bedside chart. 

Patients must be continuously monitored for signs of distress and tube migration. If there is concern that the tube is not in the stomach, tube position should be checked. It is good practice to check the position of the tube if the patient is being x-rayed for any other reason.

1. Nursing staff must train the patient or carer on how to check tube position with pH testing of aspirate and indicator strips prior to discharge.
2. Patients should be issued with a supply of pH strips on discharge.
3. Nursing staff must complete the training section on page 3 of the nasogastric tube care booklet (patient held record).
4. The ward dietician is responsible for arranging community dietician follow up.
5. Training on use of an enteral feeding pump must be arranged prior to discharge by the dietician and given by the home feeding nurse trainer.
6. Discharge planning must include district nurse.
7. Multidisciplinary enteral feeding care plans must be completed.
8. The ward nursing staff are responsible for informing the dietetic department at least 48 hrs before planned discharge in order that discharge arrangements can be made.

Employees are reminded that they may have patients/carers who require communication in an alternative format e.g. other languages or signing. Additionally, some patients/carers may have difficulties with written material. At all times, communication and material should be in the patients preferred format. This may also apply to patients with learning difficulties. In some circumstances there may be religious and/or cultural issues which may impact on clinical guidelines e.g. choice of gender of healthcare professional.  Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability or impairment that makes it difficult for them to be treated/examined as set out in the guideline requiring adaptations to be made.

Patients’ sexual orientation may or may not be relevant to the implementation of this guideline however; non-sexuality specific language should be used when asking patients about their sexual history. Where sexuality may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality and Diversity Impact Assessment Tool Kit. No additional equality and diversity issues were identified. 

For further information or guidance contact:

1. Lead Nurse Stroke Services
2. Nutrition Nurse Practitioner
3. Dietetic Department at Ayr or Crosshouse.

1. De Aguilar- Nascimento, J.E. Kudsk, K.A. (2007). Use of small –bore feeding tubes: successes and failures. Current Opinion in Clinical Nutrition & Metabolic Care: 10(3):291-296.
2. I.G.N. (2010) 119 Management of Patients with Stroke: identification and Management of Dysphagia. SIGN. Edinburgh.
3. Baskin, W. (2006). Acute complications associated with bedside placement of feeding tubes. Nutrition in Clinical Practice: 21(1) 40-55.
4. Shalmovitz GZ and Shah NR. Nasogastric tube. Emedicine 2010. Available online at: http://emedicine.medscape.com/article/80925-overview
5. Metheny NA, Meert KL, Clouse RE (2007) Complications related to feeding tube placement. Curr Opin Gastroenterol. Mar; 23(2):178-82.
6. National Institute for Health and Clinical Excellence (2006), Nutrition Support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition.  Clinical Guideline 32. National Institute for Health and Clinical Excellence, London
7. National Patient Safety Agency (2005) Reducing the harm caused by misplaced nasogastric feeding tubes, National Patient Safety Agency, London
8. Medical Devices Agency (2001) Enteral feeding systems: risk of and infection Medical Device Agency London
9. C. (2005) Caring for the patient with a nasogastric tube. Nursing Standard: 20(3):59-65. Shalmovitz GZ and Shah NR. Nasogastric tube. Emedicine 2010. Available online at: http://emedicine.medscape.com/article/80925-overview
10. Nursing & Midwifery Council (2015) the Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. Nursing & Midwifery Council, London
11. Medicina (2001) Medicina indicator nasogastric tubes, Adlington, Medicina Metheny NA, Meert KL, Clouse RE (2007) Complications related to feeding tube placement. Curr Opin Gastroenterol. Mar; 23:2:178-82.
12. National Patient Safety Agency (2007) Promoting Safer measurement and administration of liquid medicines via oral and enteral routes, National Patient Safety Agency, London.
13. National Patient Safety Agency (2011). Patient Safety Alert NPSA/2011/PSA002: Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. National Patient Safety Agency, London.
14. National Patient Safety Agency. (2005). How to confirm the correct position of nasogastric feeding tubes in infants, children and adults. National Patient Safety Agency. London.
15. Oh, H.S, Suh, Y.O, Hwang, S.K, Seo, W.S. (2005). Effects of Nasogastric Tube Feeding on Serum Sodium, Potassium and Glucose Levels. Journal of Nursing Scholarship: 37(2):141-147.

Finebore nasogatric tubes confirmation of position record.

Procedure for confirming position of a fine bore NG tube using pH

For endoscopically placed tubes - please follow guidance on endoscopy report.

In line with National Patient Safety Agency (NSPA) 2011 guidance all staff must adhere to the following protocol:

1. Measure amount of tube to be inserted using the NEX process.
2. Pass NG tube to measured length
3. Check position of tube by aspirating. Test fluid obtained on pH indicator strips.

≤ 5.5 = correct position in stomach

> 5.5 = possibly not in stomach, not safe to start feed – further action required to check correct placement of tube (see guideline and flow chart).

4. Document pH obtained on Confirmation Record.
5. Once tube confirmed in stomach use indelible pen to mark tube at patient`s nostril on NG tube and fix the tube in position as per guideline.
6. Commence feed as per enteral feeding regimen.
7. Use Confirmation Record and Feed Monitoring Form to note ongoing checks, delivery of feed and medication.
8. Follow instructions on Confirmation Record. Frequent observation of the position of the limit mark is essential. If limit mark appears to have moved or in any doubt – do not feed – Re-check position by obtaining aspirate and check pH.

Forms contained in Starter pack:

• Starter Regimen
• Feed Monitoring Form
• Confirmation of Position Record
• Tube Placement Instructions / Flow Diagram.

Enteral feeding monitoring chart