Clinical Policy for the Insertion and maintenance of Fine Bore
Naso-gastric Feeding Tubes in Adults
Version
10
Name of responsible (ratifying) committee
Nursing and Midwifery Advisory Committee
Date ratified
10th October 2013
Document Manager (job title)
Clinical Nutrition Nurse Specialists
Date issued
18th December 2013
Review date
Oct 2015
Electronic location
Clinical Policies
Related Procedural Documents
See section 8
Key Words (to aid with searching)
Enteral feeding, NGT, naso-enteric tubes, patient
feeding equipment, enteral nutrition, clinical
procedures, patient safety, adults, medical staff, x-ray,
nurses.
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
10
10.10.13
Reporting of x-ray by medical staff, x-ray review form
and checking chart to include x-ray
J Pratt
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: Version 10
18/12/2013
(Review date: October 2015)
Page 1 of 32
CONTENTS
Quick Reference Guide…………………………………………………………………….…………3-4
1. Introduction………………………………………………………………………………………………...5
2. Purpose…………………………………………………………………………………………………….5
3. Scope……………………………………………………………………………………………………….5
4. Definitions…………………………………………………………………………………………………..6
5. Duties and Responsibilities………………………………………………………………………… …7-8
6. Process
…………………………………………………………………………………………… 8-16
7. Training Requirements……………………………………………………………………………………..16
8. References and Associated Documentation
………………………………
…17
9. Equality Impact Assessment…………………………………………………………………………….17
10. Monitoring Compliance
………………………………………………………………… ….18
APPENDICES:
1. Indications, Contraindications and Considerations……………………………………… …………....19
2. Anatomy and Physiology of swallowing...……………………………………………………………....20
3. Finebore nasogastric tube insertion (Adults) Flowchart……………………………………………….21
4. NG X-ray review form…………………………………………………………………………………..…22
5. NG Insertion and Checking Chart ….…………………………………………………………………. 23
,
6. NG Competency………………………………………………………………………….. .. 24, 25, 26, 27
7. Product and ordering information……………………………………………………………………......28
8. NG Feeding starter regime……………………………………………………………………....29, 30, 31
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults:
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(Review date: October 2015)
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QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy. The quick reference can take the form of a list or a flow chart, if the latter would more easily
explain the key issues within the body of the document
This policy must be followed in full when developing or reviewing and amending Trust procedural
documents. For quick reference the guide below is a summary of actions required. This does not
negate the need for the document author and others involved in the process to be aware of and
follow the detail of this policy.
1. Before a decision is made to insert a nasogastric tube, an assessment is undertaken to
identify if nasogastric feeding is appropriate for the patient, and the rationale for any decisions
is recorded in the patients medical notes
2. Nasogastric feeding tubes should be used for short-term (4-6 weeks) enteral feeding in
patients with a functioning gastrointestinal tract.
3. Nasogastric tubes used for feeding, medication and fluid administration should be radioopaque throughout their length and have externally visible length markings.
4. NG tube insertion must be documented in the patients’ notes and on the NG checking chart at
the bedside.
5. Aspirate with a pH of 4.5 or below should be obtained to confirm gastric placement prior to
using the tube.
6. NG tubes must not be flushed or have anything introduced into them until gastric placement
has been confirmed. Internal guidewires must not be flushed with water prior to insertion
7. NG tubes should be checked (using the pH aspirate test) at the bedside for correct position
prior to each use, if there is any indication that the NG tube may have moved, and at least
every 24hrs when in continuous use. This is to be documented on the checking chart.
8. Do not use sterile water to flush NG tubes as this has a pH of 4.5 and could lead to a false
positive pH reading. Drinking tap water should be used.
9. X-ray should only be used on initial insertion if aspirate obtained has a pH of above 4.5 or if
aspirate cannot be obtained.
10. Before requesting an x-ray ward staff should contact the Nutrition Nurse team to review the
patient (0900 – 1600 hrs, Mon-Fri).
11. If x-ray is required to check NG tube position this should be requested between the hours of
0800 – 16.00 (Mon to Fri).
12. Between 0800 -16.00 hrs (Mon to Fri) radiology will report the x-ray direct onto PACS and
remove any NG found to be in the lung whilst the patient is in the x-ray department.
13. Ward clinician must review the PACS report and document in the patient’s medical notes that
the NG tube is safe to be used for feeding, prior to the NG being used.
14. If x-ray required after 1600 hrs(Mon –Fri), or at weekends, the referring clinical team
Consultant/Registrar must be available to review the x-ray and document in the patients
medical notes that the NG tube is within the stomach and safe to use for feeding. If the NG is
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults:
Version 10 18/12/2013
(Review date: October 2015)
3
found to be in the lung it must be removed immediately. Consultant/Registrar must have
completed the on-line NG x-ray training available through ESR.
15. Patients who repeatedly displace NG tubes should be referred to the CNNS team for
assessment for a nasal bridle to prevent displacement.
.
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults:
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(Review date: October 2015)
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1. INTRODUCTION
Nasogastric tube feeding is common practice and many tubes are inserted daily without
incident. However, there is a small risk that the tube can become misplaced into the lungs
during insertion, or move out of the stomach at a later stage (1, 4). Auscultation must not be
used to check correct nasogastric tube (NGT) placement as studies have shown this method to
be inaccurate. NG tubes should be aspirated and the tube position confirmed using pH
indicator strips that are CE marked and intended for use on human gastric aspirate (12). X –ray
should not be routinely used but is required on NG insertion if the pH test has failed to confirm
gastric placement (no aspirate or pH >4.5) (1, 10, 12). If an x-ray is required the film must be
interpreted by a competent clinician and confirmation of correct position must be documented in
the patients medical notes before the NG is used. NG tubes must not be flushed or have
anything introduced into them until gastric placement has been confirmed. Internal guidewires
must not be flushed with water prior to insertion (13).
2. PURPOSE
This policy is designed to guide all Healthcare Professionals in the safe insertion and
maintenance of fine bore naso-gastric feeding tubes in adults.
.
3. SCOPE
This policy applies to all competent Healthcare Professionals inserting and/or maintaining fine
bore naso-gastric feeding tubes in Adult patients in Portsmouth Hospitals NHS Trust.
They are applicable to adult patients who require short term (4-6 weeks) feeding via a fine bore
naso-gastric feeding tube.
For administration of medication via a fine bore naso-gastric feeding tube please refer to
Administration of Drugs to Adult Patients with Feeding Tube guidelines (12)Administration of
Medicine Policy
For the administration of Enteral feed via a fine bore naso-gastric feeding tube please refer to
Enteral Tube Administration Policy (Adults). Enteral Tube Administration Policy (Adults)
For fine/wide bore naso-gastric feeding tubes or orogastric feeding tubes inserted other than at
the bedside (ie endoscopy, imaging, and theatres) this policy should be adhered to for the
verification of tube position. NG tubes that are placed under direct visualisation or palpation
must still be checked using the pH aspirate test prior to use (or x-ray if pH is above 4.5) as
there is a risk that the tube may have moved subsequent to placement or that the tip of the tube
may be in the oesophagus rather than the stomach.
The Department of Critical Care is responsible for producing its own specialty specific
guidelines to Trust standards.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults:
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4. DEFINITIONS
Fine bore naso-gastric feeding tube:Defined as between a 6 – 8 french gauge. The length of the tube is measured in cms starting
at the distal tip (stomach end = “0” cms). The tube is made of silicone or polyurethane which is
passed through the nostril via the naso-pharynx into the oesophagus, then stomach. (See
Process 6A). Nasogastric tubes used for the purpose of feeding must be radio-opaque
throughout their length and have externally visible length markings(12).
In this Trust a Merck Corflo 8fg, 92cm, fine bore feeding tube is the tube of choice as it has
easily identifiable cm markings and is radio-opaque along its length without the guidewire insitu.
Naso-gastric feeding:The administration of artificial nutrition via a fine bore naso-gastric tube. Feeding via a nasogastric tube is usually a short- term intervention (4-6 weeks). A route for permanent enteral
access should be considered if enteral support is required for longer than this.
Healthcare Professionals:A registered or trained competent member of staff including (doctors, nurses and midwives.)
Competency level 2 and above (Appendix 4).
Competence:Competence and competences are job related, being a description of an action, behaviour or
outcome that a person should demonstrate in their performance.
Competency and competencies are person orientated, referring to a person’s underlying
characteristics and qualities that lead to effective/superior performance in their job.
.
Maintenance of a Naso-gastric tube:Including correctly checking tube position, and maintaining the patency of that tube. Ongoing
management including skin care, checking tube position. (See Process 6C)
Enteral Syringes:Purple single use non I.V. compatable syringes for enteral use only. Available as female luer
slip and catheter tip.
PH Aspirate test:
Fluid obtained from the stomach via the NGT using an enteral syringe. Aspirate is then
checked for pH using indicator strips. PH 4.5 or below indicates gastric placement.
Blackcurrant Test:
If swallow is intact ask patient to drink 200mls blackcurrant, or other acidic fluid such as lemon
or orange squash, and attempt to aspirate via NGT. Aspirate is tested for pH and should be 4.5
or below as an acidic drink has been consumed. Not to be used on dysphagic patients or
patients with oespohageal stricture/obstruction.
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5. DUTIES AND RESPONSIBILITIES
Medical Staff:The decision to commence artificial nutrition via a naso-gastric tube is a medical decision to be
made in conjunction with the patient, the patients’ family and members of the MDT. Before a
decision is made to insert a nasogastric tube, an assessment is undertaken to identify if
nasogastric feeding is appropriate for the patient, and the rationale for any decisions is
recorded in the patients medical notes (12)
Medical staff are responsible for requesting an x-ray to verify the position of a nasogastric tube
where aspiration of the tube has failed to verify gastric placement (pH > 4.5 or no aspirate). The
x-ray form must clearly state that the purpose of the x-ray is to establish the position of the
nasogastric tube for the purpose of feeding(12).
0800 – 1600 hrs (Mon – Fri) : medical staff are responsible for reviewing the x-ray on PACS
and documenting in the medical notes that the NG tube is within the stomach and safe to use
for feeding.
If an x-ray is required to verify NG tube position after 1600 hrs, or at weekends, the referring
clinical team Consultant/Registrar must be available to review the x-ray and document in the
patients medical notes that the NG tube is within the stomach and safe to use for feeding. If the
NG is found to be in the lung it must be removed immediately. Consultant/Registrar must have
completed the online NG x-ray training through ESR “Reducing the risk of feeding through a
misplaced feeding tube”(search “nasogastric”).
The x-ray report should state the following and all 4 criteria should be met in order to correctly
identify the NGT as being in the stomach:
1. The NGT follows the oesophagus and avoids the contours of the bronchi
2. The NGT clearly bisects the carina or bronchi
3. The NGT crosses the diaphragm in the midline
4. The NGT tip is clearly visible below the left hemi-diaphragm
Radiology Department:
Radiographers:- are responsible for ensuring that the nasogastric tube can be clearly seen on
the x-ray to be used to confirm tube position.
Radiology Consultant/Registrars or Advanced Practitioner Radiographers(with suitable training)
are responsible for reporting x-ray films onto PACS between the hours of 0800 -16.00 hours
Mon to Fri. Any tube found to be in the lung will be removed immediately by the person
reporting the image whilst the patient is in the x-ray department.
The x-ray report should state the following and all 4 criteria should be met in order to correctly
identify the NGT as being in the stomach:
1. The NGT follows the oesophagus and avoids the contours of the bronchi
2. The NGT clearly bisects the carina or bronchi
3 The NGT crosses the diaphragm in the midline
4 The NGT tip is clearly visible below the left hemi-diaphragm
Healthcare Professionals (including Registered Nurses)
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults:
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It is expected that fine bore naso-gastric tubes will be inserted and maintained by a level
2 and above practitioner in a safe and competent manner (Appendix 4) and in
accordance with this Policy.
Healthcare Professionals are responsible for establishing the gastric placement of NGTs prior
to their use and to document this using the NG checking chart.
It is the responsibility of the Healthcare Professional to develop and maintain their own level of
competency (Appendix 4).
Clinical Nutrition Nurse Specialists(CNNS):
CNNS team will provide support to clinical areas in the insertion and management of finebore
nasogastric feeding tubes between 0900 hrs and 1600 hrs, Monday – Friday.
X-ray requests to verify NG tube position will be notified to the CNNS team who will review the
patient prior to x-ray. If a pH of 4.5 or below is gained the CNNS will cancel the x-ray request
(Mon-Fri 0900-1600 hrs).
CNNS team are responsible for the development and review of this policy.
CNNS team are responsible for providing training and education to PHT staff on the insertion
and management of finebore nasogastric feeding tubes.
Clinical Nutrition Nurse Specialists in conjunction with Modern Matrons, Ward Managers,
Practice development Nurses and Clinical Educators are responsible for the management and
implementation of this policy.
6. PROCESS
Insertion of fine bore Naso-Gastric feeding tubes in Adults.
List of Equipment for Procedure:Clean Tray or trolley
1 x Corflo 8 fg, 92cm, nasogastric tube
1 x glass of drinking tap water and straw
1 x 10ml enteral syringe filled with drinking tap water
1 x 50ml enteral syringe
Bioclusive / Hypafix
Merck Serono pH Indicator strips 0-6
ACTION
RATIONALE
EVIDENCE
1. Explain procedure to
patient.
To obtain patients consent and cooperation.
1,2,
2. If patient does not have
capacity to consent to
treatment a best
interests decision must
be made
To ensure NG insertion is in the
patients best interests.
17
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults:
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How to insert the NG tube
2a. Where possible the patient
should be sitting in a semiupright position supported with
pillows.
This position allows easy swallowing
and ensures that the epiglottis is not
obstructing the oesophagus.
Appendix 2.
2
2b. For the semi-conscious
patient it is often easier to be in
a lying position.
3. Wash hands and apply
gloves. Assemble required
equipment, select appropriate
tube.
To ensure a clean procedure is
maintained throughout.
Consider fg required depending on
diagnosis.
4. Check nose and mouth for
any signs of obstruction and
ensure both are clean.
To aid passage of NGT
Check nasal patency by sniff
with each nostril occluded in
turn.
Patient may have one nostril which is
clearer than the other e.g. deviated
nasal septum.
5. Check that the guidewire
moves freely and then secure
the guidewire into the end of
the NG tube. Close the purple
port on the NG tube.
To aid correct insertion of tube and to
be able to aspirate tube post insertion
Manufacturers
guidelines.
1
6. Lubricate the NG tube by
immersing end of tube in
drinking tap water.
This will facilitate easy passage when
inserting the tube.
Sterile water has a pH of 4.5 and its use
may lead to a false positive pH reading.
Drinking tap water has a pH of > 5
1,2
2. Insert the tube into the
clearest nostril and slide
backwards and inwards
along the floor of the nose
to the nasopharynx
approx 10-12cm and
STOP
If any obstruction is felt
withdraw tube slightly and try
again at a slightly different
angle.
There are two distinct stages when
passing the tube.
8a. If the patient can swallow
coincide passing NGT with
swallowing a sip of drinking tap
water.
The passing of the NGT can be coordinated with observing for laryngeal
movement. During this phase the
epiglottis covers the airway and NGT
2
a. Nose → pharynx → stop and swallow
b. Pharynx → stomach.
2
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults:
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can pass into oesophagus.
8b. If the patient is dysphagic
but can swallow own
secretions- trickle 1-2 mls of
drinking tap water into the
mouth using a syringe
To elicit a swallow.
Repeat the water/swallow and
advance tube to 50-60cms.
If swallow reflex is not initiated
DO NOT continue with this
method.
Risk of aspiration.
8c. If the patient is dysphagic
and unable to swallow
secretions or the above fails,
attempt to pass the tube
unaided to 50-60cms.
This reduces the risk of aspirating
fluids.
NB Advance chin forwards
and/or turn head to one side.
May facilitate tube advancement
9. If you are unsuccessful
repeat above procedure in
other nostril. Consider smaller
bore and/or unweighted tube.
Do not repeat procedure more
than 3 times.
One nostril may be clearer than the
other. Smaller gauge or unweighted
tube may be easier to pass on specific
patients.
10. Once at appropriate
measurement secure nasogastric tube in place using
hypafix/bioclusive across side
of face. Do not apply tape to
the nose.
T o prevent displacement of tube post
insertion
18
Mark NGT with pen at point of
entry into nostril.
This will provide an easily identifiable
mark as a baseline
4,14
DO NOT INSERT ANY FLUID
INTO THE TUBE
GASTRIC PLACEMENT HAS NOT
YET BEEN CONFIRMED
12,13
11.How to verify the position
of the NG tube
A. Using a 50ml enteral syringe
aspirate the NGT by
withdrawing plunger on syringe
and test the pH using Merck
Serono pH indicator strips0-6.
The pH of aspirate should be measured
using pH indicator strips in the range 06 with ½ point gradations.
Merck Serono pH indicator strips are
CE marked and intended for use on
human gastric acid.
Litmus paper must not be used as it
does not indicate the degree of acidity.
1,10, 12
3,10
PH aspirate result:
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: 10
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- pH of 4.5 or below means
that the NG is safe to use.
X-ray is not required.
Flush NG tube with 10mls of
drinking tap water and
remove guidewire
Proceed to step 17 below.
A pH of 4.5 and below (acid) indicates
gastric placement.
.
Flushing of the NG tube will aid removal
of guidewire.
NG tube should only be flushed once
gastric placement has been confirmed
10
Manufacturers
guidelines
13
- If unable to obtain aspirate
or pH above 4.5 do not use
the NG tube.
Follow steps 12, 13 and 14
below.
Gastric placement of NG tube has not
been confirmed and it is unsafe to use
the NG tube
12.If unable to obtain aspirate
or pH is above 4.5 try the
following:
This clears tube of debris and forces
the end of the tube away from the
stomach mucosa.
6,8
Tip of tube may not be in fluid pool in
the stomach- advancing tube should
enable aspirate to be obtained as tip of
tube should be in gastric fluid pool.
3
Withdrawing tube should allow aspirate
to be obtained-by putting tip of tube in
gastric fluid pool.
3
A. Inject 20ml of air into the NG
tube
A. Consider length of NGT.
If measurement at nose is 50 55cm consider advancing tube
5-10cms.
B. If measurement at nose is
above 60 – 65 cm consider
withdrawing tube 5-10cms.
C. Consider changing the
patients position e.g. from
sitting to lying, or lying on side.
D. If aspirate obtained and
pH 4.5 or below then the tube
is safe to use. X-ray is not
required. Flush NG tube with
10mls of drinking tap water
and remove the guidewire.
Proceed to step 17.
To change the fluid level in the
stomach-as this may enable aspirate to
be obtained.
2,3,6
. A pH of 4.5 and below (acid) indicates
gastric placement
10
Flushing of tube will aid removal of the
guidewire. NG tube should only be
flushed once gastric placement has
been confirmed
Manufacturers
guidelines
13
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Version 10 18/12/2013
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13. If still unable to obtain
aspirate or ph is above 4.5
AND ONLY IF THE PATIENTS
SWALLOW IS SAFE.:
A. Ask patient to drink 200mls
of blackcurrant ORALLY.
Blackcurrant should then be in the
patients’ stomach.
10
B. Using a syringe attempt to
gain aspirate from NGT.
If tip of NGT is in gastric fluid pool
blackcurrant will be aspirated.
10
C.If aspirate is obtained- check
the Ph using Merck Serono
pH indicator strips0-6
PH of aspirate should be 4.5 or below
as blackcurrant is acidic.
D. If aspirate obtained and
pH 4.5 or below then the tube
is safe to use. X-ray is not
required. Flush NG tube with
10mls of drinking tap water
and remove the guidewire.
Proceed to step 17.
A pH of 4.5 and below (acid) indicates
gastric placement
DO NOT USE THIS METHOD
UNLESS PATIENTS
SWALLOW IS SAFE.
It is not safe to ask patient to drink if
swallow is NOT intact.
DO NOT USE ON PTS WITH
OESOPHAGEAL STRICTURE
OR CA OESOPHAGUS.
The NG tube may be sitting above the
stricture /tumour. Fluid taken orally may
pool above the stricture/tumour and
lead to a false positive pH aspirate test:
pH 4.5 or below but NG tube is actually
in oesophagus and unsafe to use
14 In the absence of a positive
aspirate test contact the CNNS
team for review before
requesting an x-ray.
CNNS team may be able to obtain
aspirate of pH 4.5 or below and x-ray
will not be required.
15. If after following steps 11 14, a positive aspirate test
cannot be obtained an x-ray
will be required to verify the
position of the NG tube prior to
its use.
On initial insertion only- x-ray will
provide confirmation of position and a
baseline from which to base ongoing
clinical judgments on whether the NG is
safe to use.
10
The x-ray form must clearly
state that the purpose of the xray is to establish the position
of the nasogastric tube for the
purpose of feeding
X-ray need to know this as a specific
density is required – on a standard
chest x-ray the tube may not be visible
and the x-ray may not go down far
enough to see the tip of the NG tube.
8, 12
Flushing of tube will aid removal of the
guidewire. NG tube should only be
flushed once gastric placement has
been confirmed
10
Manufacturers
guidelines
13
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16. i
X-ray 0800 - 1600 hrs(MonFri)
NPSA alert 2011/PSA 0002: main
causal factor in the use of misplaced
NG tubes was misinterpretation of x-ray
12
a.Radiology will report x-ray
direct onto PACS
b.If tube is in lung it will be
removed in x-ray dept
To provide documentation in the
patients medical notes that the tube is
safe to use
c.Post x-ray the ward Doctor
must review the x-ray report on
PACS and document in the
patients medical notes that the
NG tube is safe to use for
feeding, before it is used.
X-ray 1600 – 0800 hrs, or at
weekends
a.Defer x-ray unless a
competent clinician is available
to interpret the x-ray
Evidence from Never Events reports
suggest that there are increased risks
with x-ray checking at night due to a
lack of senior support.
12
b. Competent
Consultant/Registrar must
interpret the x-ray and remove
the NG tube if it is in the lung
c. Consultant/Registrar must
document in the patients
medical notes that the tube is
within the stomach and safe to
use prior to use
16. ii
If you have not been able to
obtain any aspirate prior to xray you will need to flush the
NG with 10mls of drinking tap
water and then remove the
guidewire once x-ray has
confirmed correct position of
the NG tube.
.
To ensure patient safety
In order to remove the guidewire the
lubricant within the tube must be
activated by fluid. The NG tube must
not be flushed until gastric placement
has been confirmed
Manufacturers
guidelines
13
1
17. Document the insertion
procedure in the patients
medical notes. This should
include:
- date and time
- patient consent
- type of tube used
-nostril tube inserted into
-length of tube at nostril
-outcome of aspiration test
-if tube is safe to use or not
and further actions required
Recording the procedure is a
requirement in law and provides a
baseline for further measurement
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: 13
Version 10 18/12/2013
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Implement NG tube checking
chart (Appendix 4) at bedside.
To ensure documentation of NG
position checks.
12
6A Ongoing checking of NG tube position
As the healthcare professional caring for the patient with an NGT it is your responsibility to ensure
the tube is in the correct position.
i) Tube position should be checked by aspiration and documented on the NG checking chart:-
ACTION
RATIONALE
EVIDENCE
1. Each bolus feed or drug
administration.
2. At least once every 24 hrs when
continuous feeds are used.
3. If the patient complains of
discomfort or feed reflux into the
mouth.
4. After vomiting or violent retching.
5. After severe coughing bouts /
respiratory distress.
To confirm correct position prior to use.
1
To ensure tube has not displaced.
1,4
To ensure tube has not displaced.
Tube may be coiled in back of throat.
1,4
To ensure tube has not displaced.
To ensure tube has not displaced.
Check back of throat to ensure that tube
is not coiled.
To ensure tube has not displaced.
1,4,6
1,4,6,10
To ensure tube has not displaced.
1
6. After endotracheal or
tracheostomy tube suctioning.
7.If tube has obviously displaced on
checking measurement.
8. Following a patient slip/trip/fall
To ensure tube has not displaced
9.On return to the ward if the patient
has been for an investigation or
procedure
10. On receipt of patient being
transferred prior to using tube.
To ensure tube has not displaced
To ensure tube has not displaced.
1,6
1
ii)Tube position should be monitored by visual check of measurement at nostril and
documented on NG checking chart:-
ACTION
1. On changing a bag of feed if
patient on continuous feeding
2.On administration of medication if
patient on continuous feeding
3. When moving/turning/transferring
the patient if on continuous feeding
4. Every 8 hours if none of the above
occur
RATIONALE
To ensure tube has not displaced
EVIDENCE
To ensure tube has not displaced
To ensure tube has not displaced
To ensure tube has not displaced
If any of the visual checks indicate that the tube has moved then an aspiration test must be
carried out and gastric position confirmed as for tube insertion.
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: 14
Version 10 18/12/2013
(Review date: October 2015)
6B Problem solving for Ongoing NG Checking (not to be used on placement of NG)
It is recognized that obtaining aspirate for ongoing checking may at times be difficult. In the absence
of aspirate pH 4.5 or below a clinical decision should be made as to whether the tube is safe to use in
conjunction with the NG checking chart. A level 2 practitioner may need to refer to a Level 3 or 4
practitioner for advice.
The following is provided to assist in your decision making.
Follow the guidance below ONLY for NGTs that have previously been confirmed to be
in the correct position by pH aspiration test/x-ray.
ACTION
1. Check that a level 2
practitioner has followed the
process for tube verification on
insertion (above).
2. Review NG checking chart:
3. Obtain patient history: Check
measurement at nose, has
patient vomited, violently
coughed, or complained of feed
reflux? Look in patients mouth
to check if tube is coiled at back
of throat
4. If patient has an intact
swallow use the blackcurrant
test.
5. Only if tube position has not
moved and pt has not vomitted,
inject 5/10mls of drinking tap
water into NG tube. Attempt to
re-aspirate using a 20ml enteral
syringe.
6. Contact the Nutrition Nurses
for advice
EVIDENCE
RATIONALE
To ensure correct procedure
has been followed on initial
insertion.
To aid clinical judgment and
guide decision whether tube is
safe to use
To check if tube has moved.
To ensure tube has not
displaced.
If measurement is the same at
the nose, no vomiting or violent
coughing, tube not coiled in
throat - assume tube position is
unchanged.
If tip of tube is in stomach
blackcurrant will be aspirated
via the NGT and can then be
pH tested.
This has been shown to ease
the procedure for obtaining
aspirate.
Do not use sterile water as this
has a pH of 4.5 and could lead
to a false positive result
1
10
3
6C. Ongoing Management
Skin Care:ACTION
DAILY
Check that tape securing tube is To ensure tube is safely
intact and not in need of
secured in position.
replacement.
Check around nostril for any
signs of pressure necrosis.
An adverse incident form needs
EVIDENCE
RATIONALE
18
Tape may need to be changed
to secure tube in a different
position.
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: 15
Version 10 18/12/2013
(Review date: October 2015)
to be completed if any pressure
necrosis is found
18
Tape should be placed across
patients cheek
To safely secure tube in
position
If patient is NBM ensure mouth
care is maintained 2 hourly.
To ensure oral hygiene is
maintained reducing risk of
infections.
Maintaining Patency:ACTION
RATIONALE
Flush tube with 30ml-50mls
water before and after feed
using a 50ml enteral syringe.
To ensure tube does not
become blocked.
If fluid restricted may need to
reduce these amounts.
To ensure fluid in 24hr period
does not exceed restrictions.
EVIDENCE
4,7
If continuous feeding flush
every 4-6 hrs.
Where possible medications
should be given in liquid /
dispersible form.
To aid administration of
medication via the NG.
4,7,18
If feed in progress tube MUST
be flushed with water prior to
giving medications via the tube.
To reduce the risk of tube
blockage.
4,7,18
Medications to be given
individually with a water flush in
between
To reduce the risk of tube
blockage
4,7,18
Flush tube with water at end of
medications and prior to
recommencing feed.
To reduce the risk of tube
blockage
4,7,18
Administration of Medicine
Policy
7. TRAINING REQUIREMENTS

It is expected that fine bore naso-gastric tubes will be inserted and maintained by a level 2
and above practitioner in a safe and competent manner (see Appendix 4: NG
Competency, also available on learning and development pages (intranet)
Departmental/Specialty Competencies: Care of fine bore NG tube).

Ward Managers, Clinical Educators and Modern Matrons are to ensure staff are aware of
Policy and that it is adhered to at ward level.

Ward managers are responsible for ensuring staff complete competency to required level

CNNS to maintain a high profile in clinical areas to support implementation of this policy.

Teaching by CNNS team: Patient Safety Day; RN Induction; NG Workshops; Nutrition
Champion Day; Nutrition Support Study Day; ward teaching.
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: 16
Version 10 18/12/2013
(Review date: October 2015)

CNNSs to provide training on Preceptorship, RN Induction, Patient Safety Day, Nutrition
Champion Study Days and Artificial Feeding Study Days. Specific training also provided
as required by individual ward areas.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
1. Stroud, M. Duncan, H & Nightingale, J. (2003) Guidelines for Enteral Feeding in Adult
Hospital Patients. Gut, 52 (suppl. Vii), Vii-Vii 12.
2. Burham,P. (2000). A Guide to Nasogastric Tube Insertion. Nursing Times Plus 96 (8), 6-7.
3. Reid, W. (2002. Clinical Governance: Implementing a Change in Workplace Practice.
Nasogastric Tube Placement. Professional Nurse, 17 (12), 734-737.
4. Cannaby, A. Evans, L. & Freeman, A. (2002). Nursing Care of Patients with Nasogastric
Feeding Tubes. British Journal of Nursing, 11 (6), 366-372.
5. Chrestiensen, M. (2001). Bedside Methods of Determining Nasogastric Tube Placement: A
literature Review. Nursing in Critical Care 6(4), 192-199.
6. Colagiovanni, L. (1999) Taking the Tube. Nursing Times 95 (21), 63-71.
7. Colagiovanni, L. (2000). Preventing and Clearing Blocked Feeding Tubes. Nursing Times
Plus, 96 (17), 3-4.
8. Ellett, M.L.C. (2004). What is known about methods of correctly placing gastric tubes in
adults and children? Gastroenterology Nursing, Vol 27 (6) 253-259.
9. Metheny, n. & Tiler, M.G. (2001). Assessing Placement of Feeding Tubes. American
Journal of Nursing, 101 (5), 36 – 45
10. Great British National Patient Safety Agency (2005). Reducing the harm caused by
Misplaced Nasogastric Feeding Tubes.
11. Great Britain. National Patient Safety Agency (2007). Promoting safer measurement and
administration of liquid medicines via oral and enteral routes.
12. Great Britain. National Patient Safety Agency (2011). PSA002: Reducing the harm caused
by misplaced nasogastric feeding tubes in adults, children and infants.
13. Great Britain. National Patient Safety Agency (2012). Rapid Response Report
NPSA/2012/RRR001: Harm from flushing of nasogastric tubes before confirmation of
placement.
14. Portsmouth NHS Trust (2005). Administration of Drugs to Adult Patients with Feeding
Tubes. Drug Therapy Guideline No 52.01, p1-25.
15. Metheny, N. et al. (2005) Indicators of Tubesite during Feedings. Journal of Neuroscience
Nursing, 37 (b), 320-325.
16. Taylor, S & Clemente, R. (2005). Confirmation of nasogastric tube position by pH testing.
Journal of Human Nutrition and Dietetics, 18, 371-375.
17. Great Britain. National Institute for Health and Clinical Excellence. (2006). Nutrition Support
in Adults (Clinical Guideline 32) London: NICE.
18. Pickering, K. (2003). The administration of drugs via enteral feeding tubes. Nursing Times.
99 (46) 46-48.
19. Portsmouth NHS Trust (2010). Consent to examination or Treatment Policy.
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
All policies must include this standard equality impact statement. However, when sending for
ratification and publication, this must be accompanied by the full equality screening assessment
tool. The assessment tool can be found on the Trust Intranet -> Policies -> Policy
Documentation
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: 17
Version 10 18/12/2013
(Review date: October 2015)
10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
This document will be monitored to ensure it is effective and to assurance compliance.
Minimum requirement
to be monitored
On insertion NG
position is confirmed as
per policy
Lead
Jo Pratt
Tool
Audit
Data collection
Frequency of
Report of
Compliance
2 years
Reporting arrangements
Policy audit report to:

Lead(s) for acting on
Recommendations
Jo Pratt
Nutrition Support Team
Correct use of NG
 checking charts
NG tubes are checked
at least daily
X-ray is only performed
on
insertion
when
aspirate of 4.5 or below
cannot be obtained
X-ray taken between
0800 -1600, Mon to Fri,
are
reported
onto
PACS by radiology
Jo Pratt
Jo Pratt
Audit
Data collection
2 years
Audit
Data collection
2 years
Policy audit report to:

Jo Pratt
Nutrition Support Team
Policy audit report to:
Jo Pratt
 Nutrition Support Team
X-ray taken after 1600,
or at weekends, are
interpreted
by
a
competent Consultant
or Registrar from the
patients
referring
clinical team
NG tubes are removed
immediately if found to
be in the lung on x-ray
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: Version 10 18/12/2013
Page 18 of 32
(Review date: October 2015)
APPENDIX 1:
A INDICATIONS
Indication for feeding
Unconscious patient
Swallowing disorder
Physiological anorexia
Upper GI obstruction
Partial intestinal failure
Increased nutritional
requirements
Psychological problems
GI, gastrointestinal:









Example
Evidence
Head injury, ventilated patient
Post-CVA, multiple sclerosis, motor
neurone disease.
Liver disease (particularly with ascities)
Oesophageal stricture
Postoperative ileus inflammatory bowel
disease, short bowel syndrome.
Cystic fibrosis, renal disease, critical
illness
Severe depression or anorexia nervosa
Cerebrovascular accident.
1.
B CONTRADINDICATIONS
Fractured Base of skull
Bleeding Oesophageal Varices
Perforated oesophagus
Perforated pharyngeal pouch
C CONSIDERATIONS
NGT insertion may be problematic if the patient is known to have: Head & Neck malignancy/obstruction
Upper Gastrointestinal Malignancy/obstruction/surgery i.e. Gastrectomy
Pharyngeal pouch
Hiatus Hernia
Fractured cervical spine
COMPLICATIONS
Type
Complication
Insertion
Nasal damage, intracranial insertion,
pharyngeal/oesophageal pouch
perforation, bronchial placement,
variceal bleeding.
Post insertion trauma
Discomfort, erosions, fistulae, and
strictures.
Displacement
Reflux
Tube falls out, bronchial
administration of feed. *See below.
Potential aspiration pneumonia.
GI intolerance
Oesophagitis, aspiration
Metabolic
Nausea, bloating, pain, diarrhoea.
Refeeding syndrome,
hyperglycaaemia, fluid overload,
electrolyte disturbance.
Evidence
1.
*In a patient with a functioning Gastro-Intestinal Tract, who repeatedly displaces NGTs it may be
possible to insert a nasal retaining loop which will prevent displacement (See Nasal Retaining Loop
guideline). Nasal Retaining Loop guideline Please contact the Clinical Nutrition Nurse Specialist.
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: Version 10
18/12/2013
(Review date: October 2015)
APPENDIX 2: ANATOMY AND PHYSIOLOGY OF SWALLOWING
Upper Oesophageal
sphincter contracted
(a)
Upper Oesophageal sphincter contracted
Pass NG tube into pharynx
Upper Oesophageal
sphincter relaxed
(b)
Upper Oesophageal sphincter relaxed
When patient swallows upper Oesophageal sphincter relaxes,
epiglottis closes over trachea sealing off airway, therefore NG tube
more likely to pass into Oesophagus.
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: Version 10 18/12/2013
2015)
(Review date: October
Appendix 3
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: Version 10
18/12/2013
(Review date: October 2015)
Name
Appendix 4
D.O.B.
Hospital Number
Ward
Nasogastric tube X-ray review form
Date of x-ray………………….. Time of x-ray ………..
Part A: to be completed if x-ray has been taken Mon –Fri 0900-1600 and has been reported onto PACS
This is the most recent CXR for this patient.
I have read the PACS report.
YES / NO
YES / NO
The NG tube is within the stomach and safe to use for feeding.
YES / NO
If NG is not in stomach and /or unsafe to use state action taken:……………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
Part B: to be completed if x-ray taken after 1600 hrs Mon-Fri or at the weekend.
This is the most recent CXR for this patient.
YES / NO
The x-ray meets the following 4 criteria:
1. NGT follows the oesophagus and avoids the contours of the bronchi
2. NGT clearly bisects the carina or bronchi
3. NGT crosses the diaphragm in the midline
YES / NO
YES /NO
YES / NO
4. NGT tip is clearly visible below the left hemi-diaphragm YES / NO
If the above criteria are not met you should seek senior review before deciding if the NG is
safe to use or not.
The NG tube is in the stomach and safe to use for feeding.
YES / NO
If NG is not in stomach and /or unsafe to use state action taken….....................................
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
Note: if NG is in the lung it must be removed immediately
PHT policy is that Registrars and Consultants, who have completed the online NG x-ray
training, should interpret x-rays to confirm NG position.
Form completed by:……………………………
Sign:………………………………
Designation: …………………………………
Date:………………….................
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: Version 10
18/12/2013
(Review date: October 2015)
Appendix 5
NG TUBE INSERTION AND CHECKING CHART
Adult Patients
Name:
D.O.B
POSITION OF NG TUBE MUST BE CHECKED ON INSERTION AND THEN DAILY IF
CONTINUOUSLY FEEDING OR BEFORE EACH USE IF INTERMITTENTLY FEEDING
Hospital Number:
Ward;
Please document on chart a visual check of cm measurement at the tip of the nose every 8 hours
Date
Time
New
NGT
Insertion
Y/N
Length of
NGT in
cms at tip
of nose
PH of aspirate
Is x-ray
needed
Did x-ray
confirm NG
is in
stomach?
Y/ N
Y/ N/ NA
(NG safe to use if
pH 4.5 or less)
pH
No
aspirate
Is the NGT safe to use?
Y/ N
Use this box to explain the reasons
for your decision
If pH is above 4.5 the NGT
must be x-rayed prior to use:
on insertion, if pt vomits, or if
NGT moves out at the nose.
Sign and print name and
designation
*Do not use blackcurrant test if patient has an unsafe swallow or Oesophageal stricture/Ca.
If unsure seek senior guidance and refer to policy for The Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults. Contact CNNS on ext 5918
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: Version 10 18/12/2013
(Review date: October 2015)
Appendix 6
Name:
APPENDIX
5: NG Competency
Competency Statement: Care of a patient with a fine bore Naso-gastric feeding Tube
1.1. Competency
Indicators
Achieved
Assessor
Signature
Competency
Indicators
2nd Level
1st Level
After obtaining consent from the
patient (as appropriate)
a) Understands the implications of
having an NG tube from a
patient perspective
b) Assist healthcare professional
with the insertion of NG tube as
per NG Policy
c) Has knowledge of and acts in
accordance with
enteral
administration policy
d) Records information
/intervention accurately in
patient record
e) Completes MUST score on
admission and weekly
thereafter
f) Report significant changes to
trained nurse, e.g tube moved
at nose, pt vomiting, pump
alarming.
g) Provide information to patients,
relatives and significant others
regarding care provided
h) Maintain patient comfort and
a)
b)
c)
d)
e)
After obtaining
consent from the
patient (as
appropriate)
Level 1+
Has an
understanding of
ethical issues
surrounding enteral
tube feeding.
Demonstrates
knowledge of
complications
associated with NG
insertion and
maintenance
Following medical
/MDT decision is
able to insert NG
tube as per Policy
On insertion is able
to check NG
position and
document as per
policy prior to use.
Maintains pt safety
by checking NG
Achieved
Assessor
Signature
Competency
Indicators
3rd level
After obtaining
consent from the
patient (as
appropriate)
Level 1 and 2+
a) Manage and
ensure that all
nutritional
interventions are
provided by the
appropriate Health
Care Professional
in accordance with
Trust Policies.
b) Ensure clinical
area has
appropriate
equipment
pertaining to NG
insertion and
feeding.
c) Lead multidisciplinary
discussion
involving patient,
relative and
significant others,
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: Version 10 18/12/2013
Achieved
Assessor
Signature
Competency
Indicators
4th level
After obtaining
consent from the
patient (as
appropriate)
Level 1, 2 and
3+
a) Act as a resource
to support and lead
the multidisciplinary team in
the planning of
further treatment
and intervention.
b) Member of
Nutrition Support
Team and Nutrition
Support Group
c) Undertake audit,
set Trust wide
standards and
policies for the care
of the patient with
a fine bore feeding
tube.
d) Lead regular
(Review date: October 2015)
Achieved
Assessor
Signature
i)
j)
safety e.g skincare.
Knows how to access and
maintain supplies at ward level,
e.g ordering feed, admin sets,
enteral syringes, NG tubes
,indicator strips and feeding
pumps
Attends appropriate
training
position as per
policy, e.g daily if
on continuous
feeding, before
each use if
intermittent.
f) Competently uses
NG checking chart
to document tube
position
g) Has received
training on and can
competently use
enteral feeding
pump
h) Demonstrate ability
to maintain tube
patency and
ensure correct feed
regime is
administered.
i) Has knowledge of
and acts in
accordance with
Policy for the
Administration of
Medicines
j) If competent to
administer
medications, is
able to correctly
give medicines via
an NG tube.
k) Is able to respond
appropriately to
any significant
changes
in the ethical
issues and the
appropriateness of
planned
intervention.
d) Able to manage
difficult tube
insertions on a
range of patients.
e) Utilising experience
and knowledge,
manage any
complications,
referring to
Nutrition Nurse
Specialist/Nutrition
Support Team as
required.
f) Participates in
discharge planning,
supporting the
patient in self
management
g) Facilitate learning
and practice
development within
clinical area.
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: Version 10 18/12/2013
reviews of
equipment in use
and update a s
required
e) Leads on
innovation and
change in
response to
national and
organisational
strategies/priorities
e.g NPSA alerts,
NICE
Act as an expert
resource, advising,
teaching and
supporting
members of
Portsmouth NHS
Trust.
g) Advanced clinical
skills:
Nasal Retaining
Loop Insertion
h) Coordinates and
facilitates
discharge for
patients with NG
tubes
i) Management of
patients in the
community with
NG tubes
f)
(Review date: October 2015)
Recognises when
patients require
referral onto other
HCP e.g Nutrition
Nurse Specialist.,
Dietitian
m) Initiate discharge
planning as per
Discharge Policy
Education resources to support your development
l)
-
-
Policy & Guidelines for gaining
Consent
Policy for The Insertion and
Maintenance of Fine bore Nasogastric Feeding Tubes in Adults.
Enteral Administration Policy
Administration of Medications
Policy
Discharge Policy
Infection ControlPolicy
CNNS webpage via intranet
Access Clinical Nutrition Nurse Specialists
Contact No 023 9228 6000 ext 5918
Author: Jo Pratt
-
PHT Artificial Feeding Study
Day (bi-annual)
Nutrition Champion Study Day
Department: Nutrition Nurses
Web Site:
British Association of Enteral & Parental Nutrition (BAPEN) www.bapen.org.uk
Review Date: Aug 2014
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: Version 10 18/12/2013
(Review date: October 2015)
Record of Achievement.
To verify competence please ensure that you have the appropriate level signed as a record of your achievement in the boxes below.
Level 1
Level 2
Level 3
Level 4
Date
Date
Date
Date
Signature of Educator/ Trainer
Signature of Educator/ Trainer
Signature of Educator/ Trainer
Signature of Educator/ Trainer
Date:
Date:
Date:
Date:
Signature of Assessor
Signature of Assessor
Signature of Assessor
Signature of Assessor
References to Support Competency
1. Cannaby, A et al. (2002) Nursing Care of Patients with Nasogastric Tubes British Journal of Nursing 11 (6) 366-372
2. Christensen, M. (2001) Bedside Methods of Determining Nasogastric Tube Placement: A literature review. Nursing in Critical Care 6 (4) 192-199
3. Colagiovanni, L. (1999). Taking the Tube Nursing Times 95 (21) 63-71
4. Great Britain. National Patient Safety Agency (2005). Reducing the harm caused by misplaced Nasogastric Feeding Tubes.
5. Great Britain. National Patient Safety Agency (2007). Promoting safer measurement and administration of liquid medicines via oral and other enteral routes.
6. Great Britain National Patient Safety Agency (2011). PSA002: Reducing the harm caused by misplaced nasogastric feeding tubes.
7. Great Britain. National Patient Safety Agency(2012). NPSA/2012/RRR001. Rapid Response Report: Harm form flushing of nasogastric tubes before confirmation of placement.
8. .Great Britain. National Institute for Health and Clinical Excellence (2006). Nutrition Support in adults (Clinical Guideline 32) London: NICE
9. .Metheny, N., et.al. (2005). Indicators of Tube site during Feedings. Journal of Neuroscience Nursing 37 (b), 320-325.
10. Stroud, Duncan & Nightingale (2003). Guidelines for enteral feeding in Adult Hospital Patients GUT 52 (suppl. V111) V11-1 – V11-12
11.. Taylor, S. & Clemente, R. (2005). Confirmation of Nasogastric tube position by pH testing. Journal of Human Nutrition and Dietetics 18 371-375.
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: Version 10 18/12/2013
(Review date: October 2015)
APPENDIX 7: PRODUCT INFORMATION / TUBE SELECTION / ENTERAL SYRINGES
PRODUCT
COST
HOW TO ORDER
(NHS SUPPLY CHAIN)
Merck Corflo 8fg weighted NG tube
£10.97
FWM 301
Merck Corflo 6fg weighted NG
£10.97each
FWM243
Merck Serono pH Indicator Strips 0-6
£10.07 pack (100)
FWM 1216
Catheter tip 60ml enteral syringe
£18.48 (box of 50)
60ml enteral syringe (female luer lock)
£18.39 (box of 50)
20ml enteral syringe (female luer lock)
£17.38 (box of 100)
10ml enteral syringe (female luer lock)
£13.31 (box of 100)
FTA189
FTA 149
FTA 156
FTA 148
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: Version 10 18/12/2013
(Review date: October 2015)
DEPARTMENTS OF NUTRITION AND DIETETICS AND CLINICAL NUTRITION
STARTER REGIMEN
FOR NASO-GASTRIC TUBE FEEDING IN ADULTS
The following instructions have been devised to enable competent Healthcare Professionals (level 3) to
commence artificial feeding via a naso-gastric tube.
Refer patient as soon as possible to the Dietitians for assessment and an individualised Feeding Regimen –
see telephone extensions on page 2 or use OrderComms if you have access.
The decision to commence artificial feeding is a medical decision.
If a naso-gastric tube has been inserted for feeding, this document will provide a regimen until the Dietitian has
assessed the patient and provided a regimen tailored to their individual needs. Do not withhold feeding until
the Dietitian is available to provide a feeding regimen.
The starter regimen is designed to avoid starvation and to introduce feed slowly and safely so as not to cause
harm to the patient, not to meet the patients total nutritional requirements.
Prior to commencement of feed you must request that the medical team review the patient to ensure there are
no contraindications or special measures that may apply (for example: renal failure/congestive cardiac
failure/fluid restricted patients/gastro-intestinal obstruction).
You and the medical team will need to assess if the patient is at risk of Refeeding Syndrome. If the patient is
at risk you must use the feeding regimen on page 3. Please see PHT Guidelines for the Prevention and
Treatment of Adult Patients at Risk of Developing Refeeding Syndrome for further details.
If the patient is not at risk use the regimen on page 2.
If the patient is very underweight i.e. less than 40 kg you must follow the Refeeding regimen as the patient will
need to be fed very small amounts to start with.
The following starter regimens have been designed to be used at the end of the patient’s bed as a stand-alone
document outside of this policy.
Patient Experience Service
Tel: 023 9228 6757
PRODUCED BY Registered Dietitians and Clinical Nutrition Nurse Specialists
DATE: June 2006
REVIEWED: April 2013
REVIEW DATE: June 2014
Portsmouth Hospitals NHS Trust
1
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: Version 10 18/12/2013
(Review date: October 2015)
Portsmouth Hospitals NHS Trust – Departments of Nutrition and Dietetics AND Clinical Nutrition
NASOGASTRIC TUBEFEEDING STARTER REGIMEN FOR ADULTS
Ward:…………... Name:……………..………………… DOB:.…. DATE:….. Sheet No:……..
Fluid Balance should be closely monitored. Feed should be delivered within the context of careful fluid balance
with intravenous fluids being reduced or discontinued as required*.
Biochemistry (within last 48 hours) should be checked before starting and regularly monitored during feeding.
Recommended rates are for guidance and not to contravene medical opinion.
REFER PATIENT TO DIETITIAN AS SOON AS POSSIBLE
For patients 40 kg weight and over
(if patient less than 40 kg use regimen for Refeeding Syndrome – see over)
Date/Day
number
DAY 1
Feed Type
Rate
(ml/hour)
30
20
Duration
(hours)
4
20
Volume
(ml)
120
400
Water
Fresubin
Original
DAY 2
Water
30
4
Fresubin
30
20
Original
DAY 3
Water
50
4
Fresubin
50
20
Original
Patient may require additional intravenous fluids* - please assess fluid balance
120
600
200
1000
Continue as Day 3 until Dietetic Review


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Ensure the patient’s head is elevated to at least 30 degrees during feeding, and for one hour after feeding has
stopped.
Feeding tubes should be flushed before and after medication and whenever the feed is started/stopped with 30 ml
water.
Giving sets should be changed daily.
If symptoms of intolerance occur (vomiting, abdominal distension, diarrhoea etc) – consult medical staff.
If problems with tube management occur eg tube choice, insertion techniques, position check and ongoing care;
please contact the Nutrition Nurses ext 5918.
Further information:
Policy on Insertion and Maintenance of Fine Bore Naso-gastric feeding Tubes in Adults, Clinical Guidelines, PHT
Intranet. This Starter Regimen is Appendix 6 of this Clinical Policy.
Marsden Manual Chapter 27 pp385-401 – Nutrition Support - located on ward and PHT Intranet.
NICE Clinical Guideline 32 – Nutrition Support in Adults - (URI on PHT Intranet).
2 Drug Therapy Guideline No: 52.01 – Administration of Drugs to Adult Patients with Feeding Tubes.
3 Drug Therapy Guideline No: 46.00 – Guidelines for the Prevention and treatment of Adult Patients At Risk of
Developing Refeeding Syndrome.
Dietitians x 7700 6150 QAH x 7701 3720 SMH
Nutrition Nurses x 7700
2
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: Version 10 18/12/2013
(Review date: October 2015)
FOR ADULT PATIENTS AT RISK OF REFEEDING SYNDROME
Ward:…………... Name:……………..………………… DOB:.…. DATE:….. Sheet No:……..
Occasionally patients will be at risk of Refeeding Syndrome. They can be identified from the following
list. Patients with:
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ONE OR MORE OF THE FOLLOWING:
Little or no nutritional intake for more than 10 days
Unintentional weight loss greater than 15% within the last 3-6 months
Body Mass Index less than 16
Low levels of potassium, phosphate or magnesium prior to feeding
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TWO OR MORE OF THE FOLLOWING:
Little or no nutritional intake for more than 5 days
Unintentional weight loss greater than 10% within last 3-6 months
Body Mass Index less than 18.5
A history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics
Fluid Balance should be closely monitored. Feed should be delivered within the context of careful fluid balance
with intravenous fluids being reduced or discontinued as required.*
Thiamine - 100 mg three times daily (the first dose 30 minutes prior to starting feeding3) either orally OR
crushed via feeding tube2.
Vitamin B compound strong - 1 tablet three times daily orally if appropriate, DO NOT ADMINISTER VIA
TUBE.
AND Forceval Soluble – 1 tablet a day, dissolved in at least 50 ml water via feeding tube. 1, OR Sanatogen
Gold – 1 tablet daily orally2 3 DO NOT ADMINISTER VIA TUBE. .
Biochemistry should be closely monitored BEFORE STARTING (within last 24 hours) and DAILY during
feeding, especially Potassium, Magnesium, Phosphate, and Corrected Calcium. If any of these are low do not
increase feed rate – do inform medical staff and dietitian when available.
Recommended rates are to guide but not contravene medical opinion.
Recommend not to start nutritional supplement drinks (eg Fresubin Energy, Fresubin Jucy etc) at same time
as starter regimen if patient at risk of Refeeding syndrome.
REFER PATIENT TO DIETITIAN AS SOON AS POSSIBLE.
Feeding must be increased slowly in accordance with the regimen below following thiamine administration,
see above.
For patients At Risk of Refeeding Syndrome or below 40 kg in weight
Date/Day
number
Day 1
Feed Type
Rate
(ml/hour)
30
15
Duration
(hours)
4
20
Volume
(ml)
120
300
Water
Fresubin
Original
Day 2
Water
30
4
120
Fresubin
20
20
400
Original
Day 3
Water
30
4
120
Fresubin
25
20
500
Original
Patient will require additional intravenous fluids*
SEE INFORMATION REGARDING DAILY PATIENT MANAGEMENT WHILST FEEDING
DEPARTMENTS OF NUTRITION AND DIETETICS AND CLINICAL NUTRITION
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: Version 10 18/12/2013
(Review date: October 2015)
Clinical Policy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults: Version 10 18/12/2013
(Review date: October 2015)