Adult Nasogastric Tube Insertion Procedure & Management Policy

Adult Nasogastric Tube Insertion Procedure & Management Policy
Document Status FINAL

Version V2
Document Change History
Version DATE Comments (i.e. Viewed, reviewed
amended or approved by person or
Committee
Draft V1.1 04/12/2009 Reviewed and agreed by Alex Mayor
Draft V2.1 23/08/2011 Reviewed and amended by Emma Tyler
and J ulie Morley Nutrition Nurse Specialist
Nurses in accordance with NPSA Alert
Mar 2011
Draft V2.2 23/08/2011 Approved by the Clinical Governance
Steering Group

Authors (s) J ulie Morley & Emma Tyler - Nutrition Nurse
Specialists, Paula Wooldridge - Practice Educator.
Approver Clinical Governance Steering Group
Names & Roles of
Contributors
Mark Sair, ICU Consultant, Paula Chudleigh Staff
Nurse Critical Care, Rosemarie Taylor and J eanette
Snowden, Radiographers.
Relevant to: Staff Groups Medical, Nursing, AHP
Document Reference: TRW/CLI/POL/395/2
Review date October 2014 or sooner as necessary
EIA Not Required
Links to other Policies &
Procedures
Adult Enteral Tube Feeding Guidelines. Consent to
Examination Treatment Policy, Mouth Care
Procedure
Distribution Full
TRW.CLI.POL.395.2 Adult Nasogastric Tube Insertion Procedure & Management Policy

2
Trust Commitment to Valuing People

PHNT is committed to creating a fully inclusive and accessible service. By
making equality and diversity an integral part of the business, it will enable
us to enhance the services we deliver and better meet the needs of patients
and staff.

We will treat people with dignity and respect, promote equality and diversity,
and eliminate all forms of discrimination regardless of (but not limited to)
age, disability, gender reassignment, race, religion or belief, sex, sexual
orientation, marriage/civil partnership and pregnancy/ maternity.

An electronic version of this policy is
available on the TrustDocuments Network
Share Folder:

G:\TrustDocuments

Larger text, Braille and Audio versions can be
made available upon request to the Human
Resources Department.

3
Contents

Contents .................................................................................................................. 3
1. Introduction ........................................................................................................ 4
2. Policy Statement ............................................................................................... 4
2.1 Purpose ...................................................................................................... 4
2.2 Accountability, Authorisation and Responsibility ......................................... 5
2.3 Consent ...................................................................................................... 5
2.4 Risk Assessment & Contra-indications ....................................................... 6
3. Nasogastric Tube Selection Adult patients ..................................................... 6
4. Procedure for the Insertion of a Nasogastric Tube for the Adult ........................ 7
5. Post insertion care and management of Nasogastric Tubes once insitu ......... 15
6. Enteral Feeding ............................................................................................... 15
7. Administration of Medicines via a Nasogastric Tube ....................................... 16
8. Review and Revision ....................................................................................... 16
9. Audit & Monitoring ........................................................................................... 16
9.1 Document Control ..................................................................................... 16
9.2 Dissemination and Implementation ........................................................... 16
10. References ................................................................................................... 17
11. Appendices .................................................................................................. 20

Appendix A Checklist for the Review and Approval of Procedural Document

Appendix B Plan for Dissemination of Procedural Documents

Appendix 1 Competency Assessment Process Insertion and Care of Nasogastric
Tubes for Adults Supporting Information for Assessors and Managers

Appendix 2 Insertion and Care of Nasogastric Tubes for Adults Competency
Assessment Process for Registered Healthcare Professionals

Appendix 3 Decision Tree for Nasogastric Tube Placement Check in Adults

Appendix 4 Record of Insertion of Nasogastric Tube Sticker

Appendix 5 Nasogastric Tube Position Record and Care Plan

Appendix 6 Ongoing Post Insertion Care and Management of Nasogastric Tubes

Appendix 7 Audit Form


4

1. Introduction
The NPSA has published a list of never events which are specific serious
untoward incidents that can cause serious harm but should be avoidable if national
guidance is followed. One Never Event relates to: Naso tubes placed in the
respiratory tract rather than the gastrointestinal tract and not detected prior to
commencement of feeding or other use.
This policy has been written to comply with the latest guidance from the National
Patient Safety Agency.
The insertion of a nasogastric (NGT) tube is defined as the passage of a
nasogastric tube via the nostril into the stomach..
This policy and procedure gives information and instruction regarding safe and
effective placement and confirmation of tube placement to reduce risk in line with
current Clinical Governance. The document has been developed to support staff in
the ongoing management of nasogastric tubes once a tube has been inserted.
This policy is intended for use in the adult patient (aged over 16 years).
2. Policy Statement
Plymouth Hospitals NHS Trust aims to deliver safe and effective care to all its
patients.
The insertion, tube position check and subsequent management of nasogastric
tubes will be safe, effective and comfortable for the patient.
Staff engaged in the process of inserting, checking and managing the use of
nasogastric tubes are expected to be competent to do so and comply with this
policy.
2.1 Purpose
The procedures described below are intended to support staff in complying with the
stated Trust policy and to ensure care is safe and effective.
The purpose of a nasogastric tube is to:
a) allow drainage of the contents of the stomach when indicated
b) allow removal of air from the stomach when indicated
c) Provide a safe access route to the gastrointestinal tract for the
administration of fluids, medicines and or nutrients

5
Fig 1. Examples of Indications for use of a Nasogastric Tube
INDICATION ACTION RATIONALE
Paralytic Ileus

Gastrointestinal disease

Gastrointestinal surgery
Leave tube on free
drainage

Aspirate as indicated or
requested

Check tube position
To allow drainage of
accumulated gastric
contents and facilitate
gastric motility

To avoid aspiration of
gastric contents
To provide nutrition for the
patient

To hydrate the patient

To administer medication
Check tube position
before the introduction of
any substance into the
tube
To confirm the correct
placement of the tube in
order to avoid aspiration
of gastric contents and
subsequent complications
2.2 Accountability, Authorisation and Responsibility
Staff should only undertake this procedure if they are appropriately trained (by
completing the Insertion and Care of Nasogastric Tubes Competency Assessment
Process. See section 6.0 and 7.0, and must be either:
Registered Adult Nurses, Midwives and Health Visitors
Registered Childrens Nurse
Registered Medical Staff
Nurses/Medical staff in training supervised by one of the above
All practitioners are personally responsible for updating their practice to
maintain competencies and skills.
It is recommended that this is done 12 monthly if not undertaking procedure
regularly.
Accept accountability for their practice.
Informal carers i.e. those individuals who have undertaken daily care
regimes for the patient on a routine basis and have been appropriately
trained by a practitioner named above.
2.3 Consent
Consent for the procedure should be sought under the guidance of the Policy for
Consent to Examination and Treatment (available on the intranet under PHNT
Trust documents TRW.CGW.POL.216)

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2.4 Risk Assessment & Contra-indications
An individual risk assessment should be conducted and documented by a
competent person that balances the risks and difficulties of nasogastric tube
insertion. The following group of patients are at a high risk of incorrect tube
positioning, dislodgement and aspiration and appropriate specialist advice should
be taken if the patient has:
Maxillo-facial disorders, surgery or trauma
Skull fractures confirmed or suspected
Laryngectomy
Recent radiotherapy to head and neck
Any disorder of the oesophagus e.g. varices, stricture.
Oro-pharyngeal tumours or oro-phayrngeal surgery
Unstable Cervical Spinal Injuries
Nasal C.P.A.P.
Oro-gastric positioning may be indicated following head injury or neuro-surgery.
High Risk also includes patients who: -
Are comatose/semi-comatose
Are ventilated/sedated
Have a swallow dysfunction
Have recurrent retching/vomiting
Need to be nursed prone
3. Nasogastric Tube Selection Adult patients
There are two types of nasogastric tubes available. These have been chosen to
due to their radio-opaqueness, should X-ray be needed.
Polyvinyl Chloride (PVC) for short term use up to 30 days (e.g. Ryles tubes)
usually used within PHNT for gastric drainage (and for feeding in the Critical Care
setting only)
Polyurethane (PUR) Fine bore tubes used within PHNT for the administration of
nasogastric feed and medications.
The nasogastric tube should be selected that is appropriate for its purpose.
Various lengths and lumen diameters are available for adult patients.
Patients with nasogastric tubes inserted under direct vision.
Most patients who are unconscious or sedated have nasogastric tubes inserted
routinely for drainage of gastric aspirate and/or feeding. The patient is usually
sedated or anaesthetised or has an altered conscious level. They will have an
endotracheal tube in situ and have the nasogastric tube placed under direct vision
into the oesophagus. The tube is then advanced until green/yellow/brown contents
are freely aspirated.

7
If a tube is inserted under direct vision (as outlined above), the tube can be
confirmed to be in the stomach at the time of insertion. Documentation of the
insertion should be completed in the perioperative pathway and completion of the
Record of insertion of nasogastric tube sticker (Appendix 4).
Subsequent checks of the tube position must follow the Decision Tree for
nasogastric tube placement checks in adults (Appendix 3) unless repeat
direct visualisation of the tube position in the stomach is carried out.
4. Procedure for the Insertion of a Nasogastric Tube for the
Adult
Equipment required:
1. Clinically clean tray
2. Fully Radio-opaque Nasogastric tube which is appropriate for its designated
use
3. Topical Gauze
4. Tape to secure E.g. Nasofix
5. 60ml purple enteral syringe
6. pH indicator strips (CE marked for human aspirate)
7. Disposable receiver
8. Spigot/Drainage Bag (if necessary)
9. Glass of water, straw (only if able to swallow)
10. Mouth sponges
11. Non sterile gloves and apron
12. Record of Insertion of Nasogastric Tube Sticker
13. Nasogastric Tube Position Record Form and Care Plan
14. A pen
ACTION RATIONALE EVIDENCE
1 Before a decision is made to insert
a nasogastric tube, an assessment
is undertaken to identify the
reason for the nasogastric tube
insertion:

a) for drainage only
b) for drainage and possible
feeding (Critcal Care
ONLY)
c) for feeding and medication

The rationale for any decisions are
recorded in the patients medical
notes, including purpose and type
of nasogastric tube to be inserted.
To ensure that the
nasogastric tube
insertion is
necessary, avoiding
putting the patient
through an
unnecessary
procedure and
potential
complications.
NPSA (2011)

8
2 Check patient ID and explain the
procedure to the patient.

Ensure patient is in agreement
with the procedure and that
verbal/informed consent is gained
and documented.
To obtain the
patients consent and
co-operation.

To be able to
document consent. If
patient is unable to
consent then
capacity must be
established and
action is in best
interests.
Price (2009)

DOH (2001)

Mensforth and
Nightingale
(2001)

Mallett and
Dougherty
(2000)

Mental Capacity
Act (2005)
3 The patient should be monitored
closely throughout the procedure
by nursing staff.

In the acute setting the procedure
should be carried out in a clinical
area which has access to
emergency equipment in full
working order.

In the community setting an
individual risk assessment should
be made.
Early detection of
cyanosis or
bradycardia will
prevent further
deterioration of the
patients condition
throughout the
procedure.

Emergency
equipment in full
working order will
enable medical and
nursing staff to deal
with serious
complications should
they arise in the
acute setting.

To ensure that risk
versus benefit is
assessed.
Mensforth et al
(2001)

4 Assist the adult patient to sit in a
supported upright position,
ensuring the patients head and
shoulders are well supported by
pillows. If the patient is
unconscious or semi-conscious,
place into a safe position by laying
the patient on their side.
To allow for easy
passage of the tube.
This position allows
easy swallowing and
ensures the epiglottis
is not obstructing the
oesophagus.
To ensure correct
passage and position
of the NG tube.
Miller et al
(1985)

McConnell
(1997)

Mallett and
Dougherty
(2000)
5 Wash hands with soap and water,
rinse and dry well. Put on
gloves/apron. Assemble the
equipment required.
To minimise cross
infection.

Anderton (1995)
Pratt (2001)
NICE (2006)

9
6 Select the appropriate length to be
passed by measuring the distance
placing the tip of the tube from the
nose, extend tube to the patients
earlobe and then to the
xiphisternum (NEX measurement
see diagram below). Mark the
length on the tube with a pen.

To ensure the
appropriate length of
tube is passed into
the stomach.
Price (1989)
Mallett and
Dougherty
(2000)
NPSA (2011)
7 If the nasogastric tube of choice
has a guidewire , pull the wire out
5cms and replace.

To ensure easy
withdrawal of the
guidewire.

Mensforth and
Nightingale
(2001)
8 Check that the nostrils are patent.
If appropriate, ask the patient to
blow nose first.

If patients are unable to swallow
carry out mouth care prior to
inserting the tube.

To identify any
obstructions liable to
prevent insertion.

If the patient has
dysphagia (loss of
swallow reflex) they
will be unable to
swallow water safely
and should not be
asked to drink whilst
tube is inserted.
McConnell
(1997)
9 Lubricate proximal end of tube
with water.

(N.B. Do not use aqueous jelly as
a lubricant)
To assist passage
through the naso-
pharynx.

Aqueous jelly dries
and can block nasal
passages irritating
the patient.
Mensforth and
Nightingale
(2001)

Mallett and
Doughherty
(2000)
10 Insert the rounded end of the tube
into the clearest nostril and slide it
backwards and inwards along the
floor of the nose to the
nasopharynx. If any obstruction is
felt, withdraw the tube and try
To facilitate the
passage of the tube
by following the
natural anatomy of
the nose.
Mensforth and
Nightingale
(2001)

Mallett and
Dougherty

10
again in a slightly different
direction or use the other nostril.
(2000)
11 As the tube passes down into the
nasopharynx ask the patient to
swallow water via a straw.

(If there is doubt of a patients
ability to swallow safely a
Speech and Language
assessment may be necessary).
A swallowing action
closes the glottis
enabling the tube to
pass into the
oesophagus.

Miller et al
(1985)

McConnell
(1997)

12 Advance the tube through the
pharynx as the patient swallows
until the predetermined mark on
the tube has been reached.

If the patient shows signs of
distress e.g. gasping, coughing or
cyanosis, remove the tube
immediately. If respiratory distress
does not resolve with removal of
the tube at this point, abandon the
procedure and inform medical
staff. If the patient complains of
sudden onset ear pain the tube
should be removed immediately
and inform medical staff.
Distress or ear pain
may indicate the
incorrect placing of
nasogastric tube into
the trachea.

Signs of respiratory
distress may be
absent in patients
with a poor gag
reflex.
Bayes et al
(1992)

Colagiovanni
(1999)

Mallett and
Dougherty
(2000)

Miller et al
(1985)

Gharib (1996)

Arslantas et al
(2001)
13 pH testing is used as the first line
test method, with pH between 0
and 5.5 as the safe range see
Section 13a-13d, and that each
test and test result is documented
on the Nasogastric Tube Position
record and care plan (Appendix 5),
which is kept at the patients
bedside.

Nasogastric tubes are NOT
flushed, nor any liquid/feed
introduced through the tube
following initial placement, until
the tube tip is confirmed by pH
testing or x-ray, to be in the
stomach.
To ensure that the
tube is in the
stomach before any
fluid is administered.
Cirgin-Ellett et
al (1999)

Gharib et al
(1996)
13a Aspirate a sample of fluid using a
60ml purple enteral syringe with
gentle suction aspirating 2-5mls
(5mls Critical Care) of fluid.


11
Place the aspirate onto pH paper
(CE marked for human aspirate)
and check the reading.

N.B. If it is not possible to obtain
an aspirate from the nasogastric
tube, please see section 13b.

A pH of 0- 5.5 indicates a
reading deemed to be within a
safe range.

If pH 0 -5.5 complete Record of
Insertion of Nasogastric Tube
sticker (Appendix 4) and file in
patients medical notes.

If the aspirate gives a result of a
pH greater than 5.5 note
medication (see warning below)
and retry after 20-60 minutes.

Warning

Patients receiving the following
drugs may have a high gastric pH:

H2 Antagonists e.g.
ranitidine
Proton pump inhibitors e.g.
omeprazole

The gastric aspirate obtained from
these patients therefore, may be >
6. If patients swallow is intact and
not NBM, give acidic drink e.g.
Pineapple or Blackcurrant. Retry
after 20 minutes. These patients
therefore may require repeat
aspirate tests observing times of
drug administration. If pH still >6
an initial chest x-ray may be
appropriate to confirm gastric
placement see section 14.

Stomach contents
are acidic and have a
pH around 3-4.
However the National
Patient Safety
Agency state that a
pH reading of 5.5 or
below is acceptable

Bronchial secretions
read greater than pH
6.

Prokinetics can affect
the ability to gain an
aspirate due to their
effect of increasing in
stomach emptying.
PPIs inhibit gastric
acid secretion.
NPSA (2011)

NPSA (2011)
13b

(i)

If it is not possible to obtain an
aspirate try the following:

Give mouth care to patients who
are nil by mouth.

Stimulates gastric
secretion.

Pulling R (1992)


12

(ii)

(iii)

(iv)

If the patient is able to swallow ask
them to drink a small amount of
water.

Flush the tube with 10-20mls of
air.

Turn the patient on their left side
and retry aspiration after 20 60
minutes.

Adds fluid to the
stomach.

Acts in moving the
tube away from the
stomach wall to aid
aspiration.

Improves position of
stomach contents.

Colagiovanni L
(1999)

Mensforth and
Dougherty
(2001)
13c

Whoosh tests, acid/alkaline tests
using litmus paper, or
interpretation of the appearance of
aspirate ARE NEVER USED to
confirm nasogastric tube position.
Use of these
methods are
unreliable.
NPSA (2011)
13d If still unable to gain aspirate or
aspirate is still above 5.5 then DO
NOT USE THE TUBE and consult
medical staff. Document the
medical decision and strategy for
that individual patient in the
medical notes. Document all
techniques that have been used to
try to obtain aspirate before a
request for chest X-ray is made.

Complete Record of Insertion of
Nasogastric Tube sticker
(Appendix 4) and file in patients
medical notes.

If the decision is to proceed to a
Chest X-ray please see section 14
below.
NPSA (2011)
14

X-ray is used only as a second
line test when:

a gastric aspirate is
unobtainable after
placement following the
instructions in section
13b and in Appendix 3
Decision Tree for
nasogastric tube
placement checks in
adults.
Or
Warning:

Please note that an
X-ray to verify the
position of a
nasogastric tube is
only valid at the
time it is taken.

NPSA (2011)


13

(i)

(ii)

a gastric aspirate is
obtainable and has a pH
of 6 or greater and can
not drink an acidic drink.

This should ideally be done in
daytime working hours to ensure
that sufficient knowledge/expertise
is available to interpret chest x-ray
and position of the nasogastric
tube, unless clinically urgent. The
rationale for any decisions made is
recorded in the patients medical
notes.

X-ray request forms clearly state
that the purpose of the x-ray is to
establish the position of the
nasogastric tube, stating the
purpose for feeding or drainage.

The chest x-ray should be
reviewed by a competent
practitioner, in most cases this will
be a medical practitioner who has
been assessed through theoretical
and practical learning.

Documentation of the tube
placement checking process
should include:

any x-ray viewed was the
most current x-ray for the
correct patient.

how placement was
interpreted.

clear instructions as to
required actions.

The above should be recorded in
the patients medical notes.

Any tubes identified to be in the
lung are removed immediately,

To prevent potential
errors of staff
confirming tube
position out of hours.

To ensure that the
radiographer adjusts
the exposure of the
x-ray.

To reduce the risk of
misinterpretation of
the chest x-ray.

To avoid a Serious
Untoward Incident

NPSA (2011)

NPSA (2011)

NPSA (2011)

14
whether in the x-ray department
or clinical area.
and patient harm

14 Only when the correct position is
confirmed and if a guide-wire is
present, the guide-wire will need to
be removed. Flush the guidewire
port of the tube with 10 mls of
freshly drawn tap water and the
guide-wire can be gently rotated
and withdrawn from the tube.

To be aware that the
tube can be
misplaced by rapid
withdrawal of the
guidewire and
requires flushing with
water to activate
water soluble
lubricant.
Rollins (1997)
15 Consider cleaning the nose/cheek
with an alcohol swab prior to
securing the tube.

Secure the tube to the nostril and
cheek with appropriate tape and/or
fixation device.

If nasogastric tube for drainage
purpose, apply drainage bag or
spigot.

If nasogastric tube for feeding,
follow dietetic instruction/starter
regime.

Remove gloves/apron and wash
hands.
Cleaning with an
alcohol swab will
remove grease from
the skin, increasing
the chance of the
tube being
successfully secured.

To maintain the tube
in place.

To allow drainage of
gastric contents.

To commence safe
enteral feeding.

To minimise cross
infection risk.

Della Faille al
(1996)
17 Document insertion procedure by
completing the record of insertion
of a nasogastric tube sticker
( Appendix 4) and place in
patients medical notes.
To provide a record
of care.
To identify that safe
procedures have
been carried out.
NMC 2002a
18 Post insertion and management
of a nasogastric tube.

See Appendix 6.

19 A full multidisciplinary supported
risk assessment is made and
documented before a patient with
a nasogastric tube is discharged
from acute care to the community.
(See section 11 of the Adult
Enteral tube Feeding Guidelines)
NPSA (2011)

15
To remove the tube

Explain the procedure to the
patient and obtain their informed
verbal consent.

Provide tissues for the patient to
clean or blow their nose after
removal of the tube.

Wash hands and put on gloves
and apron.

Take off the fixation tape and
gently withdraw through the nostril.

Ensure the tube is intact and
document removal.

To reduce anxiety.

To ensure that the
tube has been
removed intact.

MDA (2001)

5. Post insertion care and management of Nasogastric Tubes
once insitu
Serious adverse effects on the patients condition may be associated with the
incorrect use of the tube once inserted. The patient must be observed for adverse
signs and symptoms which may indicate tube misplacement or dislodgement.
See Appendix 6 for relevant information: Ongoing Post-Insertion Care and
Management of Nasogastric Tubes.
6. Enteral Feeding
Please see TRW CLI.NUT.GUI.87 Adult Enteral Tube Feeding Guidelines for
further supporting information on:
Indications for enteral tube feeding
Choice of feeding route
Enteral feeding equipment
Infection control and enteral tube feeding
Commencing enteral tube feeding
Administration of medicines via an enteral feeding tube
Trouble shooting guidelines
Guidelines for management of enterally fed adult patients with diabetes
Home enteral feeding

16
7. Administration of Medicines via a Nasogastric Tube
Please refer to TRW CLI.NUT.GUI.87 Adult Enteral Tube Feeding Guidelines,
Version 1:6, Section 8.
8. Review and Revision
This policy should be reviewed bi-annually or when significant guidance is received
from external agencies e.g. MHRA/NPSA.
9. Audit & Monitoring
This policy will be monitored through:
A timely review of patients with NG tubes by Matron / Ward Manager must be
carried out
(see Appendix 7)
Incidents related to NG tubes will be reviewed via Datix
9.1 Document Control
This document is published on the Trust Documents Network Share Folder. The
Information Governance Team are responsible for holding and maintaining a
master file containing a register and evidence of ratification of the document and
corresponding Equality Impact Assessment.
The Information Governance Team will ensure that old versions of the document
are archived in the archive master file. Access to archived documents will be
through the Information Governance Team.
The Information Governance Team will issue the document numbers and maintain
an index that will include the documents title, number & version, owner, issue date
and next review date.
The approvals are indicated by the front sheet of the document as is the version
(i.e. issue) control.
9.2 Dissemination and Implementation
Following approval and ratification, this document is being rolled out across the
Trust.
Publication of this document has been publicised in Vital Signs, the Trusts weekly
staff news briefing. All Directorate Managers will have had the document sent to
them and it is available electronically on the Trust Documents Network Share
Folder.

17

10. References
Adam.S (1994) Aspects of current research in enteral nutrition in the critically ill. Care of
the Critically Ill 10(6): 246-51 Nov-Dec.
Anderton, A. (1995) Reducing bacterial contamination of enteral tube feeds. British J ournal
of Nursing. 4 (7) 368 376.
Arslantas, A., Durmaz, R., Cosan, E., Tel, E. (2001) inadvertent insertion of a nasogastric
tube in a patient with head trauma. Childs Nervous System. J an. 17(1-2): 112 114.
Arrowsmith, H. (1993) Nursing management of patients receiving a nasogastric feed.
British J ournal of Nursing Vol 2, No. 21, p 1053 1058.
Bayes, R.J ., Kruse, J .A., (1992) Nasogastric and nasoenteric intubation. Critical Care
Clinics. 8(4), 865 867.
Beattie, T.K., Anderton, A., White, S. (1996) Aspiration (of gastric residuals) a cause of
bacterial contamination of enteral feeding systems? J ournal of Human Nutrition and
Dietetics. 9, p 105 115.
Burnham, P. (2000) A guide to nasogastric tube insertion. Nursing Times plus. Vol 96,
No.8, P6 7. Centre for Clinical Effectiveness. (2000) What is the optimum method for
ensuring correct placement of nasogastric tubes? Southern Health Services/Monash
Institute for Public Health Clayton.
Christen, S. & Hess, T. (1996) is clinical positional control for nasogastric tubes good
enough? A prospective study of 43 patients. (article in German) Dtsch Med Wochenschr,
121 (37) 1119 1122 sept 13.
Cirgin-Ellett Backstand, J (1999) Examination of gavage tube placement in children. The
J ournal of Child and Family Nursing 3 (1): 42-4 J an Feb 2000.
Colagiovanni, L. (1999) Taking the tube. Nursing Times. May 26. 95 (21), 63 68.
Department of Health (2001) Reference Guidelines, 23618, 2p 500k April (col).
Della Faille D, Schmelzer B, Hartoko T, Vandenbroucke M, Brands C, DeDeyn PP.
Securing nasogastric tubes in non-cooperative patients. Acta Oto-Rhino Laryngologica
Belgica. 1996. 50 (3): 195 197.
Duncan, H.D., Silk, D.B.A. (2001) Insertion and care of enteral feeding tubes, in
Nightingale, J .M.D. (ed). Intestinal failure. Pp 281 303. Greenwich Medical Press,
London.
Gharib A.M. et al (1996) Nasogastric and Feeding Tubes. Post Graduate Medicine. Vol.99,
No. 5, p 165 176.
Harrison, M. (1997) Nursing Standard. 11, 27, 43 45.
Keohane, P.P., Attrill, A., Silk, D.B.A. (1986) Clinical effectiveness of weighted versus
unweighted fine-bore nasogastric feeding tubes in enteral nutrition: a controlled clinical
trial. J . Clinical Nutrition, Gastroenterology. 1: 189 193.
Mallett, J . and Dougherty (2000) 5
th
edition The Royal Marsdens Hospital Manual of
Clinical Nursing Procedures. Blackwell Science. London.
McConnell, E.A. (1997) Clinical dos and donts: inserting a naso-gastric tube. Nursing.
J an.72. Page 10 of 15
(MDA) Medical Devices Agency. Devices in practice. A guide for health and social care
professionals. 2001. MDA. London.

18
Medical Devices Agency (MDA) (1995) The re-use of medical devices supplied for single
use only. MDA Bulletin DB 9501. J anuary. MDA, London.
Medical Devices Agency (MDA) (2001) Devices in practice. A guide for health and social
care professionals. MDA. London.
Mensforth, A., Nightingale, J .M.D. (2001) Insertion and care of enteral feeding tubes. In
Nightingale, J .M.D. (ed) Intestinal Failure. Greenwich Medical Media, London.
Mental Capacity Act (2005) DOH.London
Metheny, N. Williams P et al. (1989) Effectiveness of PH Measurements in Predicting Feed
Tube Placement. Nursing Research Vol 38, No.5, p 280 285.
Metheny, N. McSweeney, M., Wehrle, M., Wiersma, L. (1990) Effectiveness of the
auscultory method in predicting feeding tube location. Nursing Research. 39 (5), 262
267.
Metheny, N., Dettenmeier, P., Hampton, K., Wiersma, L., William, P. (1990) Detection of
_nadvertent respiratory placement of small bore feeding tubes: a report of 10 cases. Heart
Lung. 19: 631 638.
Metheny, N., Spiers, M. Eisenberg (1988) Measures to test placement of Nasoenteral
FeedingTubes. Western J ournal of Nursing Research. 10(4) p 367 383.
Metheny, N. (1993) Minimising respiratory complications of naso-enteric tube feedings:
state of the service. Heart Lung. 22: 213 223.
Metheny, N.A., Clouse, R.E., Clarke, J .M., Reed, L., Wehrie, M.A., Wiersma, L. (1994) pH
testing of feeding tube aspirates to determine placement. Nutr. Clin. Prac. 9: 185 190.
Miller, K.S., Tomlinson, J .R., Sahn, S.A. (1985) Pleuro-pulmonary Complications of Enteral
Tube Feedings; Two reports, reviews of the literature and recommendations. Chest. 88 (2)
p230 233.
National Institute for Clinical Excellence (2006) Nutrition Support in Adults. London: NICE
National Patient Safety Agency (2004) Advice to the NHS on reducing harm caused by the
misplacement of naso-gastric feeding tubes. www.npsa.nhs.uk
National Patient Safety Agency (2011) Advice to the NHS on reducing harm caused by the
misplacement of naso-gastric feeding tubes. www.npsa.nhs.uk
Neumann, M.J ., Meyer, C.T., Dutton, J .L., Smith, R. (1995) Hold that X-ray: aspirate pH
and auscultation in enteral tube placement. J . Clin. Gastroenterology 20 (4), 293 295.
(NMC) Nursing and Midwifery Council. (2002a) Guidelines for records and record keeping.
NMC London.
Payne-J ames, J .J . (1988) Enteral nutrition: clinical applications. Intensive Therapy and
Clinical Monitoring. 7, 239 246.
Pratt, R.J . (2001) The Epic Project. Developing national Evidence based guidelines for
preventing health care associated infections. The J ournal of Hospital Infection Vol.47.
Supplement. Page 23 28.
Price, B. (1989) Nasogastric intubation. Nursing Times. Vol 85, No. 13, p 50-52.
Pulling, R. (1992) The Right Place. The Canadian Nurse 88 (2): 29 30 Feb.
Rollins, H. (1997) A nose for trouble. Nursing Times. Vol 93, No.49, P66 67.
Royal College of Nursing (RCN) (1999) Guidelines for Good Practice. Restraining, holding
still and containing children. Royal College of Nursing. London.

19
Storm, H. (2000) Closed System Enteral Feedings; Point-counterpoint. Nutrition in
Clinical Practice, 15, p193 200.
Sizer, T., Russell, C.A., Wood, S. et al. (1996) Standards and Guidelines for Nutritional
Support Page 11 of 15 of Patients in Hospital. British Association for Parenteral and
Enteral Nutrition.

20
11. Appendices
Appendix A Checklist for the Review and Approval of Procedural Document
To be completed and attached to any document which guides practice when
submitted to the appropriate committee for consideration and approval.
Title of document being reviewed:
Yes/No/
Unsure
Comments
1. Title Style & Format
Is the title clear and unambiguous? Yes
Does the Style & Format comply with
Trust Policy?
Yes
Is it clear whether the document is a
guideline, policy, protocol or standard?
Yes
2. Rationale
Are reasons for development of the
document stated?
Yes
3. Development Process
Is the method described in brief? Yes
Are people involved in the development
identified?
Yes
Do you feel a reasonable attempt has
been made to ensure relevant expertise
has been used?
Yes
Is there evidence of consultation with
stakeholders and users?
Yes
Has an Equality Impact Assessment
(EIA) been completed and is it attached
to the document?
Yes
4. Content
Is the objective of the document clear? Yes
Is the target population clear and
unambiguous?
Yes
Are the intended outcomes described? Yes
Are the statements clear and
unambiguous?
Yes

21

5. Evidence Base
Is the type of evidence to support the
document identified explicitly?
Yes
Are key references cited? Yes
Are the references cited in full? Yes
Are supporting documents referenced? Yes
6. Approval & Ratification
Does the document identify which
committee/group will approve and ratify
it?
Yes
If appropriate have the joint Human
Resources/staff side committee (or
equivalent) approved the document?
N/A
7. Dissemination and Implementation
Is there an outline/plan to identify how
this will be done?
Yes
Does the plan include the necessary
training/support to ensure compliance?
Yes
8. Document Control
Does the document identify where it will
be held?
Yes
Have archiving arrangements for
superseded documents been
addressed?
N/A
9. Process to Monitor Compliance and
Effectiveness

Are there measurable standards or KPIs
to support the monitoring of compliance
with and effectiveness of the document?
Yes
Is there a plan to review or audit
compliance with the document?
Yes
10. Review Date
Is the review date identified? Yes
Is the frequency of review identified? If
so is it acceptable?
Yes

22

11. Overall Responsibility for the
Document

Is it clear who will be responsible for co-
ordinating the dissemination,
implementation and review of the
document?
Yes

Individual Approval
If you are happy to approve this document, please sign and date it and forward to the
chair of the committee/group where it will receive final approval.
Name Date
Signature

Committee Approval
If the committee is happy to approve this document, please sign and date it and
forward copies to the person with responsibility for disseminating and implementing
the document and the person who is responsible for maintaining the organisations
database of approved documents.
Name Date
Signature


23

Appendix B Plan for Dissemination of Procedural Documents

To be completed and attached to any document which guides practice when
submitted to the appropriate committee for consideration and approval.
Acknowledgement: University Hospitals of Leicester NHS Trust.

Title of
document:
Adult Nasogastric Tube Insertion Procedure & Management
Policy
Date finalised: 23 August 2011 Dissemination lead:
Print name and contact
details
Kerri West
Quality
Facilitator
39691
Previous
document
already being
used?
Yes
(Please delete
as appropriate)
If yes, in what
format and
where?
Trust Document Network Share Folder
Proposed action
to retrieve out-
of-date copies of
the document:
N/A
To be
disseminated to:
How will it be
disseminated, who
will do it and
when?
Paper
or
Electronic
Comments
All Clinical Staff Published on Trust
Document Network
Share Folder by
document controller.
Advertised in Vital
Signs and by email
to all managers
Electronically

Dissemination Record - to be used once document is approved.
Date put on register /
library of procedural
documents
September
2011
Date due to be
reviewed
October 2014
Disseminated to:
(either directly or
via meetings, etc)
Format
(i.e. paper
or
electronic)
Date
Disseminated
No. of
Copies
Sent
Contact Details /
Comments


Appendix 1 - Competency Assessment Process Insertion and Care of
Nasogastric tubes for Adults Supporting Information for Assessors
and Managers

Competency Assessment Process
Insertion and Care of Nasogastric
tubes for Adults

Supporting Information
for assessors and managers


Introduction
To avoid catastrophic injury or fatal consequences,the National Patient Safety
Agency ( NPSA 2011) requires Healthcare Professionals to be competent in
the insertion and subsequent management of nasogastric tubes (NGT). Staff
have a responsibility to seek advice and training when necessary. This
document has been developed to provide information for assessors and
managers who have within their scope of practice the potential to manage the
care of patients who require NGTs. It will assist Registered Healthcare
Professionals in the training and recording of competency in the insertion and
subsequent management of fine bore and wide bore NGT .

The aim of the competency assessment process is to ensure the healthcare
practitioner is able to:
Abide by, and fully implement the NPSA directives relating to the
insertion and management of fine and wide bore NGT
Understand of the decision making process for the use of NGTs
Understand the potential risks and contraindications associated with
the use of NGT and how to minimise/respond to these.
Demonstrate competency in the insertion and subsequent care of NGT.
Promote best practice throughout the healthcare environment in the
use and care of NGTs

This competency assessment process consists of 4 parts:
1. Knowledge and Understanding Section:This must be successfully
completed prior to the assessment by clinical observation
2. Practice Assessment for the insertion and confirming position of
nasogastric tubes.
3. Practice Assessment for the Care of the patient with a nasogastric tube
inserted
4. Practice Assessment for the administration of medications via the enteral
route


Who should complete this competency assessment process?

Practitioners who are inexperienced in this skill (such as the newly
qualified, newly appointed to post)
Those staff who have been identified by their manager or clinical
educator as not competent or considered to be at risk of under
performing in their role.
Practitioners who are regularly performing this skill must also be
assessed as competent by a trained assessor using this competency
process.
ALL practitioners who use NGTs within their scope of practice must
sign to declare they have read and are fully understand the current
PHNT policy regarding the insertion and management of NGTs and all
relevant NPSA directives.
Those staff who have fully competed this assessment process, but
have not undertaken this skill for over 6 months should be reassessed
using a simulated assessment technique, if necessary. A manikin for
this purpose is available via the Clinical Education Facilitator.
The Statement of this Competence( example in Appendix 1) at the
end of the learners competency document, must be signed by the
manager and the trained assessor, prior to the practitioner being able
to perform this skill. This record should be entered onto OLM as
training received.

N.B Students undertaking pre-registration programmes should always carry
out the procedure under the supervision of a qualified mentor .


Assessors must be Registered Healthcare Professionals who have:-
Successfully completed the competency assessment process to level 4
Maintained their competency by regularly performing this skill. If an
update is necessary contact the Education Facilitator for a simulated
assessment.

Assessor Responsibilities
Before signing the Statement of Competence assessors should ensure that
on successful completion of this pack, the learner is able to:-
Demonstrate knowledge of PHNT policy and NPSA directives local
related to this skill.
Demonstrate the ability to carry out the procedure competently.
Identify problems and deals with them appropriately.
Demonstrate correct documentation for the procedure.
Assessors must report to manager if any learner fails to achieve
required level of competence
Completed formative statements and action plans must accompany
this report.


Line manager`s responsibilities

Identify those staff who require assessment of competency in the
Insertion and management of nasogastric tubes.
Ensure assessors within their area are fully competent to level 4 of
the assessment criteria
If informed of non achievement of competency, ensure learner is
not given authority to undertake skill until successful.
Record successful completion of clinical competency process and
the Knowledge and Understanding section onto the electronic
training records ( OLM)
Store competency package within staff members` education
records or the employees record file held by the line manager(this
can be electronic)
Store signed Statements of Competency in accessible folder in
order to provide evidence of staff training and record of competency
if requested.

.

Learner Responsibilities

Registered Health Professionals who undertake training to insert and manage
nasogastric tubes must:
Complete the requirements of the NGT Competency Assessment
process within 6 months of commencement
Read the current PHNT policy and all relevant NPSA documents for
insertion and management of NG tubes.
Undertake supervised practice with a competent practitioner who is
skilled in the procedure and has already successfully competed this
competency process.
Take responsibility thereafter for maintaining competence in the skill
and seek supervision from a competent practitioner if for reason of
sickness or absence they have not carried out the procedure in the
previous 6 months.
If due to lack of clinical opportunity a reassessment is necessary
please contact the Clinical Education Facilitator to arrange an update
and reassessment.

Assessment process
Perform a self assessment with a competent practitioner of the
skill and formulate an action plan to address learning needs
Complete Part 1 knowledge and understanding section with their
assessor before attempting Part 2,3 and 4
Undertake a formative assessment using simulation if necessary.
A training manikin is available for this purpose, by contacting the
Clinical Education Facilitator.
Undertake a summative assessment; the learner must reach
level 3 to be signed off as competent this may be achieved at the
formative stage, if all performance criteria are satisfied.

The performance criteria are provided with each competency to help towards
the interpretation of the competency statements and are intended as a guide
but all listed cues should be discussed and demonstrated in practice to
achieve competence.

Assessment scoring system

Level 0 Unsafe practice
Has minimum knowledge/skill
Unprofessional behaviour

Level 1 Doubt knowledge and ability to meet assessment criteria without
direct supervision.

Level 2 Able to perform skill with supervision
Has factual knowledge base

Level 3 Has knowledge and skill to perform task safely without
supervision
Ability to apply problem solving skills
Consistently demonstrates clinical competence

Level 4 Has knowledge and skill to perform task unsupervised
Can facilitate knowledge and skill to another
Has attended a specific train the trainer session and is able
teach and assess others


Appendix 1

Insertion and Care of Nasogastric tubes for Adults
Statement of competence
PASS / REFER

I confirm I have assessed this learners practice and it is at the standard
stated within this competency document and is competent in the following:
Part 1 Knowledge and understanding section
Part 2 Insertion and confirmation of position of nasogastric tubes
Part 3 Management of nasogastric tubes
Part 4 Administration of medications via the enteral route

Assessor Name (please print): .....................................................................................

Assessor Signature: .....................................................................................................

Managers signature providing authority for practitioner to perform task:

Date

Learner declaration:

I have read and understood the PHNT policy and the the National Patient
Safety Alerts related to the insertion and management of nasogastric
tubes and enteral administration of medications

Learners Name (please print): .....................................................................................

Learners Signature: .....................................................................................................

In the event of a referral or failure to reach required level of competence
within 6 months:

Date manager informed.
Name of manager (please print).
Manager signature of receipt of report.
Review date for second assessment

This sheet to be printed and stored for evidence of training.

1
Appendix 2 Insertion and Care of Nasogastric Tubes for Adults
Competency Assessment Process for Registered Healthcare
Professionals

Insertion and Care of Nasogastric
tubes for Adults

Competency Assessment Process for
Registered Healthcare Professionals

Learners Name

Mentor/Assessor Name

Date Commenced

Date Completed

Mentor Signature

Learner Signature


2

Contents
Aim of the competency process 3
Assessment process 4
Part 1 - Core knowledge and understanding

6
Assessment Record and Feedback sheet

7
Part 2 - Practice Assessment sheet for the insertion and confirming
position of fine bore and wide bore nasogastric tubes
9

10
Part 3 - Practice Assessment sheet for the management of fine bore
and wide bore nasogastric tubes
11

12
Part 4 Practice Assessment sheet for the administration of
medications via the enteral route
13

14

15


3
Introduction
To avoid catastrophic injury or fatal consequences,the National Patient Safety
Agency ( NPSA 2011) requires Healthcare Professionals to be competent in
the insertion and subsequent management of nasogastric tubes(NGT). Staff
have a responsibility to seek advice and training when necessary. This
document has been developed to to assist Registered Healthcare
Professionals in the training and recording of competency in the insertion and
subsequent management of fine bore and wide bore NGTs .

The aim of this competency assessment process is to ensure the healthcare
practitioner is able to:
Abide by, and fully implement the NPSA directives relating to the
insertion and management of fine and wide bore NGT
Understand of the decision making process for the use of NGTs
Understand the potential risks and contraindications associated with
the use of NGT and how to minimise/respond to these.
Demonstrate competency in the insertion and subsequent care of NGT.
Promote best practice throughout the healthcare environment in the
use and care of NGTs
The most important propose of this assessment process is to maintain
patient safety is at all times.

This competency assessment process consists of 4 parts:
1. Core Knowledge and Understanding :This section must be
successfully completed prior to the assessment by clinical observation
2. Practice Assessment for the insertion and confirming position of
nasogastric tubes.
3. Practice Assessment for the Care of the patient with a nasogastric
tube inserted
4. Practice Assessment for the administration of medications via the
enteral route

4
Assessment process

Read the current PHNT policy and all relevant NPSA documents for
insertion and management of NG tubes.
Perform a self assessment with a competent practitioner of the skill
and formulate an action plan to address learning needs
Complete Part 1 Core knowledge and understanding section with their
assessor before attempting Part 2,3 and 4
Undertake a formative assessment using simulation if necessary. A
training manikin is available for this purpose, by contacting the Clinical
Education Facilitator.
Undertake a summative assessment; the learner must reach level 3
to be signed off as competent this may be achieved at the formative
stage, if all performance criteria are satisfied.

In addition:
Complete the requirements of the NGT Competency Assessment
process within 6 months of commencement.
Take responsibility thereafter for maintaining competence in the skill
and seek supervision from a competent practitioner if for reason of
sickness or absence they have not carried out the procedure in the
previous 6 months.
If due to lack of clinical opportunity a reassessment is necessary
please contact the Clinical Education Facilitator to arrange an
assessment using a simulated assessment technique.

NB.
The performance criteria are provided with each competency to help towards the
interpretation of the competency statements and are intended as a guide but all listed
cues should be discussed and demonstrated in practice to achieve competence.


5

Assessment scoring system

LEVEL 0 Unsafe practice
Has minimum knowledge/skill
Unprofessional behaviour

LEVEL 1 Doubt knowledge and ability to meet assessment criteria without
direct supervision.

LEVEL 2 Able to perform skill with supervision
Has factual knowledge base

LEVEL 3 Has knowledge and skill to perform task safely without
supervision

Level 4 Has knowledge and skill to perform task unsupervised
Can facilitate knowledge and skill to another
Has attended a specific train the trainer session and is able
teach and assess others

N. B. For more information regarding the assessment process please read the
accompanying Supporting Document


6

Part 1 Knowledge and understanding

Prior to clinical assessment, the learner must demonstrate knowledge
and understanding of the following in relation to the insertion, checking
position and management of all types of nasogastric tubes

Learner to provide a short written answer to the following questions
Question 1
Describe what information should be entered into patients medical notes as
a minimum prior to the decision to insert a NGT

Question 2
Describe in detail the actions when aspirate is not obtainable for both feeding
and surgical indications

Question 3
Describe when are subsequent position checks are necessary


7

Evidence oral questioning Assessor
to indicate
with X if
not
achieved
Assessor
initial if
achieved

1 Describe the indications for insertion of fine bore
NG tubes and wide bore NG tubes.

2 Describe the basic upper GI anatomy and route of
the NGT

3 Describe the actions required to undertake
nutritional screening

4 When is it unsafe to pass a NG tube?

5 What is meant by first line check method in relation
to the NPSA and why?

6 Describe what information should be documented
following the pH test result

7 Describe possible reasons when aspirate is above
pH 5.5

8 When is it necessary to confirm position of tube by
X-ray ?

9 Describe the potential complications and
appropriate remedial action

12 Explains why three way taps should not be used

13 List at least 2 drugs which have significant
interactions with enteral feeding formula

14 Describe the legal implications of crushing drugs
or opening capsules in relation to the product licence

15 Describe the procedure for a blocked NGT for
enteral feeding and for surgical aspiration of stomach
contents


8

Knowledge and understanding Assessment Record

Assessor to initial and date to indicate level of performance refer to assessment
criteria

Self Assessment
0 1 2 3 4

Formative Assessment
0 1 2 3

4

Summative Assessment
0 1 2 3

4

Feedback Record
Comments

Action plan

Signature of Learner
Signature of Assessor
Date


9

Part 2 Assessment for the insertion and confirming position of
Nasogastric tubes
Prior to clinical assessment, the learner must demonstrate knowledge and understanding of
the procedure and successfully completed Part 1
Performance criteria - Evidence of Direct Observation and Oral
questioning
Can/is/does the learner
Assessor initial
and date each
section
PRE PROCEDURE:Check identity of patient and explain the
procedure to the patient and gain their consent
Ensure patient is given an agreed signal to stop procedure if
unable to tolerate
Position the patient correctly,sitting upright with head and
shoulders well supported with pillows. If unconscious or semi-
conscious place in a safe position by lying on their side
Assemble the correct equipment including emergency
equipment ( i.e. suctioning apparatus, oxygen)
Select the most appropriate type of NG tube
Wash hands with soap and water and dry well.
Put on gloves and apron

PROCEDURE:Measure and mark the tube using the NEX
method,mark this length with indelible pen
If using a fine bore tube with an introducer ,ensure it is
moveable by pulling out 5 cms and replacing prior to insertion.
Close all portals
Ask patient to blow nose if appropriate or clean each nostril
Lubricate end of tube with water
Insert the rounded end of tube into clearest nostril and slide
backwards and inwards along the floor of the nasopharynx.
Withdraw tube if obstruction is felt, retry on other side
Stop immediately if patient shows signs of respiratory distress
such as cyanosis and bradycardia or complains of ear pain
Instruct patient to swallow if able as tube passes the naso
pharynx (may sip water if not nil by mouth)
Advance tube gently but continuously to required position
Secure tube to patients nose and cheek/forehead using
appropriate fixing tape.

CONFIRMS TUBE IS IN CORRECT POSITION: Withdraw 2 to
5mls of aspirate using a 60ml enteral purple syringe and place
fluid onto pH indicator strip
A pH of 1 to 5.5 indicates the safe range of acidity to confirm
the tube is in the stomach.
Undertake all measures to obtain aspirate if not able to
withdraw stomach aspirate the first time
Check tube by x-ray on first insertion if unable to obtain aspirate
after all measures undertaken to do so fail
Ensure X-ray request form contains all the required information
including the purpose of the tube
For Fine bore feeding tubes only Once position confirmed,
flush tube with 10mls water and gently remove guide wire

POST PROCEDURE:Record procedure using correct
documentation, include type and length of tube and pH of
aspirate obtained
Complete NGT sticker and adhere to patients notes
Dispose of waste and used equipment appropriately


1
0
Assessment Record for the insertion and confirming position of
nasogastric tubes

criteria Indicate level of performance

Self Assessment
0 1 2 3 4

0 1 2 3

4

0 1 2 3

4

Feedback Record
Comments

Action plan

Date


1
1

Part 3 Assessment form for the Care of the patient with a
Nasogastric tube

Prior to clinical assessment, the learner must demonstrate knowledge and
understanding of the procedure and successfully completed Part 1

Performance Criteria
Can/is/does the trainee
Evidence of Direct Observation and Oral questioning
Assessor to initial
and date each
section.
Communicate with patient effectively and gains their
consent?

Ensure the correct position the patient for enteral feeding
Demonstrate the correct method to aspirate and flush the
tube

Describe indications when tube may have moved from
correct position and undertakes tube position check
after:
Violent coughing or vomiting
Before administering medications or start of
feeding regimes
After interruption of delivery of feeding regime
If it is suspected the tube as moved

Confirm the position of the NG tube correctly using the
pH indicator strip

Check length of tube in relation to position of marker at
nostril, and ensures tube is fixed securely at all times

For Wide bore (Ryes) tube only set up free drainage
system or spigot as appropriate. Checks nature of
aspirate and accurately documents amount

Demonstrate ability to attach giving set, run through feed
and set enteral feeding pump to correct rate and volume.

Administer medications via NG tube appropriately, using
correct mode (syrup, crushed etc) according to PHNT
policy and NPSA guidelines .

Take correct action to ensure patency of tube and
abides by PHNT policy for dealing with a blocked NG
tube

Demonstrate clear and accurate records using correct
documentation

Describe action to be taken for vomiting, distension,
diarrhoea

Demonstrate awareness of the special needs of the
patient with diabetes requiring enteral feeding

Abide by all infection control policies and procedures


1
2
Part 3 Assessment Record for the Care of the patient with a
Nasogastric tube

criteria

Self Assessment
0 1 2 3 4

0 1 2 3

4

0 1 2 3

4

Feedback Record
Comments

Action plan

Date


1
3

Part 4 Practice Assessment for the administration of
medications via the enteral route

Prior to clinical assessment, the learner must demonstrate knowledge and
understanding of the procedure and successfully completed Part 1

Performance Criteria
Can/is/does the learner - evidence of Direct
Observation and Oral questioning
Assessor initial and date
each section
PRE - PROCEDURE
Decontaminates hands and abides by infection control
policy
Prepares equipment, selects the most appropriate size
and type of syringe abiding by NPSA guidelines
Explains why a catheter tip syringe should be avoided
Ensures all equipment is clean and dry e.g. pestle and
mortar
Checks medication, frequency and dose using patient
drug chart according to PHNT procedure
Checks Doctor has reviewed prescription are all
medications necessary? Ensure pharmacist has
reviewed prescription
Checks prescription has considered mode? e.g. Liquid
alternative available?
Seeks advice for patients on fluid restrictions.
Considers if medication requires a break in feeding
regime.

PROCEDURE
Checks identity of patient
Explains the procedure to the patient and gains
consent if appropriate
Confirms tube is in correct position and patient is
comfortable
Demonstrates ability to prepare and administer via
enteral route the following
Soluble tablets
Liquids
Tablets
Capsules
Stops feed and gives a minimal flush of 30mls or as
directed before and after drug is given
If more than one drug, gives separately with 10 ml of
water flush in between
Restarts feeding regime according to care plan

POST PROCEDURE
Abides by control of infection policies and procedures
Records procedure using correct documentation
Cleans equipment thoroughly after use
Disposes of waste and used equipment appropriately.


1
4

Assessment Record for the administration of medications
via the enteral route

criteria ndicate level of performance

Self Assessment
0 1 2 3 4

0 1 2 3

4

0 1 2 3

4

Feedback Record
Comments

Action plan

Date


1
5

Insertion and Care of Nasogastric tubes for Adults
PASS / REFER

1. I confirm I have assessed this learners practice and it is at the
standard stated within this competency document in the following
Part 1 Knowledge and understanding section
Part 2 Insertion and confirmation of position of nasogastric tubes
Part 3 Management of nasogastric tubes
Part 4 Administration of medications via the enteral route

Assessor Name (please print): .....................................................................................

Assessor Signature: .....................................................................................................

Managers signature providing authority for practitioner to perform task:

Date

Learner declaration:

I have read and understood the PHNT policy and the the National Patient
Safety Alerts related to the insertion and management of nasogastric
tubes and enteral administration of medications

Learners Name (please print): .....................................................................................

Learners Signature: .....................................................................................................

In the event of a referral or failure to reach required level of competence
within 6 months:

Date manager informed.
Name of manager (please print).
Manager signature of receipt of report.
Review date for second assessment ..............................

This sheet to be printed and stored in a retrievable place for evidence of training
Appendix 3 Decision Tree for Nasogastric Tube Placement Checks in
Adults

Decision Tree for nasogastric tube placement checks in ADULTS

\

NO
If pH above 5.5 on initial and
subsequent placement check:
Medication, pt may be on a PPI
(Proton Pump Inhibitor) e.g.
Omeprazole : try to aspirate as
long as possible after giving
medication.
Feed, if feed is running
continuously: stop feed for up to
60mins and try again

NO NO
Test aspirate on 2-5mls (5mls for Critical Care pts) using CE
marked pH indicator paper for use on human aspirate.
DO NOT USE - try each of these
techniques to help gain an
aspirate:
Check length tube inserted to
(NEX measurement) advance
/withdraw tube by 5-20cms
If able to drink, give a small
drink
Give mouth care to pts who
are nil by mouth (stimulates
gastric secretion)
Inject 10-20mls air down tube
Move patient onto their left
side and retry
Wait for 20-60 minutes and
try aspirating again
NO
Is pH aspirate 0 - 5.5?
YES
Use NGT for drainage
or administration of
feed/medication as per
instructions
YES
DO NOT USE THE TUBE If aspirate cannot be obtained or is still above pH 5.5
Consult medical staff. Document the medical decision and strategy for
that individual patient in the medical notes. Document all techniques tried to
obtain aspirate before request for CXR is made.
Document
Complete record of NG
sticker accurately and
stick on current page of
pts medical notes.
Complete Innovian NG
record page (Critical
Care pts).
Complete bedside
record chart

Subsequent checks
pH recordings and
length tube inserted at
nostril in cms
(NEX measurement)
MUST be made and
recorded on bedside
documentation before
each use e. g.
aspiration
feed/medication/flush
or if cause for concern.
Is pH aspirate now 0 - 5.5? Is pH aspirate now 0 - 5.5?
On initial placement - A competent practitioner must view the CXR and
complete the NGTsticker in the patients medical notes or on the Innovian NG
page (Critical Care) and state if the NGT is safe to use.
OR
On subsequent checks - A competent practitioner must view the CXR and
document the findings in the patients medical notes or on the Innovian NG
page (Critical Care) and state if the NGT is safe to use.
If the CXR shows the NGT to be in the lungs the tube must be
removed immediately and re-passed
Does the patient need a NGT?
Ensure there is enough expertise available to insert and interpret findings of both pH and CXR (if needed)
Use a fully radio-opaque tube with visible external markings following the Trust guidelines
Estimate NEX measurement (tube tip from Nose - Ear - Xiphisternum)
Aspirate using a purple enteral syringe and gentle suction. Confirm and document secured NEX measurement

Aspirate obtained?
File in Medical notes with Nursing Records n
medical notes with F
Appendix 4 Record of Insertion of Nasogastric Tube Sticker

RECORD OF INSERTION OF NASOGASTRIC TUBE
This must be completed and stuck to the current continuation sheet in patient
medical notes or complete Innovian NG page prior to use.
Reason for NG placement:-
Feeding

Medication

Drainage
NG tube details and size
Fine Bore

Ryles
8fr

10fr

12fr

14fr

16fr

18fr
Length to which tube inserted (NEX measurement) at nostril in cms

R

L Nostril
Inserted by: Print name. Sign.Date: Time:
Ist line test 2-5mls (5mls for critical care pts) of aspirate from NGT

pH 5.5 or below, pH result

pH 6.0 or above

No aspirate
Date.Time .. Checked by: Print name..Signature.
If No or pH is above 5.5 refer to NGT policy for aspiration techniques,
then retry. If a CXR is required to confirm NGT position it should be
requested ideally before 4pm with accurate details on the request.
2nd line test CXR taken: Time..Date....
CXR checked by a competent practitioner :- Time.Date..
Print name:.................................Signature:.. . Bleep
Position confirmed visually on CXR by:-
Follows oesophagus, avoids contours of bronchi
Clearly bisects the carina/bronchi
Crosses the diaphragm in the midline
Tip visable below left hemi-diaphragm
Can the tube be used safely for feeding/meds/drainage? Yes / No

Patient Name: .
NHS No.
Hospital No..
DOB..
Ward.

(Fix Addressograph label)

Appendix 5 Nasogastric Tube Position Record and Care Plan

1

Nasogastric Tube Position Record and Care plan

Initial NGT positon check

External length of
NGT in cms at tip
of nose
Aspirate
obtained
pH value of
aspirate

If no aspirate or pH 6.0 or above
Do Not use the NGT
Follow the Decision Tree for Nasogastric Tube
placement checks in adults
Document action taken

Y / N

NB. Please ensure the NGT sticker is completed on initial tube placement and
placed in the medical notes or Innovian NG page for Critical Care.

If difficulty in obtaining an aspirate refer to NGT policy for aspiration techniques.

Subsequent NGT position checks
Date/time External
length
of NGT
in cms
at tip of
nose
Aspirate
obtained

Y / N
pH
value of
aspirate
Do Not use the NGT
Follow the Decision Tree for Nasogastric
Tube placement checks in adults

Sign and print
name

Type and size of tube inserted .
Position of the nasogastric tube should be checked:
Following initial insertion
When there is suggestion of tube displacement
e.g change in tube length, patient comfort
Before administering medications or feed
Once daily during continuous feeds
Once daily to confirm position when for drainage
Any new or unexplained respiratory symptoms
Following episodes of vomiting, retching or
coughing spasms
Patient Name: .

NHS No.
Ward.
Hospital No..
DOB..

Date/Time NGT inserted.
Inserted by, sign and print name:-

File in Medical notes with
Nursing Records n medical
notes with F

Date/time External
length
of NGT
in cms
at tip of
nose
Aspirate
obtained

Y / N
pH
value of
aspirate
Do Not use the NGT
Follow the Decision Tree for Nasogastric
Tube placement checks in adults
Sign and print
name


Appendix 6 Ongoing Post-Insertion Care and Management of
Nasogastric Tubes

Ongoing Post-Insertion Care and Management of Nasogastric Tubes
SUBSEQUENT VERIFICATION OF NASOGASTRIC TUBE POSITION
As the accountable practitioner caring for the patient with a Nasogastric tube,
it is your responsibility to ensure that the tube is in the correct position.
Tube position should be checked by aspiration :
ACTION
Following each changeover of nursing shifts
On each occasion prior to the administration of fluid, nutrition or medications.
After vomiting or violent retching.
If the patient complains of discomfort or feed reflux into the mouth.
After severe bouts of coughing or respiratory distress.
After nasopharyngeal, endotracheal or tracheostomy tube suctioning.
If the tube is accidently dislodged.
If the tube has obviously displaced on checking measurement.
If it is suspected that the tube has moved.
If there is any doubt that the tube may not be in the stomach.
At least once every 24 hours when continuous feeds are used.
Drainage tubes where a tube fails to drain or the patient is vomiting.
On receipt of patient being transferred prior to using tube.
Use Nasogastric Tube Position Recording Form (Appendix *)
to document subsequent checking of tube position
ONGOING MANAGEMENT
Securing a nasogastric tube
Daily
Check that tape securing tube is intact and not in need of replacement.
Check around nostril for any signs of pressure necrosis.
If the nose appears sore or ulcerated, consider re-passing the tube via
the other nostril.
Maintaining patency flushing.
Once tube position confirmed, flush tube with 30-50mls of water before
and after feed and medications using a 60ml purple enteral syringe.
If the tube is not flushed regularly, occlusion may occur (Colagiovanni
2000)
Where possible medications should be given in liquid/dispersible form
with a water flush in between.
If it is not possible to flush a feeding tube, then please refer to Adult
Nasogastric Tube Feeding Guidelines, Version 1:6, sections:
9.1 Enteral feeding tube blockage: causes and prevention
9.2 Procedure for irrigating a blocked enteral feeding tube
Administration of medications via a nasogastric tube
Please refer to Adult Nasogastric Tube Feeding Guidelines, Version 1:6,
section 8.

File in Medical notes
with Nursing Records n
medical notes with
F
Appendix 7 Audit Form

Plymouth Hospitals NHS Trust

Audit Plan Naso-gastric Tube Insertion and Management

To be completed monthly by matron or ward manager for all patients with NG tubes
on a pre-selected date. If there are no patients with NG Tubes response to be sent
to confirm this.

Audit Question Confirmation Comments
1 Is the request for a nasogastric tube
documented?

Yes No
2 Has the type of tube required been
identified?

Yes No
3 Is there a record of :
The time and date the tube was inserted
Who inserted it

Yes No
Yes No

4 Has the correct sticker been placed in the
patients record and completed?

Yes No
5 Is there a record of a ph test being
successfully completed?

Yes No
6 If not is there evidence of an Xray to
confirm position?

Yes No
7 Is there a record of medical staff having
viewed xray and confirming position?

Yes No
8 Is there confirmation that staff
administering feed / medication via tube
have checked documentation of it being
correctly sited?

Yes No
9 Are staff on duty aware of policy &
procedure and where this can be found?

Yes No

Date: Time: Ward/Dept:

Name of person completing audit ( please print)t:

Signature:

Designation:


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