NASOGASTRIC TUBE

• INSERTION
• FEEDING
NASOGASTRIC TUBE : INSERTION

Nasogastric (NG) Tube

The nasogastric (NG) tube is passed through the
nose, past the throat, down the stomach.

Nasogastric Tube Insertion

refers to the process of placing a soft plastic
nasogastric (NG) tube through a patient's nostril,
pass the pharynx and down the esophagus into a
patient's stomach.
PURPOSE
to deliver tube feedings to a patient when they are unable
to eat.

INDICATIONS: Patients who may need a NG tube for

feedings include: premature babies, patients in a coma,
patients who have had neck or facial surgery or patients
on mechanical ventilation.
PURPOSE
To remove substances from the stomach.

INDICATIONS: A NGT is used to empty the stomach when

accidental poisoning or drug overdose has occurred.
A NG tube is used to remove air that accumulates in the
stomach during cardiopulmonary resuscitation (CPR).
NGT : INSERTION & FEEDING

Precautions
1. Do not use force when inserting a NG tube. If resistance occurs,
rotate and retract the tube slightly and try again. Forcing the tube
can cause traumatic injury to the tissue of the nose, throat or
esophagus

2. Always check the tube positioning before giving feedings. If the

tube is out of place the patient may aspirate the feeding solution into
the lungs.
NGT : INSERTION & FEEDING

Precautions
3. Keep the patient in an upright or semi-upright sitting position when
delivering a tube feeding to enhance peristalsis and avoid
regurgitation of the feeding.

4. Check patients who are receiving continuous feedings via a pump

or gravity hourly or according to the medical settings policy, to
assure that the tube is in position, the formula is flowing at the
correct rate and the patient is comfortable with no signs of distention
or distress.
NGT : INSERTION & FEEDING

Precautions
5. Cap or clamp off the NG tube when not in use to prevent backflow
of stomach contents or accumulation of air in the stomach

6. If a patient has severe sinus conditions, nasal obstruction or has

had facial surgery, it may be necessary to place an oral-gastric tube
to avoid further nasal trauma
 NGT
INSERTION
NASOGASTRIC TUBE : INSERTION

EQUIPMENT
• Nasogastric tube of appropriate size (8–18 French)
• Stethoscope
• Water-soluble lubricant
• Normal saline solution or sterile water, for irrigation, depending
on facility policy
• Tongue blade
• Irrigation set, including a Toomey (20–50 mL)
• Flashlight
• Non-allergenic tape (1 wide)
• Tissues
NASOGASTRIC TUBE : INSERTION

EQUIPMENT
• Glass of water with straw
• Topical anesthetic (lidocaine spray or gel) (optional)
• Clamp
• Suction apparatus (if ordered)
• Bath towel or disposable pad
• Emesis basin
• Safety pin and rubber band
• Nonsterile disposable gloves
• Additional PPE, as indicated
• Tape measure, or other measuring device
• Skin barrier
• pH paper
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NASOGASTRIC TUBE : INSERTION
4. Explain the procedure to the patient and provide the rationale
as to why the tube is needed. Discuss the associated discomforts
that may be experienced and possible interventions that
may allay this discomfort. Answer any questions as needed.

Rationale: Explanation facilitates patient cooperation. Some patient

surveys report that of all routine procedures, the insertion of an NG
tube is considered the most painful. Lidocaine gel or sprays are
possible options to decrease discomfort during NG tube insertion.

5. Gather equipment, including selection of the appropriate

NG tube.

Rationale: This provides for an organized approach to task. NG tubes

should be radiopaque, contain clearly visible markings for
measurement, and may have multiple ports for aspiration.
NASOGASTRIC TUBE : INSERTION
4. Explain the procedure to the patient and provide the rationale
as to why the tube is needed. Discuss the associated discomforts
that may be experienced and possible interventions that
may allay this discomfort. Answer any questions as needed.

Rationale: Explanation facilitates patient cooperation. Some patient

surveys report that of all routine procedures, the insertion of an NG
tube is considered the most painful. Lidocaine gel or sprays are
possible options to decrease discomfort during NG tube insertion.

5. Gather equipment, including selection of the appropriate

NG tube.

Rationale: This provides for an organized approach to task. NG tubes

should be radiopaque, contain clearly visible markings for
measurement, and may have multiple ports for aspiration.
NASOGASTRIC TUBE : INSERTION
6. Close the patient’s bedside curtain or door. Raise bed to a
comfortable working position; usually elbow height of the caregiver
Assist the patient to high Fowler’s position or elevate the head of
the bed 45 degrees if the patient is unable to maintain upright
position Drape chest with bath towel or disposable pad. Have
emesis basin and tissues handy.

Rationale: Closing curtains or door provides for patient privacy.

Having the bed at the proper height prevents back and muscle strain.
Upright position is more natural for swallowing and protects
against bronchial intubation aspiration, if the patient should
vomit. Passage of tube may stimulate gagging and tearing of
eyes.
NASOGASTRIC TUBE : INSERTION
7. Measure the distance to insert tube by placing tip of tube
at patient’s nostril and extending to tip of earlobe and
then to tip of xiphoid process. Mark tube with an indelible marker.

Rationale: Measurement ensures that tube will be long enough to

enter patient’s stomach.
NASOGASTRIC TUBE : INSERTION
8. Put on gloves. Lubricate tip of tube (at least 2–4) with
water-soluble lubricant. Apply topical anesthetic to nostril and
oropharynx, as appropriate.

Rationale: Lubrication reduces friction and facilitates passage of the

tube into stomach. Water-soluble lubricant will not cause pneumonia
if tube accidentally enters the lungs. Topical anesthetics act as
local anesthetics, reducing discomfort. Consult the physician
for an order for a topical anesthetic such as lidocaine gel or
spray if needed.
NASOGASTRIC TUBE : INSERTION
9. After selecting the appropriate nostril, ask patient to slightly
flex head back against the pillow. Gently insert the tube into
the nostril while directing the tube upward and backward
along the floor of the nose. Patient may gag when tube reaches
pharynx. Provide tissues for tearing or watering of eyes. Offer
comfort and reassurance to the patient.

Rationale: Following the normal contour of the nasal passage while

inserting the tube reduces irritation and the likelihood of mucosa
injury. The tube stimulates the gag reflex readily. Tears are a natural
response as the tube passes into the nasopharynx. Many patients
report that gagging and throat discomfort can be more painful
than passing through the nostrils.
NASOGASTRIC TUBE : INSERTION
10. When pharynx is reached, instruct patient to touch chin to
chest. Encourage patient to sip water through a straw or swallow
even if no fluids are permitted. Advance tube in downward
and backward direction when patient swallows.
Stop when patient breathes. If gagging and coughing persist,
stop advancing the tube and check placement of tube with
tongue blade and flashlight. If tube is curled, straighten the
tube and attempt to advance again. Keep advancing tube until
pen marking is reached. Do not use force. Rotate tube if it
meets resistance.

Rationale: Bringing the head forward helps close the trachea and
open the esophagus. Swallowing helps advance the tube, causes
the epiglottis to cover the opening of the trachea, and helps to
eliminate gagging and coughing. Excessive coughing and
gagging may occur if the tube has curled in the back of throat.
Forcing the tube may injure mucous membranes.
NASOGASTRIC TUBE : INSERTION
11. Discontinue procedure and remove tube if there are signs
of distress, such as gasping, coughing, cyanosis, and inability
to speak or hum.

Rationale: The tube is in the airway if the patient shows signs of di

stress and cannot speak or hum. If after three attempts, nasogastric
insertion is unsuccessful, another nurse may try or the patient
Should be referred to another healthcare professional.
NASOGASTRIC TUBE : INSERTION
12. Secure the tube loosely to the nose or cheek until it is
Determined that the tube is in the patient’s stomach:

Rationale: Securing with tape stabilizes the tube while position is

Being determined.

a. Attach syringe to end of tube and aspirate a small amount

of stomach contents.

Rationale: The tube is in the stomach if its contents can be aspirated:

pH of aspirate can then be tested to determine gastric placement.
If unable to obtain specimen, reposition the patient and flush the
tube with 30 mL of air. This action may be necessary several
times. Current literature recommends that the nurse ensures
proper placement of the NG tube by relying on multiple methods
and not on one method alone.
NASOGASTRIC TUBE : INSERTION
b. Measure the pH of aspirated fluid using pH paper or a
meter. Place a drop of gastric secretions onto pH paper or
place small amount in plastic cup and dip the pH paper
into it. Within 30 seconds, compare the color on the paper
with the chart supplied by the manufacturer

Rationale: Current research demonstrates that the use of pH is

predictive of correct placement. The pH of gastric contents is acidic
(less than 5.5). If patient is taking an acid-inhibiting agent, the range
maybe 4.0 to 6.0. The pH of intestinal fluid is 7.0 or higher. The pH
of respiratory fluid is 6.0 or higher. This method will not effectively
differentiate between intestinal fluid and pleural fluid.
NASOGASTRIC TUBE : INSERTION
c. Visualize aspirated contents, checking for color and
consistency.

Rationale: Gastric fluid can be green with particles, off-white, or

brown if old blood is present. Intestinal aspirate tends to look clear
or strawcolored to a deep golden-yellow color. Also, intestinal
Aspirate may be greenish-brown if stained with bile. Respiratory or
Tracheobronchial fluid is usually off-white to tan and may be
tinged with mucus. A small amount of blood-tinged fluid may
be seen immediately after NG insertion.
NASOGASTRIC TUBE : INSERTION
d. Obtain radiograph (x-ray) of placement of tube, based on
facility policy (and ordered by physician).

Rationale: The x-ray is considered the most reliable method for identi
fying the position of the NG tube.

13. Apply skin barrier to tip and end of nose and allow to dry.
Remove gloves and secure tube with a commercially prepared
device (follow manufacturer’s directions) or tape to patient’s
nose. To secure with tape:
a. Cut a 4 piece of tape and split bottom 2 or use packaged
nose tape for NG tubes.
b. Place unsplit end over bridge of patient’s nose .
c. Wrap split ends under tubing and up and over onto nose . Be
careful not to pull tube too tightly against nose.
NASOGASTRIC TUBE : INSERTION
Rationale: Skin barrier improves adhesion and protects skin. Constant
pressure of the tube against the skin and mucous membranes may
cause tissue injury. Securing tube prevents migration of the tube
inward and outward.
NASOGASTRIC TUBE : INSERTION
14. Put on gloves. Clamp tube and remove the syringe. Cap the
tube or attach tube to suction according to the medical orders.

Rationale: Suction provides for decompression of stomach and

drainage of gastric contents.
NASOGASTRIC TUBE : INSERTION
15. Measure length of exposed tube. Reinforce marking on tube at
nostril with indelible ink. Ask the patient to turn their head to
the side opposite the nostril the tube is inserted. Secure tube to
patient’s gown by using rubber band or tape and safety pin.
For additional support, tube can be taped onto patient’s cheek
using a piece of tape. If a double-lumen tube (e.g., Salem
sump) is used, secure vent above stomach level. Attach at
shoulder level
NASOGASTRIC TUBE : INSERTION

Rationale: Tube length should be checked and compared with this

initial measurement, in conjunction with pH measurement and visual
assessment of aspirate. An increase in the length of the exposed
tube may indicate dislodgement. The tube should be marked with an
indelible marker at the nostril. This marking should be assessed
each time the tube is used to ensure the tube has not become
displaced. Securing prevents tension and tugging on the tube.
Turning the head ensures adequate slack in the tubing to prevent
tension when the patient turns their head. Securing the
double-lumen tube above stomach level prevents seepage of
gastric contents and keeps the lumen clear for venting air.
NASOGASTRIC TUBE : INSERTION
16. Assist with or provide oral hygiene at 2- to 4-hour intervals.
Lubricate the lips generously and clean nares and lubricate as
needed. Offer analgesic throat lozenges or anesthetic spray for
throat irritation if needed.

Rationale: Oral hygiene keeps mouth clean and moist, promotes

comfort, and reduces thirst.

17. Remove equipment and return patient to a position of comfort.

Remove gloves. Raise side rail and lower bed.

Rationale: Promotes patient comfort and safety. Removing glove

Properly reduces the risk for infection transmission and
contamination of other items.
NGT FEEDING
NASOGASTRIC TUBE : FEEDING

EQUIPMENT
• Prescribed tube feeding formula at • Enteral feeding pump (if ordered)
room temperature • Rubber band
• Feeding bag or prefilled tube • Clamp (Hoffman or butterfly)
feeding set • IV pole
• Stethoscope • Water for irrigation and hydration as
• Nonsterile gloves needed
• Additional PPE, as indicated • pH paper
• Alcohol preps • Tape measure, or other measuring
• Disposable pad or towel device
• Asepto or Toomey syringe
NASOGASTRIC TUBE : FEEDING
5. Assemble equipment on overbed table within reach.

Rationale: Organization facilitates performance of task.

6. Close the patient’s bedside curtain or door. Raise bed to a

comfortable working position, usually elbow height of the
Caregiver. Perform key abdominal assessments as described.

Rationale: Closing curtains or door provides for patient privacy.

Having the bed at the proper height prevents back and muscle
strain. Due to changes in patient’s condition, assessment is vital bef
ore initiating the intervention.
NASOGASTRIC TUBE : FEEDING
7. Position patient with head of bed elevated at least 30 to
45 degrees or as near normal position for eating as possible.

Rationale: This position minimizes possibility of aspiration into

trachea. Patients who are considered at high risk for aspiration
should be assisted to at least a 45-degree position.

8. Put on gloves. Unpin tube from patient’s gown. Verify the

position of the marking on the tube at the nostril. Measure
length of exposed tube and compare with the documented
length.

Rationale: Gloves prevent contact with blood and body fluids. The
tube should be marked with an indelible marker at the nostril. This
marking should be assessed each time the tube is used to ensure
the tube has not become displaced.
NASOGASTRIC TUBE : FEEDING
9. Attach syringe to end of tube and aspirate a small amount of
stomach contents, as described.

Rationale: The tube is in the stomach if its contents can be

aspirated: pH of aspirate can then be tested to determine gastric
placement. If unable to obtain specimen, reposition the patient and
flush the tube with 30 mL of air. This action may be necessary
several times. Current literature recommends that the nurse ensures
proper placement of the NG tube by relying on multiple methods
and not on one method alone.
NASOGASTRIC TUBE : FEEDING
10. Check the pH as described.

Rationale: Current research demonstrates that the use of pH is

predictive of correct placement. The pH of gastric contents is acidic
(less than 5.5). If patient is taking an acid-inhibiting agent, the
Range may be 4.0 to 6.0. The pH of intestinal fluid is 7.0 or higher.
The pH of respiratory fluid is 6.0 or higher. This method will
not effectively differentiate between intestinal fluid and pleural
fluid.
The testing for pH before the next feeding in intermittent feedings
is conducted since the stomach has been emptied of the feeding
formula. However, if the patient is receiving continuous feedings,
the pH measurement is not as useful, since the formula
raises the pH.
NASOGASTRIC TUBE : FEEDING
11. Visualize aspirated contents, checking for color and
consistency.

Rationale: Gastric fluid can be green with particles, off-white, or

brown if old blood is present. Intestinal aspirate tends to look clear
or strawcolored to a deep golden-yellow color. Also, intestinal
Aspirate may be greenish-brown if stained with bile. Respiratory or
tracheobronchial fluid is usually off-white to tan and may be
tinged with mucus. A small amount of blood-tinged fluid may
be seen immediately after NG insertion.
NASOGASTRIC TUBE : FEEDING
12. If it is not possible to aspirate contents; assessments to check
placement are inconclusive; the exposed tube length has
changed; or there are any other indications that the tube is
not in place, check placement by x-ray.

Rationale: The x-ray is considered the most reliable method for

identifying the position of the NG tube.
NASOGASTRIC TUBE : FEEDING
13. After multiple steps have been taken to ensure that the feeding
tube is located in the stomach or small intestine, aspirate all
gastric contents with the syringe and measure to check for
the residual amount of feeding in the stomach. Return the
residual based on facility policy. Proceed with feeding if
amount of residual does not exceed agency policy or the limit
indicated in the medical record.

Rationale: Checking for residual before each feeding or every

4 to 6 hours during a continuous feeding according to institutional
policy is implemented to identify delayed gastric emptying.
Research suggests continuing the feedings with residuals up to 400
mL. If greater than 400 mL, confer with physician or hold feedings
according to agency policy. For patients who are experiencing
gastric dysfunction or decreased level of consciousness, feedings
may be held for smaller residual amounts (400 mL).
NASOGASTRIC TUBE : FEEDING
14. Flush tube with 30 mL of water for irrigation. Disconnect
syringe from tubing and cap end of tubing while preparing the
formula feeding equipment. Remove gloves.

Rationale: Flushing tube prevents occlusion. Capping the tube

deters the entry of microorganisms and prevents leakage onto
the bed linens.

15. Put on gloves before preparing, assembling and handling any

part of the feeding system.

Rationale: Gloves prevent contact with blood and body fluids and
deter transmission of contaminants to feeding equipment and/or
formula.

16. Administer feeding.

When Using a Feeding Bag
(Open System)
a. Label bag and/or tubing with date and time. Hang bag on
IV pole and adjust to about 12 above the stomach. Clamp
tubing.

Rationale: Labeling date and time of first use allows for

disposal within 24 hours, to deter growth of microorganisms.
Proper feeding Bag height reduces risk of formula being
introduced too quickly.
When Using a Feeding Bag
(Open System)
b. Check the expiration date of the formula. Cleanse top of feeding
container with a disinfectant before opening it. Pour formula into
feeding bag and allow solution to run through tubing. Close clamp.

Rationale: Cleansing container top with alcohol minimizes risk for

Contaminants entering feeding bag. Formula displaces air in tubing.
When Using a Feeding Bag
(Open System)
c. Attach feeding setup to feeding tube, open clamp, and regulate
drip according to the medical order, or allow feeding
to run in over 30 minutes.

Rationale: Introducing formula at a slow, regular rate allows the

Stomach to accommodate to the feeding and decreases GI distress.
When Using a Feeding Bag
(Open System)
d. Add 30 to 60 mL (1–2 oz) of water for irrigation to feeding
bag when feeding is almost completed and allow it to run
through the tube.

Rationale: Water rinses the feeding from the tube and helps to keep
it patent.
When Using a Feeding Bag
(Open System)
e. Clamp tubing immediately after water has been instilled.
Disconnect feeding setup from feeding tube. Clamp tube and
cover end with cap.

Rationale: Clamping the tube prevents air from entering the

stomach. Capping the tube deters entry of microorganisms and
covering end of tube protects patient and linens from fluid leakage
from tube.
When Using a Large Syringe
(Open System)

a. Remove plunger from 30- or 60-mL syringe.

When Using a Large Syringe
(Open System)
b. Attach syringe to feeding tube, pour premeasured amount
of tube feeding formula into syringe,open clamp, and allow food to
enter tube. Regulate rate, fast or slow, by height of the syringe.
Do not push formula with syringe plunger.

Rationale: Introducing the formula at a slow, regular rate allows the

stomach to accommodate to the feeding and decreases GI distress.
The higher the syringe is held, the faster the formula flows.
When Using a Large Syringe
(Open System)
c. Add 30 to 60 mL (1–2 oz) of water for irrigation to syringe
when feeding is almost completed,and allow it to run through
the tube.

Rationale: Water rinses the feeding from the tube and helps to keep
it patent.
When Using a Large Syringe
(Open System)
d. When syringe has emptied, hold syringe high and disconnect
from tube. Clamp tube and cover end with cap.

Rationale: By holding syringe high, the formula will not backflow

out of tube and onto patient. Clamping the tube prevents air from
entering the stomach. Capping end of tube deters entry of
microorganisms. Covering the end protects patient and linens from
fluid leakage from tube.
When Using an Enteral Feeding Pump
a. Close flow-regulator clamp on tubing and fill feeding bag with
prescribed formula. Amount used depends on agency policy. Place
label on container with patient’s name, date, and time the feeding
was hung.

Rationale: Closing clamp prevents formula from moving through

tubing until nurse is ready. Labeling date and time of first use
allows for disposal within 24 hours, to deter growth of
Microorganisms.

b. Hang feeding container on IV pole. Allow solution to flow

through tubing.

Rationale: This prevents air from being forced into the stomach or
intestines.
When Using an Enteral Feeding Pump
c. Connect to feeding pump following manufacturer’s directions.
Set rate. Maintain the patient in the upright position throughout
the feeding. If the patient needs to temporarily lie flat, the feeding
should be paused. The feeding may be resumed after the patient’s
position has been changed back to at least 30 to 45 degrees.

Rationale: Feeding pumps vary. Some of the newer pumps have

built-in Safeguards that protect the patient from complications.
Safety Features include cassettes that prevent free-flow of formula,
automatic tube flush, safety tips that prevent accidental attachment
to an IV setup, and various audible and visible alarms. Feedings are
started at full strength rather than diluting the feeding, which was
Recommended previously. A smaller volume, 10 to 40 mL, of
feeding infused per hour and gradually increased has been shown
to be more easily tolerated by patients.
When Using an Enteral Feeding Pump
When Using an Enteral Feeding Pump
d. Check placement of tube and gastric residual every 4 to
6 hours.

Rationale: Checking placement verifies the tube has not moved out
of the stomach. Checking gastric residual (outlined in Step 7)
Monitors absorption of the feeding and prevents distention, which
could lead to aspiration. However, presence of large amounts
of residual, such as more than 250 to 400 mL, should not be the
sole criteria for stopping the enteral feeding.
When Using an Enteral Feeding Pump
17. Observe the patient’s response during and after tube feeding
and assess the abdomen at least once a shift.

Rationale: Pain or nausea may indicate stomach distention, which

maylead to vomiting. Physical signs such as abdominal distention
and firmness or regurgitation of tube feeding may indicate
intolerance.

18. Have patient remain in upright position for at least 1 hour

after feeding.

Rationale: This position minimizes risk for backflow and

discourages aspiration, if any reflux or vomiting should occur.
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