Nasogastric Tube

Management and
Care Clinical
Guideline

MEMBERS:
Anastacio, Saraline
Asok, Glaidel
Enar, Maesarah
Encallado, Melody
Galcon, Joana Mae
Gentapao, Claire

Submitted to: Mary Darline Limatoc-Denosca

February 20, 2025

I. INTRODUCTION
 A Nasogastric Tube (NGT) is a flexible, hollow tube that is inserted through the
nose, down the esophagus, and into the stomach.

Nasogastric tube feeding has been common practice in all groups of patients,
from neonates to older people, for many years. Thousands of nasogastric feeding
tubes are inserted daily without incident. However, there is a small risk that
nasogastric feeding tubes can be misplaced in the lungs during insertion, or can
migrate out of the stomach at a later stage.

II. PURPOSE
 To provide nutrition and medication to patients unable to eat orally.
 To remove gastric contents for patients with gastrointestinal obstructions
or poisoning (lavage).
 To relieve abdominal distension by decompressing the stomach.

III. IMPORTANCE OF NGT

 Ensures adequate nutrition and hydration.
 Facilitates medication administration.
 Aids in gastric decompression, reducing nausea and vomiting.
 Essential for diagnostic and therapeutic procedures.

IV. CASES THAT REQUIRE THE INSERTION OF NASOGASTRIC

TUBE (NGT)
 Dysphagia (difficulty swallowing).
 Unconscious or intubated patients.
 Gastrointestinal obstruction or ileus.
 Severe malnutrition or inability to consume adequate nutrition orally.
 Poisoning or overdose (for gastric lavage).
Gastric lavage, also known as stomach pumping or gastric irrigation, is a medical
procedure used to clear the stomach's contents. It involves inserting a tube
through the mouth or nose into the stomach and flushing it with saline or water,
followed by suctioning out the gastric contents.

Uses of Gastric Lavage

1. Poisoning or Drug Overdose – To remove ingested toxins (only effective if

performed within 1–2 hours of ingestion).
2. Gastrointestinal Bleeding – To clear the stomach for better visualization
during endoscopy.
3. Preparation for Surgery or Diagnostic Tests – To empty the stomach before
certain procedures.
4. Severe Gastrointestinal Obstruction – To decompress the stomach and
relieve pressure.
V. TYPES OF NASOGASTRIC TUBES
1. Levin Tube

 Single-lumen tube made of plastic or rubber.

 Used for feeding, medication administration, or decompression.
 Requires intermittent suction.
 Size: 12-18 Fr for adults; 5-12 Fr for pediatric patients.

2. Salem Sump Tube

 Double-lumen tube with an air vent (blue pigtail) to prevent suction injury.
 Used for continuous suction and gastric decompression.
 Size: 12-18 Fr for adults.

3. Dobhoff Tube

 Small-bore, weighted tube for long-term feeding.

 Requires an X-ray for accurate placement verification.
 More comfortable for patients and reduces risk of nasal ulceration.

VI. Pre and Post Procedure Interventions

Pre- Procedure Interventions

 Verify physician’s order and patient’s identity.

 Obtain informed consent.
 Assess patient’s nasal patency and history of nasal surgery.
 Gather necessary equipment.
 Explain the procedure to the patient to alleviate anxiety.
 Post-Procedure Interventions:

 Assess for discomfort, nausea, or respiratory distress.

 Monitor gastric output, pH of aspirate, and tube patency.
 Ensure proper documentation.

VII. SAFETY CONSIDERATIONS

- the precautions that must be followed to minimize risks, prevent complications,

and ensure the well-being of both patients and healthcare providers during a
medical procedure or intervention.

 Prevent aspiration by confirming tube placement before feeding.

 Monitor for nasal pressure ulcers or irritation.
 Maintain tube patency by flushing with water.
 Ensure patient comfort and dignity throughout the procedure.

VIII. PRE AND POST FEEDING

A. Pre- Feeding Considerations

1. Verify Physician’s Order

o Confirm feeding type, amount, and rate (e.g., bolus or continuous
feeding).
o Check for any restrictions (e.g., NPO status for procedures).
2. Confirm Tube Placement
o Gold standard: X-ray confirmation (for initial placement).
o Routine verification before each feeding:
 Aspirate Gastric Contents and check pH (should be 1-5 for
gastric placement).
3. Assess for Bowel Sounds
o Use a stethoscope to confirm active bowel sounds in all four
quadrants.
 o Absent or hypoactive bowel sounds may indicate an obstruction or
intolerance.
4. Position the Patient
o Elevate the head of the bed (HOB) to 30-45 degrees.
o Reduces the risk of aspiration pneumonia.
5. Check for Allergies or Intolerance
o Assess for any previous reactions to enteral formulas.
6. Prepare the Formula
o Ensure formula is at room temperature (cold formulas can cause
cramping).
o Shake well before administering.

B. Post- Feeding Considerations

1. Maintain Patient Positioning

 Keep the head of the bed elevated (30-45 degrees) for at least 30-60 minutes
after feeding.
 Prevents aspiration and promotes digestion.

2. Flush the Tube

 After feeding and medication administration:

o Flush with 30-50 mL of sterile water (for adults).
o Helps maintain patency and prevents clogging.

3. Assess for Tolerance

 Monitor for:
o Abdominal distension, nausea, vomiting (signs of intolerance).
o Diarrhea (may indicate formula intolerance or bacterial
contamination).
o Constipation (may indicate inadequate hydration).
4. Monitor Hydration Status

 Check for signs of dehydration (dry mouth, poor skin turgor, decreased urine
output).
 Encourage oral fluids if allowed or increase free water administration via
NGT.

5. Perform Oral and Nasal Care

 Clean nostrils and securement site daily to prevent skin breakdown.

 Provide frequent oral hygiene to prevent dryness and infections.

Patient’s Comfort and Response

 Observe for gagging, coughing, or difficulty breathing during insertion.

 Monitor anxiety or discomfort and provide reassurance.
 Ensure oral and nasal hygiene.
IX. DOCUMENTATION
Documentation of NGT feeding is essential for ensuring patient safety,
continuity of care, and compliance with medical standards. It serves as legal
protection by providing proof of proper care and adherence to protocols.
Accurate records help prevent errors such as tube misplacement, overfeeding,
or underfeeding, reducing the risk of complications like aspiration or
gastrointestinal distress.
Proper documentation also allows healthcare providers to monitor the
patient’s response, track residual volumes, and make necessary adjustments
to the feeding plan.

Pre-Feeding

✅ Date & Time: (Record time of procedure)

✅ Tube Placement: Confirmed via pH test/X-ray/gastric aspirate
✅ Residual Volume: (mL) returned/discarded per protocol
✅ Bowel Sounds: Present/Absent
✅ Patient Position: Head of bed 30-45°
✅ Formula: (Type & amount, e.g., Jevity 250 mL, room temp)
✅ Patient Tolerance: No complaints / Reports nausea/discomfort

During Feeding

✅ Type: Bolus/Continuous (Rate: ___ mL/hr)

✅ Patient Response: No distress / Reports nausea/vomiting
✅ Flushing: Flushed with __ mL sterile water pre-& post

Post-Feeding

✅ Residual Check: (mL) rechecked after 1 hour if needed

✅ Patient Position: Maintained at 30-45° for 30-60 min
✅ Tube Patency: Tube intact, secured at __ cm
✅ Output: (Record any vomiting/diarrhea if present)
✅ Documentation Complete

X. PROCEDURE
Scenario: A 75-year-old patient with a history of stroke is admitted due to
difficulty swallowing (dysphagia), leading to inadequate oral intake and a
risk of malnutrition and aspiration. The healthcare team decides to insert a
nasogastric tube (NGT) for enteral feeding.
1. Contraindications
The following patients may require referral to a specialist team i.e. ENT,
radiography, endoscopy for consideration of their suitability of nasogastric
tube insertion;
 Esophageal tumors, fistula or surgery
 Laryngectomy
 Skull fractures
 Head and neck surgery
 Tracheostomy (unless in ICU)
 Patient with a known coagulopathy is receiving anticoagulant
medication, or known to have esophageal varices without first taking
advice from senior medical staff.
2. Equipment
 Clinically clean tray
 Nasogastric tube
 Fixation tape
 50, 20 or 10ml syringe depending on patient group (oral/enteral or
catheter tip syringe should be used when available)
- 50ml adult /child
- 20 ml Infant
- 10ml Neonate
 pH indicator strips (CE marked)
 Spigot (A small plastic plug used to temporarily close the NGT when it is not in use.
This prevents leakage of gastric contents and reduces the risk of contamination.)

 Glass of water & straw

XI. METHOD FOR CONFIRMING CORRECT PLACEMENT
- Correct placement of a nasogastric feeding tube should be established.
Do NOT USE THE TUBE if there is any doubt about its correct placement and seek advice from
senior staff. Aspiration, feeding and flushing of tubes should be undertaken using a 50, 20- or
10-ml enteral syringe depending on patient group.
- 50ml adult /child
- 20 ml Infant
- 10ml Neonate
All staff undertaking placement checks must be trained and competent in the technique.
When should testing take place?
 Following insertion of the nasogastric feeding tube
 Before the administration of each feed
 Before giving medication (If feed not already in progress)
 At least once a day during continuous feeding in adults and children, and prior to
changing syringe feeds in infants and neonates
 Following episodes of vomiting, retching or coughing
 Following evidence of tube displacement, e.g. visible external tube length is longer than
previously recorded, loose tapes

1. X-ray Confirmation (Gold Standard)

✅ Most accurate method.

✅ Recommended if placement is uncertain or high risk.
❌ Not always practical for frequent checks.

2. pH Testing of Aspirated Stomach Contents

✅ pH 1.0 - 5.5 suggests gastric placement.

✅ Quick and simple bedside test.
❌ pH may be altered by medications (e.g., antacids) or fasting.
❌ Not reliable for patients on continuous feeds.

3. Visual Inspection of Aspirate

✅ Gastric contents: Green, off-white, or clear.

✅ Intestinal contents: Golden-yellow or bile-stained.
✅ Respiratory secretions: Watery, frothy, or clear.
❌ Not always conclusive—may be difficult to distinguish.

4. Air Insufflation with Stethoscope (NOT Recommended)

🚫 Outdated and unreliable method (whoosh test).

🚫 Can lead to misplacement in the lungs being undetected.
5. Observing for Signs of Misplacement

Coughing, choking, cyanosis, difficulty breathing → Remove immediately!

If the patient can speak clearly, the tube is likely NOT in the airway (but still needs
confirmation).

Best Practice for Routine Checks

🔹 Always verify placement before administering anything via the tube.

🔹 If in doubt, X-ray is the safest option.
🔹 Regularly reassess tube position, especially if the patient moves a lot.

XII. REMOVAL OF NGT

 ACTION RATIONALE
1. Verify the doctor's order. Ensures that NGT removal is
appropriate and aligns with the
patient’s treatment plan.
2. Explain the procedure to the Reduces anxiety and ensures patient
patient. cooperation.
3. Perform hand hygiene and wear Prevents infection and maintains
gloves. hygiene.
4. Position the patient in a high Reduces the risk of aspiration and
Fowler’s position (45°–90°). promotes comfort.
5. Place a towel or tissue on the Reduces the risk of aspiration and
patient’s chest. promotes comfort.
6. Flush the tube with 10–20 mL of Clears residual formula or secretions,
sterile water or air. preventing aspiration during removal.
7. Instruct the patient to take a deep Closes the epiglottis, reducing the risk
breath and hold it. of aspiration.
8. Gently and steadily remove the Minimizes discomfort and reduces
NGT in one smooth motion. irritation to nasal and throat tissues.
9. Dispose of the NGT properly in a Prevents contamination and ensures
biohazard bag. proper waste management.
10. Provide oral and nasal care. Helps maintain hygiene, prevents
irritation, and improves patient
comfort.
11. Monitor for signs of discomfort, Identifies potential complications such
coughing, nausea, or abdominal as aspiration or delayed gastric
distention. emptying.
12. Document the procedure, Ensures accurate medical records for
including time, patient response, and continuity of care.
any complications.

References:
National Nursing Academy Singapore. (n.d.). The National Guidelines on Nursing Management of
Nasogastric Tube in Adult Patients. Retrieved from
https://www.nna.gov.sg/resources-tools/guidelines/the-national-guidelines-on-nursing-management-
of-nasogastric-tube-in-adult-patients

Irish Association for Emergency Medicine. (2023). Clinical Guideline on Nasogastric Tube (NGT)
Management. Retrieved from https://iaem.ie/wp-content/uploads/2023/07/IAEM-Clinical-Guideline-
NGT-V1.0.pdf