Enteral Nutrition: Inserting a Small-Bore Nasogastric or Nasoenteric Feeding Tube
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8 to 12 Fr
Some types are larger and more rigid and used for gastric decompression
Placement requires HCP order and an assessment of their coagulation status
o Anticoagulation/bleeding disorders pose risk for epitaxis during placement
1. Delegation and Collaboration
 NAP can’t insert NG tube, but can help with pt positioning and comfort measures during
placement.
 NAP informs nurse if:
o Respirations change or pt c/o SOB, coughing, or choking
o Pt vomits or NAP notices vomitus in mouth during oral hygiene
o Nasal skin irritation is present
o A change in the external length of the tube occurs
2. Assessment
 Verify orders for type of tube, enteric feeding schedule, and if HCP orders prokinetic
agent given before placement (may help advance tube into intestine)
 If pt at risk for intracranial passage of the tube, avoid nasal route. Alternatives:
o Oral placement
o Placement under medical supervision using fluoroscopic direct visualization
o Insertion of g- or j-tube
 Recognize situations in which blind placement poses an unacceptable risk
o Use devices that detect pulmonary intubation
o Clinicians trained in use of visualization or imaging techniques should place tube
3. Planning- Equipment
 Small-bore NG or Nasoenteric tube (8-12 Fr) with or without stylet
 60 mL EN-Fit syringe
 Stethoscope, pulse oximeter, capnography
 Hypoallergenic tape, semipermeable (transparent) dressing, or tube fixation device
 Tincture of benzoin or other skin barrier protectant
 pH indicator strip
 Cup of water, straw, or ice chips for pt to swallow
 Water soluble lubricant
 Emesis basin
 Towel or disposable pad
 Facial tissues
 Clean gloves
 Suction equipment in case of aspiration
 Penlight to check placement in nasopharynx
 Tongue blade
 Oral hygiene supplies
4. Planning
 Expected Outcomes
o Tube is successfully placed in stomach or small intestine
o Tube remains patent
o Pt has no respiratory distress (increased resp. rate, coughing, poor color) or
signs of discomfort or nasal trauma
 Sensations: burning in nasal passages
 Communicate by raising index finder to indicate gagging or discomfort
5. Evaluation
 Observe pts response to tube placement:
o Assess lung sounds
o Have pt speak
o Check VS
o Note any coughing, dyspnea, cyanosis, or decrease in oxygen saturation
 Confirm x-ray results with HCP
 Remove stylet (if used) after x-ray verification of correct placement
 Routinely assess naris, location of external exit site marking on tube, and color and pH
of fluid aspirated from tube
6. Unexpected Outcomes
 Aspiration of stomach contents into respiratory tract, evidenced by auscultation of
crackles, wheezes, dyspnea, or fever.
o Report change to HCP and suggest x-ray
o Position pt on side to protect airway
o Suction nasotracheally and orotracheally
o Prepare for possible initiation of antibiotics
 Displacement of tube to another site
o Aspirate GI contents and measure pH
o Remove displaced tube and insert and verify placement of new tube
o Obtain chest x-ray if there is any possibility of aspiration
Enteral Nutrition: Verifying Feeding Tube Placement
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Check tube at regular intervals (4 to 6 hours) to ensure the tip remains at the intended site or
before administering formulas or meds
Monitor length of the tube
Observe the appearance, volume, and pH of fluid aspirated through it
o Intestinal aspirates stained by bile and have distinct yellow color
o pH has no value if pt is on acid-suppressing medication
o pH reading of 5.0 or less is a reliable indicator of stomach placement.
o Auscultation of air bolus is no longer safe or reliable method
1. Delegation and Collaboration
 Verification of placement must be done by nurse.
 NAP will report to nurse:
o If respirations change or pt c/o sob, coughing, or choking
o If pt vomits or notices vomitus in pts mouth
o If nasal skin irritation or excoriation is present
o If there is a change in the external length of the tube
2. Assessment
 Do no insufflate air into tube to check for placement
 Observe for S&S of:
o Coughing
o Choking
o Reduced oxygen saturation
 Identify conditions that increase risk for spontaneous tube migration or dislocation:
o Altered LOC or agitation
o Retching, vomiting
o Nasotracheal suction
 Observe external part of tube for movement of ink or tape mark away from mouth or
naris
 Review pts medication record for orders for continuous feeding, a gastric acid inhibitor
(cimetidine, ranitidine, famotidine, nizatidine), or proton pump inhibitor (omeprazole)
 Review medical record for history of prior tube displacement.
3. Planning- Equipment
 To assess gastric pH
o 60 mL ENFit Syringe
o Stethoscope
o Clean gloves
o pH indicator strip
o small medication cup
4. Planning- Expected Outcomes
 Color, pH, and appearance of aspirate are consistent with the initial tube placement.
o Gastric fluid aspirated from a pt who has fasted for at least 4 hours usually has
pH range of 5.0 or less.
o Fluid from tube in small intestine of fasting patient usually has pH greater than
6.0
5. Evaluation
 Observe pt for respiratory distress
o Persistent gagging
o Paroxysm of coughing
o Drop in O2 saturation
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o Respiratory patterns inconsistent with baseline measurements (e.g. rate and
depth)
Verify that external length of tube, pH reading, and appearance of aspirate are
consistent with initial tube placement
6. Unexpected Outcomes
 Red or brown coloring (coffee ground appearance) of fluid aspirated from tube indicates
new or old blood in GI tract.
o If color is not related to medications recently administered, notify HCP.
 Pt develops severe respiratory distress as a result of aspiration or tube displacement in
lung
o Stop any enteral feedings
o Notify HCP
o Obtain chest x-ray as ordered
 Tube cannot be irrigated after testing
o Reattempt to irrigate tube.
o Do not force fluid
o If unsuccessful, notify HCP.