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Nasogastric feeding
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Caring for adult patients who

require nasogastric feeding tubes
NS694 Curtis K (2013) Caring for adult patients who require nasogastric feeding tubes.
Nursing Standard. 27, 38, 47-56. Date of submission: November 27 2012; date of acceptance: January 18 2013.

Abstract
Nasogastric tubes provide a safe means of delivering nutrition support
to many patients in hospital and the community. Insertion and care of
these tubes will be familiar to many nurses. Evidence has shown that
misplaced tubes, either on insertion or during use, can cause serious harm
or even death to patients. This article explores the safety challenges posed
during the insertion and maintenance of nasogastric tubes. Guidance and
evidence should provide nurses with the knowledge, skills and reassurance
to manage these tubes safely.

Author
Kristine Curtis
Nutrition nurse specialist currently on a career break and freelance writer,
Edinburgh.
Correspondence to: curtiskristine@btinternet.com

Keywords
Enteral feeding, enteral nutrition, nasogastric tube, patient safety,
tube feeding complications

Review
All articles are subject to external double-blind peer review and checked
for plagiarism using automated software.

Online
Guidelines on writing for publication are available at
www.nursing-standard.co.uk. For related articles visit the archive and
search using the keywords above.

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Aims and intended learning outcomes

This article aims to provide the reader with an
understanding of the safe and effective nursing
care of adult patients who require nasogastric
tubes for feeding. The terms feeding and feed
will be used to represent the introduction of any
feed, liquid or medication through a nasogastric
tube. After reading this article and completing
the time out activities you should be able to:
Identify

the indications and contraindications
to the bedside insertion of a nasogastric tube
for feeding.
Outline

the steps involved in the safe
insertion of a nasogastric tube and
confirmation of tube position.
Explain

the importance of clear and accurate
documentation in the prevention and detection
of nasogastric feeding tube complications.
Develop

a plan of nursing care to prevent
nasogastric tube-related complications.
Discuss

the support that a patient discharged
into the community with a nasogastric
feeding tube may need.

Introduction
Nasogastric tubes provide a vital route to deliver
nutrition, fluid and medication to patients with
impaired swallowing, unsafe oral access or
increased energy requirements that cannot be
met orally. Their clinical use for feeding began to
be realised in the 1970s, with the introduction of
fine bore nasogastric tubes (Rassias et al 1998).
These could be inserted blindly at the bedside,
and their narrowness reduced the incidence of
ulceration to the nose, pharynx and stomach.
The blind insertion of nasogastric tubes at the
bedside will always carry a risk of failure and
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misplacement (Lloyd and Powell-Tuck 2004).
It is difficult to quantify risk or incidence
of nasogastric tube misplacement, but research
suggests that 1.2-4.0% of tubes are misplaced
in the lungs and 0.3-0.7% will result in damage
to the lungs (Rassias et al 1998, Sorokin and
Gottlieb 2006, Krenitsky 2011, Sparks et al
2011, Rollins et al 2012). Taylor and Clemente
(2005) estimated that risk of death related to
blind nasogastric tube insertion could occur in
one per 100,000 people. These figures suggest
a low incidence of patient harm and that many
thousands of tubes are placed safely. However,
if a nasogastric tube is misplaced and feed is
delivered into the tracheobronchial tree or pleural
cavity, it can result in serious harm or death.
Patients can also be harmed if a correctly
sited tube becomes displaced from the stomach
into the oesophagus, or pharynx, causing feed
to be aspirated into the lungs. Patients with
endotracheal or tracheostomy tubes are at
increased risk of tube misplacement (Krenitsky
2011, Sparks et al 2011). The exact mechanism
for this is unclear, but is likely to be related
to several factors, including altered level of
consciousness, absent gag reflex, underlying
respiratory disease, patient positioning and the
endotracheal or tracheostomy tube preventing
closure of the epiglottis (Pillai et al 2005,
Sparks et al 2011). Multiple, difficult insertions
also increase the risk of misplacement on
insertion (Krenitsky 2011). Once misplacement
has occurred, the risk of future misplacement
increases (Sparks et al 2011).
In 2009 the Department of Health (DH),
classified cases of severe harm or death resulting
from failure to detect a misplaced nasogastric
tube before feeding as a never event. Never
events are serious and largely preventable
incidents that should never occur if available
guidance is followed (DH 2012). In 2011/12
there were 23 known never events involving
a misplaced nasogastric tube in England (DH
2012). The National Patient Safety Agency
(NPSA) issued two key safety alerts, in 2005
and 2011, in response to deaths and severe
harm caused by misplaced nasogastric tubes.
Both alerts stipulated actions that had to be
taken by NHS acute trusts and primary care
organisations in England and Wales to improve
patient safety (NPSA 2005, 2011).
Complete time out activity 1

Pre-insertion assessment
Nasogastric feeding is generally a short-term
therapy, ideal for providing nutrition support
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for up to six weeks (National Collaborating

Centre for Acute Care 2006). During this time
the effectiveness of enteral nutrition and the
appropriateness of longer term methods of
support can be assessed (Lloyd and Powell-Tuck
2004). Some patients may require nasogastric
feeding for longer, especially those for whom the
risk of placing a long-term feeding tube outweighs
the risk of prolonged nasogastric feeding.
A multidisciplinary assessment of the patient
is required before nasogastric tube insertion to
ensure that nasogastric feeding is indicated and
that any identified risks have been minimised
and recorded (Table 1). Assessments should
be documented in the patients medical notes
(NPSA 2011). Verbal consent should be
obtained from patients who have capacity, and
best interest decision-making guidelines should
be followed for patients lacking capacity. It
should also be determined whether the patient
has made an advanced decision or directive.

Tube selection
The primary purpose of fine bore nasogastric
tubes is feeding rather than drainage. In adults,
6-12 French gauge (Fr) tubes are recommended,
with 8 Fr being the most commonly used size
(Lloyd and Powell-Tuck 2004, National Nurses
Nutrition Group (NNNG) 2012). In patients
where drainage is requested to monitor gastric
residual volumes, 12 Fr tubes can be useful.
Tubes differ according to the manufacturer,
but short-term tubes are typically made from
polyvinyl chloride (PVC), do not require a
guidewire and can be used for a maximum of
seven to ten days. PVC contains plasticisers that
help make the tube flexible, but over time they can
leach from the tube and cause the tube to become
hard and brittle (Medicines and Healthcare
products Regulatory Agency (MHRA) 2007).
Long-term tubes are made of polyurethane
or silicone, which are softer, and often have a
guidewire to aid insertion (NNNG 2012).
Long-term tubes can be used for six to eight
weeks, but some manufacturers offer tubes
with a longer lifespan. However, the lifespan
of the tube will depend on it remaining in the
correct position. Nasogastric tubes used for
feeding must be NPSA compliant and have the
following attributes (NPSA 2005, 2007):
Fully

radio-opaque along their length, without
a guidewire, to ensure maximum visibility
on X-ray. This may be a radio-opaque stripe
along the length of the tube, or the entirety of
the tube may be radio-opaque with barium
sulphate incorporated into the polyurethane.

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TABLE 1
Indications and contraindications to blind bedside nasogastric tube insertion
Indications

Contraindications*

Unsafe swallow
(post cerebrovascular accident, neurological disease)

Basal skull fractures

(as a result of risk of intracranial insertion)

Unconscious patient
(head injury, ventilated patient)

Maxilla-facial disorders, trauma and surgery

(including transnasal transsphenoidal surgery)

Supplement poor oral intake

Coagulation disorders (uncorrected)

Increased nutritional requirements

(cystic fibrosis, renal disease)

Oesophageal or gastric abnormalities (including

surgery)

Physiological anorexia
(liver disease, sepsis)

High risk of aspiration, including hiatus hernia,

severe gastro-oesophageal reflux, previous
oesophagectomy

Psychological problems
(severe depression, anorexia nervosa)

Continuous positive airway pressure (nasal)

*Some contraindications may be relative for certain patients and in some circumstances the use of fluoroscopic or
endoscopic guidance may make placement possible and safer.
(Metheny 2002, Stroud et al 2003, Lloyd and Powell-Tuck 2004, National Collaborating Centre for Acute Care 2006)

External

markings visible along the length of
the tube to allow accurate measurement of
the length to be inserted and documentation
of that length following insertion.
Feeding

ports that are incompatible with
intravenous syringes.
Complete time out activities 2 and 3

Safe insertion
Nasogastric feeding tubes should be inserted by
nurses who have completed competency training
and in accordance with local policy (NPSA 2011).
The principles of an aseptic non-touch technique
are used on tube insertion (NNNG 2012).
Before insertion, the length of tube to be inserted
should be measured. The NPSA (2011) states
that the nose to ear to xiphisternum (NEX)
method is the most appropriate. This involves
placing the tip of the tube at the tip of the nose
and measuring from the nose to the ear lobe and
down to the tip of the xiphisternum.
Insertion can be an unpleasant experience for
patients. Some may become fearful and resist.
Reducing distress and discomfort will help
patients co-operate, reducing the likelihood of a
failed attempt (Penrod et al 1999). The following
strategies may be helpful:
Maintain

a relaxed and calm atmosphere.
At
 the start of the procedure, agree a hand
signal with the patient for use if there is a
need to halt the procedure.
Repeat

information before and during
insertion to help minimise anxiety.
Give

positive feedback during the procedure.

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Use
 a second person to assist with insertion
and provide verbal reassurance to the patient.
Slow

the pace of the procedure if necessary.
The steps involved in blind insertion of a
nasogastric feeding tube are detailed (Box 1).

Timing of tube insertion

While investigating incidents of tube

misplacement, the NPSA (2011) identified that
a number of incidents occurred outside normal
working hours. In particular, there was an
increased risk of X-rays being misinterpreted
at night by junior medical staff. As a result,
the NPSA (2011) cautioned against inserting
nasogastric feeding tubes at night or at times
when there is lack of experienced staff to help
confirm gastric placement, unless clinically
urgent. In practice, this advice will at times
conflict with the need to avoid delays in
providing nutrition and fluids. Exemplars of this
include guidance for the management of patients
with acute stroke and patients in intensive care.
Clinical guidelines for England and Wales
recommend that patients with acute stroke,
who are unable to take nutrition or fluids orally,
should have nasogastric tube feeding initiated
within 24 hours of admission (National Institute
for Health and Clinical Excellence (NICE)
2008). European guidance on enteral nutrition in
intensive care states that all patients, who are not
expected to manage a full oral diet in three days,
should be fed via an enteral feeding tube within
24 hours of admission (Kreymann et al 2006).
All decisions to insert a nasogastric
feeding tube at night or out of hours should

1 Using an anatomy
textbook, study the
structures in the head
and neck relevant
to nasogastric tube
insertion. Identify the
turbinates, epiglottis,
trachea, nasopharynx,
oropharynx,
hypopharynx and
oesophagus.
2 For each type
of nasogastric tube
available in your clinical
area, find out: is the
nasogastric tube
radio-opaque throughout
its length without a
guidewire? Does it have
clear length markings?
What is the tube made
of? What length of time
can the tube be used
for? What size is the
tube? Assess which
tubes are appropriate
for feeding and make a
list of their positive and
negative attributes.
3 Reflect on a
nasogastric tube
insertion that you
performed, assisted with
or witnessed that was
difficult, uncomfortable
or distressing for the
patient. Identify any
nursing actions that
could have been used to
make the procedure more
comfortable and less
stressful for the patient.

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take account of the available expertise and
carefully assess the benefits against the risk
of undetected misplacement. Decisions and
their rationale should be documented in the
patients medical notes.

Confirming correct tube position

X-ray is often referred to as the gold standard
test for confirming nasogastric feeding tube
position, and is the benchmark for assessing
the validity and reliability of alternative bedside
tests (Fernandez et al 2010). However, the
use of X-ray has many limitations. Delays to
feeding are often inevitable while the X-ray is
being taken and interpreted, and the outcome
documented. An X-ray only captures tube
position at the time the X-ray is taken, allowing
the potential for tube displacement before use.
These factors, combined with the need to protect
patients against unnecessary radiation exposure,
make X-ray an impractical choice for routine use
(Fletcher 2011). Alternative bedside methods of
confirming tube position are necessary.
Obtaining nasogastric aspirate and testing its
pH value aims to differentiate between gastric,
intestinal and respiratory fluid. Gastric aspirates
will typically be more acidic (mean pH 3) than
those from the intestine or lungs (mean pH 7)
(Metheny and Titler 2001). pH testing is unable
to differentiate between a tube positioned in
the lungs or intestines because of the close
correlation in pH values at these sites. Gastric pH
will typically range between 1 and 5, but can be
altered by individual patient factors, including
duodenal reflux into the stomach, delayed gastric
emptying, presence of feed in the stomach,
increasing age, uncontrolled type 2 diabetes
and acid-suppressing medication (Metheny and
Titler 2001, Hanna et al 2010). The inherent
weaknesses of pH testing are apparent in
research data that cite specificity ranges of
55-87% (misplaced tubes correctly identified)
and sensitivity ranges of 82-89% (gastric
placements correctly identified) (Fernandez et al
2010, Joanna Briggs Institute 2010).
Testing for carbon dioxide, using colorimetric
capnometry or capnography, during tube
insertion can be an effective method for
excluding tube misplacement in the lung,
particularly in mechanically ventilated patients
(Hanna et al 2010, Joanna Briggs Institute
2010). Pooled research data on colorimetric
capnometry suggests a sensitivity of 95.8%
and specificity of 99.6% (Hanna et al 2010).
However, this test can only be used as an adjunct
to X-ray or pH testing since it cannot exclude
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oesophageal or pharyngeal tube placement. It

can only be used for initial tube insertion not for
ongoing position checks, and carbonated drinks
in the stomach could give rise to false results
(May 2007, Hanna et al 2010, Miller 2011).
The reliability of many historical methods of
confirming tube placement has been discredited
(Metheny et al 1990, Simons and Abdallah
2012). This includes the whoosh test (injecting
air into the tube and using a stethoscope to
listen for gurgling over the epigastrium), the
use of blue litmus paper, observing appearance
of aspirate and listening for bubbling at the
end of the tube (NPSA 2005). Always being
able to spot tube misplacement in the lung
by witnessing respiratory distress or severe
coughing is a common myth. Misplacement
can occur without any signs of respiratory
difficulty or coughing, even in patients with an
intact gag reflex (Miller 2011).
Following an evidence-based review, the
NPSA (2005, 2011) stated that only two methods
can reliably confirm gastric positioning testing
the pH of tube aspirate and X-ray and that
X-ray should only be used as a second-line test if
no aspirate is obtained or pH testing fails.
A pH between 1 and 5.5 indicates that the
tube is positioned correctly in the stomach
and is safe to use. A pH of 6 or above could
indicate placement in the lung, small bowel or
oesophagus and the tube should not be used
(NPSA 2011). To prevent false positive readings,
tubes must not be flushed with water before
confirmation of position, including tubes with
water-activated guidewire lubrication. The NPSA
(2012) reported two patient deaths resulting
from flushing of newly inserted tubes with water
before confirmation of position. The flush was
then aspirated, giving a pH of below 5.5, falsely
indicating that the tube was correctly inserted.
Rollins et al (2012) reported that in a local
audit of 597 X-ray reports, only 307 contained
anatomical information and 21% (n = 66)
of these nasogastric tubes were positioned
in the oesophagus on insertion. A report
recommended lowering the pH cut-off value
from 5.5 to 4.0 to reduce the risk of oesophageal
tube placement being misinterpreted as gastric
tube placement (Hanna et al 2010). The authors
extrapolated this recommendation after
reviewing the research on gastro-oesophageal
reflux disease. This recommendation was not
adopted by the NPSA. It was decided that the
risks of lowering the threshold outweighed
the potential benefits (NPSA 2011). Some
healthcare organisations have conducted
their own risk analyses. Therefore, healthcare

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professionals should refer to local policy for the

pH cut-off value in their clinical area.
To aid accuracy of pH testing, the strips or
paper used should be CE marked and intended
for use with human gastric aspirate (NPSA
2011). To improve the reliability of test results
falling between a pH of 5 and 6, a second
competent nurse should independently check
the result (NPSA 2011). When reading pH
results, it is important to be aware that factors
such as lighting, and the testers eyesight and
ability to distinguish colours, can contribute
to errors (Taylor and Clemente 2005).

When X-rays are necessary, interpretation for

nasogastric tube placement can be challenging
and prone to error. X-ray misinterpretation
contributed to more than half of all incidents
of serious harm and deaths reported to the
NPSA between 2005 and 2010 (NPSA 2011).
Correct X-ray interpretation relies, in part, on
the radiographer ensuring the X-rays exposure is
adjusted correctly to enhance tube visibility and
that the tubes tip is captured (NPSA 2011). Staff
interpreting these X-rays should have received
training and demonstrated competence (Eveleigh
et al 2011, NPSA 2011). Radiologist reports

BOX 1
Blind insertion of a nasogastric feeding tube
Equipment needed:
Nasogastric feeding tube that is compliant to National Patient
Safety Agency standards.
pH indicator strips.
Enteral syringe.
Glass of water and straw (if patient has a safe swallow and
is not nil by mouth).
Water for flushing the tube once gastric position is confirmed.
Non-sterile gloves and an apron.
Soft hypoallergenic tape.
Receiver for gastric aspirate.
Vomit bowl and tissues.
Pre-procedure:
Ensure pre-insertion assessment is undertaken and
documented.
Discuss the procedure with the patient and obtain verbal
consent if the patient has capacity. If the procedure is
undertaken as a best-interest decision, ensure proper
discussions take place.
Ask a second person to assist if necessary.
Procedure:
Wash hands. Use a protective apron and non-sterile gloves
during insertion.
Explain the procedure to the patient and assist him or her into
a comfortable position: upright or semi-upright, supported by
pillows, in bed or in a chair.
If the patient is unconscious or unable to sit upright,
position him or her on his or her side with head well supported
by pillows.
Examine nostrils for any debris, deformity or obstructions.
Remove the nasogastric tube from the packaging and examine.
If a guidewire is present, make sure it does not protrude
through the tube at any point.
Measure length of the tube to be inserted using the NEX (nose
to ear to xiphisternum) method.
Lubricate the nasogastric tube tip (follow local policy and
manufacturers guidance).
Insert the tube gently into the chosen nostril, advancing it
downwards along the floor of the nostril to the nasopharynx
(around 15cm). This stops the tube hitting the turbinates,

which can cause discomfort and bleeding. Keep the patients

head in a neutral position or tilted slightly forward at this
stage. Gently placing your non-dominant hand at the back
of the patients head can help prevent the patient extending
his or her head or neck.
Once the tube has passed into the nasopharynx, ask the patient
to tuck his or her chin towards the chest and take sips of water
using the straw. If the patient is unable to swallow safely,
or is nil by mouth, suggest taking a dry swallow (simulate
swallowing).
Resistance at around 25cm may be as a result of the tube
hitting the piriform sinus in the hypopharynx. Withdraw the
tube slightly and gently re-advance.
Advance the tube gently down the oesophagus with each
successive swallow. If the patient is unable to swallow or lacks
capacity to follow instructions, gently advance the tube as the
patient exhales.
Advance the tube to the pre-measured length and secure with
tape to the patients nose and/or cheek.
Use an enteral syringe to aspirate the tube and test fluid using
pH indicator strips or paper. The volume of aspirate should be
sufficient to cover the pH strip or paper.
Removal of the guidewire: refer to local policy and
manufacturers guidance.
Principles to adhere to:
Do not flush the nasogastric tube with water, or any liquid,
until gastric placement is confirmed either by pH test or X-ray.
Do not lubricate the guidewire until gastric placement is
confirmed.
Never reinsert the guidewire into a tube that remains
in a patient.
Do not advance the tube against resistance.
Stop insertion if the patient shows signs of respiratory distress,
such as gasping, excessive coughing or cyanosis, and
withdraw the tube.
If the tube coils in the patients mouth, withdraw the tube into
the nasopharynx and re-advance. It may be helpful to ask the
patient to turn his or her head left or right.
A maximum of three attempts at insertion should be made at
one time by any one person. Seek senior advice.
Stop if the patient becomes distressed.

(Stroud et al 2003, Rushing 2005, Best 2007, Roberts et al 2007, National Nurses Nutrition Group 2012, National Patient Safety Agency 2012)

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should state the position of the tube, including
the tip, and whether it is safe for it to be used.
Advances have been made in alternative
bedside approaches to the insertion of
nasogastric feeding tubes. Electromagnetic
guided systems have been developed and small
research studies have shown 100% accuracy
(Lei et al 2007). However, they have yet to be
adopted widely, largely because of a lack of
rigorous research to justify the increased costs.

Confirmation of tube position during use

To address the risk of nasogastric feeding tubes
moving from the stomach during use, tube
position should be confirmed (Arora et al 2005,
NPSA 2011):
Before

administering every feed.
At
 least once a day during continuous feeding.
Before

administering medication.
Following

episodes of vomiting, retching and
coughing.
Following

oropharyngeal suction.
Following

any signs or suspicion of tube
movement.
Following

any change in the patients
respiratory status.
Nasogastric tubes that are inserted using
endoscopy or fluoroscopy, or tubes that are
secured with a nasal bridle, must also have
their positions confirmed at these times. The
nasal bridle is a length of cotton tape that loops
around the nasal septum and is secured to the
nasogastric tube using a plastic clip.
When obtaining aspirate, care should be
taken to ensure aspirated fluid is not merely the
remnants of the last water flush instilled in the
tube. Water flushes can produce false positive
pH results of 5.5 or below (NPSA 2012).
Undetected movement of the tube into the
oesophagus or pharynx can cause pulmonary
aspiration of feed (Metheny et al 2007).
Vomiting, retching, excessive coughing and
oropharyngeal suction are all risk factors for
displacement (Metheny et al 1986, Arora et al
2005). Marking the tube with a permanent
pen, at the nostril, provides a useful reference
to assess for tube movement, but cannot be
used in isolation (Simons and Abdallah 2012).
Tubes have been found to be displaced to the
oesophagus despite no external increase in tube
length (Metheny et al 2007).
Complete time out activity 4

Common challenges

The two most frequently encountered problems

related to tube position are pH results of 6 or
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above and being unable to aspirate the tube.

A raised pH can indicate that the tube is
incorrectly positioned, but gastric pH can also
be altered by feed and acid suppressants such
as proton pump inhibitors and H2 receptor
antagonists (Metheny and Titler 2001, Peter
and Gill 2009).
Discontinuing or suspending acid
suppressants should be considered, assessing the
benefits against the risks posed by difficulty in
confirming tube position (Taylor and Clemente
2005). If needed, timings can be adjusted to
ensure the longest period of time possible has
lapsed between administration and pH testing.
The presence of feed in the stomach may
elevate pH results, and this can be particularly
problematic in patients being fed continuously.
Incorporating a break in feeding of at least
60-90 minutes should allow gastric pH values
to decrease sufficiently for a successful pH test
(Lloyd and Powell-Tuck 2004, Simons and
Abdallah 2012).
Inability to aspirate the tube is a common
cause of missed feeding days (Bergin et al
2009). Failure to aspirate, as with raised pH
levels, can indicate displacement, but often will
reflect the position of the tube tip in relation
to gastric fluid. There will always be a small
amount of fluid in the stomach, but the tube
tip may not be in contact with it (Khair 2005).
It can be helpful to assist the patient to lie on
his or her side, allowing the tip of the tube
to become immersed. Advancing the tube
10-20cm can also help reach any gastric fluid
present. The tip of the tube could be in the
duodenum where pH values are higher (pH
6-8) and aspiration is more difficult. This can
be resolved by withdrawing the tube 10-20cm.
The tip of the tube can sometimes sit against
the gastric mucosa causing occlusion on
aspiration. Gently injecting 10-20mL of air can
help the tube move away and allow aspiration
(NPSA 2005). This technique is not the
whoosh test. Caution should be exercised when
injecting air into a newly inserted nasogastric
tube. If the tube has been misplaced in the lung,
the injection of air could damage the pleura
(Kawati and Rubertsson 2005).
Nasogastric feeding tubes that cannot be
aspirated must never be flushed with water or
any other liquid (NPSA 2011). If the patient has
a safe swallow, elevated pH values and inability
to aspirate may simply be addressed by asking
the patient to have an acidic drink (Taylor and
Clemente 2005).
If pH testing is unable to confirm tube
position, X-ray may be required, but all

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attempts to obtain a successful pH test should

be exhausted. If pH testing has failed and an
X-ray is deemed unsafe or impractical, local
guidance may allow nasogastric feeding tubes to
be used following a risk assessment of the tube
and patient (NPSA 2011). Where such guidance
exists, it should be followed stringently and
supported with comprehensive documentation.
pH testing or X-ray must always confirm
position of newly-inserted tubes.

Documentation
The size and type of tube inserted, NEX
measurement, length of tube inserted, nostril
used, outcome of pH test and whether
X-ray is required should be documented in
the patients medical notes (NPSA 2011).
It is good practice to document how the
patient tolerated the procedure, number of
attempts made at insertion and any difficulties
encountered (NNNG 2012). During use,
a dedicated bedside chart should be used to
record, at least, the date and time the tubes
position was checked, whether aspirate was
obtained, pH value, external length of the
tube and who checked the tube (NPSA 2011).
All X-ray results should state the position
of the tube and its tip, whether it is safe to
use, and who interpreted the X-ray (NPSA
2011). Comprehensive documentation can
become a valuable resource in assessing and
troubleshooting tubes that are difficult to
aspirate or returning pH values of 6 or greater.
Complete time out activity 5

Administering food and fluids safely

Securing the tube
It has been estimated that half of all nasogastric
feeding tubes are removed accidentally by
patients or staff (Lloyd and Powell-Tuck
2004). Tubes should be taped securely, but not
excessively, to the nose and/or cheek, using soft
hypoallergenic tape (NNNG 2012). Tape should
be inspected and changed regularly, assessing
for signs of pressure damage caused by the tube
pressing against the nostril. Tape should not pull
the tube against the side of the nostril.
The use of a nasal bridle may be an
alternative option to tape in patients for
whom displacement, either accidentally or
purposefully, is preventing adequate feeding.
Research conducted in acute stroke care and
intensive care units indicates that nasal bridles
can reduce accidental tube displacement
significantly, allowing improved delivery of

NURSING STANDARD / RCN PUBLISHING

p47-56w38.indd 53

feed and fluid (Beavan et al 2010, Seder et al

2010). The use of hand control mittens, a form
of mechanical restraint, may be appropriate for
certain patients where repeated tube removal
is preventing essential treatment. Their use
should be supported by local policy or guidelines
that inform unambiguous decision making
and ensure compliance with the Nursing and
Midwifery Council professional code of conduct
(Horsburgh et al 2008, Williams 2008). All
decision making must adhere to the legal
principles in the Mental Capacity Act 2005,
for England and Wales, and the Adults with
Incapacity (Scotland) Act 2000.

Infection control

More than 30% of enteral feeds have been

found to be contaminated by microorganisms,
often as a result of poor feed preparation,
storage and administration (NICE 2012).
Once contaminated, the tube acts as a
reservoir for microorganisms. Effective hand
hygiene can break the transfer of bacteria to
and from the feeding tube (Ho et al 2012).
Wearing non-sterile gloves and using an
aseptic non-touch technique when handling
ports and administration sets are key infection
control measures (DH 2010, NICE 2012).
Reconstituting and decanting feeds should
be avoided wherever possible, in favour
of pre-packaged, sterile ready-to-use feeds
(DH 2010, NICE 2012). Ready-to-use feeds
should hang for a maximum of 24 hours and
reconstituted feeds for no more than four hours
(DH 2010, NICE 2012). Increased bacterial
growth will occur when feed is left standing in
an administration set (Ho et al 2012). Feed
should be discarded if administration is not
possible. This will also help prevent tube
blockages. Equipment should be disposed of
appropriately, discarding single-use syringes,
administration sets and feed containers after
use (Best 2008, NICE 2012).
Guidance advises that sterile water should
be used to flush all feeding tubes in hospital
(DH 2010, NICE 2012). Sterile water bottles
should be dated and unused contents discarded
in line with local guidance. Freshly drawn tap
water or cooled freshly boiled water is advised
for patients in the community (DH 2010, NICE
2012). Local infection control team guidance
may differ and should be followed.

Syringe choice

In the UK, enteral feeding tubes must have

ports that are incompatible with intravenous
syringes to prevent wrong route administration

4 Why might it be
difficult to aspirate a
nasogastric tube? What
might aspirated fluid
with a pH 6 or above
indicate?
5 Reflect on
your standard of
documentation
when inserting and
confirming the position
of nasogastric feeding
tubes. In your clinical
area, what charts or
stickers do you have to
assist in the safe and
accurate documentation
of nasogastric tube
insertion and pH tests?
If you have patients
with nasogastric tubes
inserted, review their
documentation. Can you
find all the information
necessary to assess
whether the nasogastric
tubes have been
monitored safely?

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17/05/2013 13:25

Learning zone enteral nutrition

6 Refer to local
policy and guidelines
on enteral tube
feeding. What is
your local cut-off pH
value for confirming
safe positioning of a
nasogastric feeding
tube? What type of
water is advocated to
flush nasogastric tubes?
What syringes are in
use and are they being
used correctly?
7 Label the following
statements as either true
or false, and explain why:
1. Good oral hygiene can
reduce the likelihood
of pulmonary
aspiration.
2. The presence of a
cuffed tracheostomy
reduces the likelihood
of misplacing a
nasogastric tube
in the lungs.
3. Patients will always
show signs of
respiratory distress if
a nasogastric tube is
misplaced in the lungs.
4. Water can sometimes
produce an acidic pH
value.

of medication, feed or flushes intended for

enteral use (NPSA 2007). Such errors are
classed as never events (DH 2012). It is
unsafe practice to measure medication to be
given via a feeding tube with an intravenous
syringe. Oral/enteral syringes must be used
for the measurement and administration of all
enteral flushes, feed and medication to prevent
accidental intravenous administration.
A 30-50mL syringe is widely recommended
for administering medication, feed or flushes
(Bowers 2000, Best 2005, Roberts et al 2007).
It is commonly believed that small syringes,
below 20mL, will produce pressures capable of
rupturing feeding tubes or causing tube walls
to collapse when aspirating (Cannaby et al
2002). This advice is largely based on expert
opinion (Reising and Neal 2005, Knox and
Davie 2009). However, a recent research study
concluded that small syringes generate less
pressure than larger syringes (Knox and Davie
2009). The research study also demonstrated
that large syringes were capable of higher
vacuum forces when aspirating, potentially
damaging gastric mucosa. Pressures generated
when using small syringes to flush a blocked
tube were not investigated. Further research
is required. Local guidance and manufacturer
instructions should be followed.
The MHRA (2011) states that single-use
syringes must not be re-used in any
circumstances. Single-use products are identified
by the single-use symbol on the packaging.
Re-usable enteral syringes are available, but are
commonly used in the home rather than
hospitals. These syringes should be cleaned and
stored according to manufacturer advice.

Medication considerations

Pharmacists should be made aware of all

patients with feeding tubes and their advice
sought on the safety of drug preparation and
administration. Alternative routes of drug
administration should be considered where
possible, including the oral route if the patient
has a safe swallow and transdermal routes. The
fundamentals of safe medication administration
are adherence to the 5 rights: right patient,
right drug, right dose, right route and right time
(DH 2004). A sixth right could be added for
tube-fed patients: right preparation.
Preparations should be effervescent, dispersible
or liquid. Decisions to crush tablets should
be made in collaboration with a pharmacist
because this can adversely affect absorption
(White and Bradnam 2011). Enteric coated and
modified release tablets should never be crushed.

54 may 22 :: vol 27 no 38 :: 2013

p47-56w38.indd 54

Containers used to crush or dissolve tablets

should be rinsed with water and this water
administered to ensure the full dose of medication
is received (White and Bradnam 2011). The
absorption of some drugs, for example phenytoin,
can be altered if they interact with feed and will
need to be identified so that feed regimens can
be tailored to allow sufficient rest periods before
and after drug administration (Wilson and Best
2011). An appropriately sized syringe should
be used when measuring liquids, because large
and catheter-tip syringes will not measure small
volumes accurately. Blockages can occur as a
result of poor flushing, interactions between feed
and medications, or clogging by medication or
feed. Prevention is the key to avoiding delays in
feeding or unnecessary tube removal.
Adverse drug-feed and drug-drug
interactions can be minimised by flushing
feeding tubes with at least 30mL of water before
administration, flushing with at least 10mL of
water between each drug, followed by a final
flush of at least 30mL of water after the last
drug has been given (British Association for
Parenteral and Enteral Nutrition 2003). Liquid
medications should be inspected for particles
or granules that could block the tube. Water is
widely accepted to be the most effective solution
for flushing and resolving tube blockages
(Metheny et al 1988, Reising and Neal 2005).

Pulmonary aspiration

Despite a correctly positioned tube, pulmonary

aspiration can occur silently. There is significant
evidence and consensus that elevating the
patients upper body or head of the bed by at least
30, unless clinically contraindicated, will reduce
the risk of aspiration and pneumonia (Stroud
et al 2003, Lloyd and Powell-Tuck 2004,
Metheny et al 2010). Critically ill and ventilated
patients are at particularly high risk of aspiration
as a result of delayed gastric emptying. Feeding
into the jejunum (post pyloric) should be
considered in preference to gastric feeding
(Metheny et al 2011). Inadequate oral hygiene
has also been identified as a risk for aspiration
(Leibovitz et al 2003).
Complete time out activities 6 and 7

Nasogastric tube use in the community

All patients should undergo a risk assessment
before discharge that involves the full
multidisciplinary team (NPSA 2011). This
should address how difficulties in confirming
tube position and the need for tube re-insertion
are to be managed.

NURSING STANDARD / RCN PUBLISHING

17/05/2013 13:25

Patients and carers need to be taught the

importance of hand hygiene and how to
use pH paper or strips, store feed, open and
connect feeds safely using an aseptic non-touch
technique, use feed pumps (if appropriate),
administer medications if needed, and deal
with blockages and other problems that may
arise. They also need adequate supplies of
initial discharge stock, which at a minimum
should include a seven-day supply of feed,
administration sets, pH indicator strips,
syringes, a feed pump and literature that
includes care instructions and contact details
(Best and Hitchings 2010). Information about
out-of-hours support services is also important.
Many patients will have their equipment
and supplies delivered by specialist home care
companies who will have a supporting nursing
team. Good communication and co-operation
between acute care and community nursing
and dietetic services is essential to ensure
successful discharge (Bjurester et al 2008).
Complete time out activity 8

Nasogastric tube removal

Nasogastric tube feeding can stop when
patients recover their swallow, are able to meet

full nutritional needs orally or an alternative

long-term feeding tube has been inserted. When
removing a nasogastric tube, the patient should be
assisted into a comfortable semi-upright position
in bed or a chair. The tape should be loosened
and the tube gently pulled out; the tube should
be checked to ensure it is intact before disposal.

Conclusion
Nasogastric feeding tubes are important for
many patients in hospital and the community.
They can be inserted at the bedside, but the
blind nature of bedside insertion will always
pose a threat to patient safety. Confirming the
correct position of nasogastric feeding tubes is
essential on insertion and during use. This can
be challenging, and the guidance and evidence
discussed in this article provide nurses with
knowledge to reduce incidences of harm caused
by incorrectly positioned tubes.
Understanding the principles of safely
administering feed, fluids and medication
via nasogastric feeding tubes can reduce
the incidence of tube-related complications,
including accidental tube removal, pulmonary
aspiration of feed and tube blockage NS
Complete time out activity 9

8 Go to the website
www.pinnt.com.
Reflect on the effect
and changes that tube
feeding at home could
have on everyday life.
Speak to a dietitian
or nutrition nurse
specialist involved in
home enteral feeding
about the availability
of patient support in
your community.
9 Now that you have
completed the article,
you might like to write
a practice profile.
Guidelines to help you
are on page 60.

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