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Guidance on the insertion of

Nasogastric (NG) tubes,


management of feeds and
administration of medicines via
an NG tube or via a
Percutaneous Endoscopic Gastric
tube (PEG) in adults

Guidance on the insertion of Nasogastric (NG) tubes, management of


feeds and administration of medicines via an NG tube or via a
Percutaneous Endoscopic Gastric tube (PEG) in adults

Document Type Clinical Guideline


Unique Identifier CL-035
Document Purpose To set out evidence based practice for the insertion and
management of NG tubes and care of patients receiving feeds via an
NG tube.
Document Author Vicky Preece, Deputy Director of Nursing
Target Audience All health care professionals responsible for the care of patients with
an NG tube and receiving feeds via an NG / PEG tube.
Responsible Group Clinical Policies Group
Date Ratified April 2012
Expiry Date April 2015

This validity of this policy is only assured when viewed via the Worcestershire Health and
Care NHS Trust website (hacw.nhs.uk.). If this document is printed into hard copy or saved
to another location, its validity must be checked against the unique identifier number on
the internet version. The internet version is the definitive version.
If you would like this document in other languages or formats (i.e. large print), please
contact
the
Communications
Team
on
01905
760020
or
email
at
communications@hacw.nhs.uk.

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via an NG tube or via a Percutaneous Endoscopic Gastric tube (PEG) in adults Page 1 of 24

Version History

Version

Circulatio
n
Job Title of Person/Name of Group circulated to
Date

1/12/11

28/03/12 Clinical Policies Group

Brief
Summary
of
Change

Community Hospital Matrons


Locality Managers
Chief Pharmacist
Patient Safety Manager
Consultant Nurse Infection Prevention & Control
Clinical Services Operational Lead (South
Worcestershire)
Clinical Services Operational Lead (Redditch &
Bromsgrove)
Clinical Services Operational Lead (Wyre Forest)
Governance Manager
Professional Standards Manager
Training & Development Manager
CNS Palliative Care
Learning Disability Manager
Speech & Language Therapist Lead
Stroke Team Lead
Medical Director
Professional Practice Facilitator District Nursing
Trust Dietician

Minor

Accessibility
Worcestershire Health and Care NHS Trust has a contract with Applied Language Solutions to
handle all interpreting and translation needs. This service is available to all staff in the trust via a
free-phone number (0800 084 2003). Interpreters and translators are available for over 150
1
languages.
From this number staff can arrange:
Face to face interpreting;
2
3

Instant telephone interpreting;


Document translation; and

4British Sign Language interpreting.


Training and Development
Worcestershire Health and Care NHS Trust recognises the importance of ensuring that its
workforce has every opportunity to access relevant training. The Trust is committed to the provision
of training and development opportunities that are in support of service needs and meet
responsibilities for the provision of mandatory and statutory training. All staff employed by the Trust
are required to attend the mandatory and statutory training that is relevant to their role and to
ensure they meet their own continuous professional development.
The insertion of Nasogastric (NG) tubes, management of feeds and administration of medicines

via an NG tube or via a Percutaneous Endoscopic Gastric tube (PEG) in adults Page 2 of 24

Contents
1. Introduction

Page 4

2. Purpose of document

Page 5

3. Definitions

Page 5

4. Scope

Page 5

5. Training / Competencies

Page 5

6. Responsibilities and Duties

Page 6

7. Contraindications for inserting an NG tube

Page 6

8. Safety Considerations

Page 6

9. Gaining Informed Consent

Page 7

10. Re-feeding syndrome

Page 7

11. Procedure for insertion and management of an NG tube

Page 7

12. Safety and appropriate checks

Page 13

13. Administration of feeds via an NG/PEG tube

Page 14

14. Administration of medicines via an NG tube

Page 16

15. Other measures in support of safe practice

Page 18

16. Monitoring implementation

Page 19

17. References

Page 20

18. Associated documentation

Page 20

Appendix 1
Nasogastric Tube (NG) Care Plan

Page 21

Appendix 2
Nasogastric Care Patency Check Sheet

Page 22

Appendix 3
Competency assessment sheet for registered healthcare professionals
For the insertion of a fine bore Nasogastric (NG) tube

Page 24

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1.

Introduction
1. Malnutrition is both a cause and a consequence of ill-health. The consequences of

malnutrition include vulnerability to infection, delayed wound healing, impaired function


of heart and lungs, decreased muscle strength and depression. Surgical patients, who
have malnutrition for example, have around three times as many postoperative
complications and four times greater risk of death than well nourished patients having
similar operations. If poor dietary intake or complete inability to eat persists for weeks,
the resulting malnutrition can be life-threatening in itself (NICE, 2006).

2. All patients who are unable to take adequate food and fluids orally should be

considered for an alternative route for feeding (Enteral Feeding). This may be
necessary both on a short term or long term basis. Nasogastric feeding is usually
considered as a first line in artificial nutritional support and therefore should only be
considered as a short term method of feeding, normally no more than six weeks (Royal
Marsden, 2008). This method of feeding involves passing a Nasogastric tube (NG tube)
through the nose and into the stomach, where it remains in place in order to pass liquid
feeds directly into the patients nasogastri
3. Nasogastric feeding may be a patients only supplement the patients oraled dietindividually,.
takingEach pa into account their clinical condition, treatment plan and nutritional status. If a
nasogastric route is used for feeding a fine bore NG tube should be used in preference
to a wide bore or Ryles tube. Fine bore feeding tubes are more comfortable for the
patient and are less likely to cause complications such as rhinitis, oesophageal irritation
and gastritis (Royal Marsden, 2008).

4. Percutaneous endoscopic gastrostomy is an endoscopic procedure in which a tube

(PEG tube) is passed into the patient's stomach through the abdominal wall, most
commonly to provide a means of feeding when oral intake is not adequate. PEG
administration of enteral feeds is the most commonly used method of nutritional support
for patients in the community.

5. These guidelines focus on the insertion of NG tubes but also refer to NG and PEG
tubes in relation to the administration of feeds and medicines.

6. Early consideration should be given to NG feeding in dysphagic patients following

stroke (Clarke et al 2005). For some patients with life threatening illnesses, nutritional
support may be advantageous even if the underlying disease process continues to
deteriorate. However, it should be noted that to continue with nutritional support and
hydration in patients at the end stage of their illness may not be in , theand pat
decisions to continue with this type of active treatment or to commence such treatment,
should be considered very carefully and involve discussions with the whole healthcare
team, the patient if appropriate and family members/carers (GMC, 2011). When
starting or stopping nutrition support, patient consent must be sought or it must be in
the patients best interest and healthcare on withholding or withdrawing nutrition support requires
consideration of both ethical
and legal principles both in common law and statute including the Human Rights Act
1998.
7. It is acknowledged that very occasionally it may be medically and clinically necessary
for some patients awaiting surgery/procedures or other medical reasons, to have
aspiration of stomach contents via the insertion of an NG tube. Whilst the rationale for
NG insertion of an NG tube is different from the purpose of feeding, it should be noted
that the insertion procedure remains the same and therefore healthcare professionals
may follow this guideline for that purpose.

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2.

Purpose of document
1. The National Patient Safety Agency (NPSA) has issued guidance indicating that
feeding patients through a misplaced NG feeding tube is largely preventable with
potentially serious and harmful effect, and they have therefore l Event.

2. The purpose of this guideline is to ensure that patients receive safe and effective

nutritional support. The guideline sets out clear evidence based practice guidelines for
the:
insertion of NG tubes;
management of feeds via an NG tube/PEG tube; and
administration of medicines via an NG tube/PEG tube.

3.

Definitions
A Never Event is a serious and largely preventable patient safety incident that should
not occur if the available preventable measures have been implemented.
Enteral feeding refers to the delivery of a nutritionally complete feed, containing
protein, carbohydrate, fat, water, minerals and vitamins, directly into the stomach,
duodenum or jejunum.

4.

Scope
1. Patients covered are those primarily within Worcestershire Health and Care NHS Trust

(WHCT) inpatient areas. NB Insulin dependent diabetic patients should have the
establishment of NG feeding in an acute hospital setting only.

2. This guideline applies to all members of the healthcare team who have a responsibility

for deciding whether an NG tube is appropriate for the patient and for the insertion of an
NG tube and administration of feeds and medicines via an NG tube. It may include
medical staff, registered nurses, dieticians, pharmacists and speech and language
therapists according to individual roles and responsibilities.

3. This guideline may also be used for patients receiving care from within community
nursing teams who require enteral feeding/hydration.

4. For the purposes of the guideline(HCP) thewillbe term referred to throughout.


5.

Training/Competencies
All staff required to insert NG tubes must receive theoretical and practical instruction
on how to safely and competently insert an NG tube.
All staff required to administer feeds and medication via an NG/PEG tube must
receive theoretical and practical instruction on how to safely and competently carry
out this task.
Training may be delivered either as theoretical instruction via e-learning or on site
training and competency assessment. A record should be kept of the training
received and the competency obtained by the individual.

1. Please refer to Appendix 2 for the appropriate competency assessment sheet for the
insertion of an NG tube.

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6.

Responsibilities and duties


1. Medical staff - are responsible, in conjunction with other members of the healthcare

team, for decisions to commence feeding via an NG/PEG tube and for the appropriate
feeding regime and if appropriate, medication.

2. Registered nurses are responsible for the safe insertion of NG tubes, the checking of

ongoing patency of NG/PEG tubes and administration of prescribed feeds and


medication as per the prescribed regime.

3. Pharmacists are responsible for ensuring correct feeds and medications are in the

correct formulation to be administered safely via an NG/PEG tube. In the community


setting, this will involve liaison with community pharmacists and clinical nurse
specialists.

4. Dieticians are responsible for providing an individual regime of feeds and for
arranging a home delivery service for feeds if relevant.

7.

Contra-indications for insertion of an NG tube


1. In some clinical conditions the insertion of an NG tube must be very carefully
considered as there may be contra-indications. These may include:

Head injury nasal intubation may be contra-indicated in patients with a fractured


base of skull because of the risk of intra-cranial insertion;
Abnormal oesophageal tract due to possible stricture, tumour or trauma;
Gastric outflow obstruction or intestinal obstruction; or
Intestinal perforation.

2. HCPs should also be aware of potential difficulties of NG insertion in patients who:


have experienced previous difficulties in attempts at NG tube insertion;
have had recent surgery to the face, head and neck;
have oesophageal reflux; or
have neurological problems that can cause an increased risk of aspiration.

3. In all these cases, medical advice should be taken before proceeding.


8.

Safety considerations
1. Most patients who are fed via an NG tube receive this care safely and effectively. If an
NG tube is wrongly placed into the lungs instead of the stomach, severe harm or even
death can result.

2. In 2005 the NPSA issued guidance to help with the safe placement of NG tubes with
the aim of reducing the occurrence of tube misplacement.

3. The NPSA guidance highlighted the unreliability of previous methods for confirming the
correct

4. It also recommended that checking the NG tube placement via chest x-rays should be

reserved for second line checking only because of the potential for misinterpreting
position check imaging (NPSA, 2005). Since that time, the NPSA have reported that
incidents continue to occur due to misinterpretation of X-rays.

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placement of the NG tube, suchsh tesas t

5. As a result in 2011, the NPSA issued a further safety alert and guidance on how to

check for correct placement of NG tubes (NPSA, 2011) recommending that the first
line testing for correct tube placement should be by pH testing. This guideline fully
supports the NPSA guidance.

9.

Gaining informed consent


1. This guideline should be read in conjunction with the Consent to Treatment Policy. The
Healthcare Professional (HCP) should aim to reduce the patients anxi the patientsfearsbefore
carrying out the procedure. They should explain fully and
clearly the reasons for nasogastric tube placement in terms the patient will understand,
and if receiving feeds or medicines via the NG tube, they should ensure that the patient
understands the reasons for this. The HCP must consider the most appropriate and
inclusive format for this communication.

2. The HCP should invite and encourage questions from the patient and obtain the
patients consent before going ahead with the procedure and make a record of this in
the patients care record.

3. In the case of patients with receptive and/or expressive speech or language difficulties,

it is likely that the patient is under the care of a Speech and Language Therapist, but for
any communication issues it is advisable to contact a Speech and Language Therapist
to obtain general advice on communication issues.

4. In the case of patients who lack mental capacity to consent, the appropriate procedures
should be followed in line with the Mental Capacity Act 2005.

5. Similar consideration must also be given to the decision to insert a PEG tube.
10.

Re-feeding syndrome
1. Re-feeding syndrome is an important, yet commonly overlooked condition affecting

patients and occurs when feeding is re-commenced after a prolonged period of


starvation e.g. Nil by Mouth, or in patients suffering from severe malnutrition.
Aggressive introduction of nutritional support can lead to fluid and electrolyte imbalance
which can cause life threatening complications including heart failure, convulsions and
in extreme cases coma and death.

2. Re-feeding should not be aggressive and should begin with a high protein, low
carbohydrate diet and increased gradually while monitoring electrolytes and physical
status. In these circumstances, early input from a dietician is advisable so that there is
effective case management.

11.

Procedure or insertion of an NG tube and ongoing care


1. Before commencing the procedure, the HCP should have obtained the consent of the

patient and be sure that the patient fully understands what will happen during the
procedure. They should ensure that they have all necessary equipment to hand and
that they have the necessary documentation ready to make appropriate records.

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11.1 Equipment needed


Fine bore nasogastric feeding tube with radio-opaque line and guide wire (such as
Flocare).
pH indicator paper.
Non-sterile gloves (NB Dependent upon technique, sterile gloves should be used
with immuno-compromised patients if a non touch technique can not be adopted).
60ml purple syringe for enteral feeding (under no circumstances should an IV
syringe be used).
Sterile water and galipot.
Clinically clean receiver.
Tissues.
Drinking water and straw for the patient to drink (unless contra-indicated).
Fixative tape.
Single use disposable plastic apron.

11.2 Illustration of correct tube positioning in nasogastric tract

11.3 Procedure for passing the nasogastric feeding tube


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ACTION

RATIONALE

1. Explain the procedure to the patient.

Reduce any anxieties, ensure the patient


understands the procedure and consents.

2. Place the patient in an upright To improve the chance of oesophageal


position with head flexed slightly intubation.
forwards. If patient unable to sit
upright lie on one side.
Diagram on the left shows correct position for
passing NG tube with head slightly flexed
forward

3. Agree with the patient a signal by


which he or she can indicate to stop
the procedure e.g. by raising a hand.

To enable the patient to stop the procedure if


they wish.

4. Cleanse hands and put on gloves.

Reduce the risk of introducing infection.

5. Measure the distance from the

To ensure that the correct length of tube is

patients ear lob

passed into the stomach. If too much tube is

nose, plus the distance from the


bridge of the nose to the bottom of
the xiphisternum, using the mark on
the NG tube using the closest mark
on the tube.

6. Lubricate the tip of the tube with


sterile water.

passed this risks kinking or coiling in the


stomach, this may cause problems when
removing the guide wire or the tube may
become blocked or knotted. If too little tube
is passed, then the tube could be lying in the
oesophagus and aspiration of feed may
ensue.
To assist the passage of the tube.

patien

To ensure there is no obstruction.


7. Check
the
deviated septum or nasal polyps.
8. Ask the patient to blow their nose if
possible.

To ensure the nostrils are clear.

9. Ask the patient to state the preferred


nostril for insertion if they are able.

To ensure patient comfort.

10. Wash and dry the nose using mild To aid

fixation of adhesive tape

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soap and water.

securing the tube later.

11. Ensure guide wire is firmly placed


inside the tube.

To make sure the guide wire does not slip


out while passing the tube.

12. Advance the tube into the nostril, aim To facilitate the passage of the tube following
the tube horizontally and posteriorly
the natural anatomy of the nose and avoiding
along the floor of the nasal cavity. If
trauma to the nasal turbinates.
obstruction is felt withdraw the tube
and try again at a slightly different
angle.

13. As the tube approaches the naso- To help the tip of the tube pass into the pharynx
ask the patient to swallow oesophagus.
water (unless contra-indicated) and
advance the tube as the patient
swallows. NB If the patient starts
coughing or gagging when the tube
reaches
the
oropharynx,
stop
advancing the tube until the coughing
stops, then continue.

14. If the patient becomes distressed or


Reduce patient distress.
agitated, withdraw the tube and
postpone the procedure.
Inform
Medical Staff and Dietician.
15. If the patient becomes short of The tube may have passed into the trachea
breath, cyanosed or
experiences and caused trauma to the lung.
chest pain, withdraw the NG tube and
seek medical help.
16. When the limiting mark on the tube is
reached stop advancing the tube.

The tip of the tube should now have reached


the stomach.

17. Lightly tape the tube to the cheek.

To hold the tube in place while position of the


tube is confirmed.

18. Confirm position of tube by attaching Ensures tube is in correct position in the
a 60ml purple syringe to the syringe
stomach prior to feed to avoid intrapulmonary
port and proceed to;
feeding
- Aspirate gastric contents (approx
1-2ml) and test aspirate with pH
paper. A pH of 5.5 or less
indicates
gastric
acid
and
confirms the tube is in the
stomach.
- Only if the tube position cannot
be confirmed by pH paper or if
there is doubt about the
positioning of the tube, should
x-ray confirmation be arranged.
19. If aspirate cannot be obtained at first
attempt;

This position may enable the tip of the tube


to lie in the gastric contents

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Try again by repositioning the


patient on their left side
If the stomach is empty, by allowing the
patient to drink will increase the volume of
If the patient is able to safely gastric contents thus making aspiration
swallow, ask them to take a easier.
small drink of water and try
again.
20. Once positioning
is confirmed, This facilitates easier removal of the guide
activate the internal lubricant of the wire.
tube by flushing 10ml of freshly drawn
drinking tap water through the guide
wire port (unless patient is immunecompromised, in which case, cooled
boiled or sterile water can be
considered) .
21. Remove the guide wire by using The guide wire should be removable with
gentle traction.
gentle traction. NB once removed the guide
wire must never be reinserted. If despite
using this technique for removal, the guide
wire will not come out, proceed to remove
the whole tube and the procedure will need
to be repeated with a new NG tube.
22. Secure tube to patientsfaceusinga
fixative tape such as Micropore,
ensuring its
kep
field of vision. The tape should be
secured in such a way that provides a
bridge between the tube and the skin
to reduce friction.

To ensure NG tube remains firmly in position


thus reducing the risk of pulmonary
aspiration and maximise patient comfort
NB Check that the pat
fixation tape.

23. A thin piece of Hydrocolloid dressing, To ensure skin integrity in the area.
such as Granuflex, can be placed
under the tubing and attached to the
patients
cheek,
reduce skin irritation especially if the
tube is in place for some time.
24. Document the insertion details in the To optimise communication between the
patient records on the NG tube healthcare team and for checking purposes.
patency sheet see Appendix 1.
25. Maintain
nasal
mouthcare.

hygiene

and To ensure patient comfort.

26. Perform ongoing checks for pressure To maintain skin integrity and patient
damage.
comfort.
27. Commence fluid balance chart.

To ensure accurate documentation.

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11.4 Actions to be taken if difficulty experienced in obtaining aspirate


1. There are a number of reasons why aspirate may not be immediately obtainable after
insertion of the NG tube. The HCP should not immediately arrange x-ray confirmation
but should consider the following reasons and actions;

Air in syringe but no aspirate the NG tube may not yet have reached the level of
gastric secretions therefore - slowly advance the NG tube (maximum of an
additional 10 cm) and repeat the aspiration.
No air or aspirate obtainable the NG tube can sometimes be occluded by being
placed up against the gastric mucosa therefore - gently withdraw the NG tube a
small amount and attempt aspiration.
No air or aspirate obtainable - the NG tube may have been advanced too far and
into the duodenum therefore very slowly pull back on the NG tube and attempt to
aspirate.
Aspirate amount obtained is less than 0.5 ml this could be due to low levels of
gastric secretions therefore position the patient onto left lateral side and if
possible at 30 degrees, and attempt aspiration again.

11.5 X-Ray confirmation of tube placement

a. X-Ray confirmation should only be considered when the pH test has been tried and
failed and then clearly documented in patients recor

2. Arrange the X-ray and ensure that the patient records are sent with the patient to the xray department. Once the x-ray has been completed, the radiology staff should write in
the patients records whether the NG tube i the x-ray.

3. NB Under no circumstances should the guide wire be reinserted into the tube if it has
already been removed. The x-ray can be taken with or without the guide wire in place
as the tube itself is radio-opaque.

4. On return to the clinical area, if the tube coughing or retching, then feeding via the NG tube can
commence. However, further
attempts at aspirating should still be carried out.

5. NB If there is any continuing doubt as to the positioning of the tube, then advice must
be sought from medical staff or other clinical specialists before proceeding with feeding.

11.6 Further advice on when to aspirate


1. Aspiration of an NG tube must be undertaken to confirm initial tube position but also:
Prior to any substance being administered such as feeds, water or medication.
If there is any doubt of the tube not being in the correct position.
If the patient is coughing, retching or vomiting.
If the recorded marked length of the tube has changed this may mean that the tube
has migrated in or out of the nostril.
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If the patient displays signs of respiratory distress such as shortness of breath,


wheezing, change of colour in the face.
If there has been a decrease in O2 SATs readings.

11.7 Management of a blocked tube


1. Occasionally fine bore NG tubes can become blocked. The following actions should be
taken:

If attached to a feeding giving set check the clamp is open.


Attach an empty 60 ml purple syringe and pull the plunger back to try and unblock
the tube.
Massage the tube by rolling it gently between your fingers using small movements
only. Start from the end furthest away from the body and work towards the nose.
Try flushing with 30 ml of warm water, wait 30 minutes then try again.
DO NOT use force and do not use any sharp objects to try and unblock tube
DO NOT try to reinsert the guide wire in an attempt to dislodge the blockage

2. If the tube will not unblock remove the tube and reinsert a new NG tube.
12.

Safety and appropriate checks of patients with NG tubes


1. This guideline sets out the procedures to follow to ensure that patients receive safe and
effective care when having an NG tube inserted, and feeds and medicines via the
nasogastric route. HCPs should remain vigilant to the potential complications of enteral
feeding and be aware of the following:
HCPs involved in carrying out the procedures contained in this guideline should
have received appropriate training and assessment of competence.
Record keeping of all procedures should be accurately recorded.
X-ray confirmation of tube placement should not be the 1 st line confirmation method
and only used if all other methods have failed, or specifically indicated.
All NG tubes require regular flushing to prevent blockage before starting a feed,
when the feed is stopped, and before and after the administration of medicines. The
tube must be flushed with 30 ml of freshly drawn drinking tap water unless the
patient is immunocompromised, in which case, cooled boiled or sterile water can be
considered.
Wherever possible, patients should be positioned sitting up at an angle of at least 30
degrees during nasogastric feeding and for at least an hour after feeding.
All syringes used for enteral use should be those designed specifically for enteral
feeding (NPSA, 2007).
Three-way taps and syringe tip adaptors should not be used in enteral feed systems
(NPSA, 2007).

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All used giving sets should be discarded after 24 hours, and all bottled feeds should
be used within a 24 hour period once removed from the fridge.
The patient should be weighed if possible at the start of a feeding regime and then
weekly, making recordings on the appropriate chart.
Assess risk of re-feeding syndrome.

13.

Administration of feeds via an NG/PEG tube


a. The feeding regime should have been discussed and agreed by the dietician/nutritionist
to ensure it meets ntsthe. patients requireme
2. Continuous feeding using a feeding pump is the method of choice and should be given
over a maximum on 20 hours. This allows the feed to be administered at a steady rate.

3. Patents should be weighed at the beginning of a feeding regime with the weight
recorded in the patient record and then weighed weekly if possible.

4. If a decision is made to stop the feeding regime, this should be discussed with the
patient if appropriate and their family/carers and form part of a multi-disciplinary team
discussion.

5. If a decision to stop a feeding regime is made because it is felt the patient has recovered their
swallowing ability, the pa monitored daily and their weight closely monitored.

6. Any weight loss or changes in the patients conditionbediscussedshouldwiththe


dietician/clinical nurse specialist/speech and language therapist to agree a treatment
plan.

13.1 Equipment needed


Prescribed feed.
Appropriate giving set.
60 ml purple syringe.

Freshly drawn drinking tap water for flushing.


Feeding pump.
Single use disposable gloves and apron.

13.2 The feeding procedure


a. The feeding procedure should be carried out as follows:

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ACTION

1.

Explain the procedure to the patient and gain their consent - ensures they are
at ease and understand what is about to be carried out.

2.

Take the feed and necessary equipment to the patient.

3.

Encourage the patient to assist if they are able to do so as this will assist in
training the patient in becoming self caring if appropriate.

4.

Undertake hand hygiene (including the patient if assisting) and put single use
disposable gloves and apron.

5.

Assist the patient into sitting position.

6.

Check placement of the NG tube prior to food/drug administration to ensure


patient safety

7.

Flush the tube with 30 ml freshly drawn drinking tap water unless patient is
immuno-compromised, when cooled boiled/sterile water should be used.

8.

Shake the feed if required and open the bottle of feed. Screw onto the giving
set with the clamp closed

9.

Decant the feed into the reservoir and screw on the cap of the giving set

10.

Prime the giving set as per manufacturers instructions to ensure there are no
air bubbles

11.

Attach the bottle to the enteral instructions.

12.

Connect the end of the giving set to the end of the tube.

13.

Set the rate on the pump to the required rate and switch the pump on.

14.

Check that the pump alarm is on by referring to manufacturersinstructions.

15.

Once the feed has run through, turn off the pump.

16.

Flush the tube with 30 ml of freshly drawn drinking tap water as soon as the
feed has finished.

17.

Ideally the patient should remain sitting up for at least an hour after the feed
has stopped.

18.

Dispose of all equipment and discard the giving set and all other
consumables. Remove personal protective equipment and undertake hand
hygiene.

19.

Document as appropriate on relevant sheet.

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14.

Administration of medicines via an NG tube


1. A major safety concern relates to the inappropriate administration of drugs intended for
oral/enteral administration via the intravenous route in error. The National Patient
Safety Agency published an alert (NPSA Patient Safety Alert 19 Issued March 2007)
and recommended the following:

1. To ensure that the risks are reduced to a minimum, the following points should be
adhered to at all times:

Only use labelled oral/enteral syringes that cannot be connected to intravenous


catheters or ports to measure and administer oral liquid medicines.
Do not use intravenous syringes to measure and administer oral liquid medicines.
Ensure stocks available are of the correct type of oral/enteral syringes.
Ensure patients or carers are supplied with the correct type of oral/enteral
syringes.
Enteral feeding systems should not contain ports that can be connected to
intravenous syringes or that have end connectors that can be connected to
intravenous or other parenteral lines.
Three-way taps and syringe tip adaptors should not be used in enteral feeding
systems because connection design safeguards can be bypassed.

2. Patients who need to have medicines administered via NG/PEG tube should have their

prescriptions reviewed and their regime simplified where possible. Consideration


should be given to using other routes and/or once-daily regimes where possible. The
pharmacist may suggest alternative medicines/routes if there is doubt about the
suitability of a medicine to be given via an NG/PEG tube.

3. The prescriber must change the route on the prescription chart to make it clear that the
medicines are to be given via the NG tube or via a PEG tube.

4. Where possible all medicines should be prescribed in liquid or soluble tablet form to

avoid blockage of tube. Some tablets that are not marketed as soluble will nevertheless
disperse in water. The HCP should discuss any medicine which does not come in liquid
or soluble form with the medical team or the pharmacist.

5. Some liquid medicine preparations can be very thick and should be diluted with an

equal volume of water before administration but specific guidance should be sought
from the pharmacist.

6. However, administration of medicines by unlicensed methods is sometimes necessary


to ensure that patients receive appropriate treatment. Such unlicensed methods would
include:
Crushing tablets.
Opened capsules to access contents.
The administration of a particular medicine via an NG tube.
Some liquid preparations check BNF.
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7. Unlicensed methods means that the medicine manufacturer will assume no liability for

any harm that may occur to the patient or the person administering the medicine.
Always seek pharmacistsadvice for the avoidance of doubt. Patients should also be
advised that an unlicensed product is being prescribed and the reasons for doing and
their consent should be documented.

8. At all times, the method chosen should minimise any potential for harm so that

the benefits of giving treatment in an unlicensed way, outweighs any potential


risks.

9. The pharmacist will advise of the appropriateness and suitability of


administering medicines in an unlicensed way HCPs should not crush tablets or
open capsules for administration through an NG/PEG tube unless this has been
discussed and agreed with the pharmacists first and this is recorded on the
administration chart.

14.1 Medicines that must NOT be crushed or opened


1. The table below indicates the oral preparations that must not be crushed or capsules
opened.

Type of Medication

Example

Reason

Enteric Coated Tablets Marked


EC/EN

Medicine designed not to be released


in stomach.

Slow Release Preparations Marked


LA / SA / CR/ XL / SR

Diclofenac, Sodium
Valproate,
Sulfasalazine
Diltiazem, Nifedipine,
Verapamil, Morphine

Cytotoxics

Methotrexate

Risk to practitioner / carer

Anitibiotics

Flucloxacillin

Risk to practitioner / carer

Prostaglandin Analogues

Misoprostol

Risk to practitioner / carer

Hormone Preparations

Cyproterone

Risk to practitioner / carer

Film Coated Sugar Coated tablets


marked f/c s/c

Quinine Sulphate /
bisulphate
Ibuprofen
Prochlorperazine buccal
Ciclosporin

Risk to practitioner / carer


Poor tasting medicine
Rapid degradation of drug
Reduced drug absorption
Poor;y soluble in water

Buccal/sublingual tablets
Soft gelatine capsules

Medicine designed to be released


over prolonged period

14.2 Procedure for administration of medicines via an NG/PEG tube


1. Stop the feed if one is in process.
2. Check if a time delay is required between the feed and administration of
medicines, before administrating the medication.
The insertion of Nasogastric (NG) tubes, management of feeds and administration of medicines
via an NG tube or via a Percutaneous Endoscopic Gastric tube (PEG) in adults
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3. Flush the tube with 30ml of freshly drawn tap water via a 60ml purple enteral
syringe.
4. Each medicine should be administered separately. If it is all administered together
and the tube becomes blocked, it would not be possible to evaluate how much of
each drug was given.
5. All medicines must be administered as soon as they are prepared.
6. Liquid medicines should be drawn up in a 60ml purple enteral syringe.
7. Injectable formulations given enterally should be diluted with 30ml freshly drawn
tap water before administration.
8. Effervescent tablets should be added to a beaker of freshly drawn tap water, and
once the reaction has finished, the solution should be drawn up with a 60ml purple
enteral syringe.
9. Between each medicine flush the tube with at least 10ml of freshly drawn tap water
using a 60ml purple enteral syringe. Flush again with 30ml once all medicines
have been administered.
10. Once all medicines have been administered, enter the total amount of water used
onto fluid balance chart.
11. Re-start feed if necessary.
NB Be aware that in fluid restricted patients, the total amount of water used for tube
flushing may have to be reduced.
Tablets some tablets will disperse which is preferable to crushing, but if
crushing is necessary, crush using a tablet crusher (or between 2 metal spoons
if not available) and add to water before drawing up into enteral syringe.
Capsules gently pull apart the capsule shell and empty the powder contents
into water before drawing up into enteral syringe.

15.

Other measures in support of safe practice

15.1 Infection prevention and control


1. Hand hygiene should be carried out before the insertion of an NG tube and before

administration of feeds. Non-sterile gloves should be worn and a new plastic apron
should be worn before each procedure.

2. All syringes and giving sets used must be single use only.
3. The use of freshly drawn tap water is appropriate in individuals who are not immuno-

compromised. Cool boiled or sterile water can be considered as an alternative option in


those who are immuno-compromised. The water must not be shared with other patients
and must be discarded after 24 hours. If sterile water is used for flushing the tube it
may be decanted from a one litre bottle of sterile water, however the bottle must be
labelled with the patient name and date and time of opening. It must not be shared with
other patients and must be discarded after 24 hours.

15.2 Record keeping


1. As with any clinical intervention, accurate record keeping is essential. Please refer to
Appendix 1 and 2 for the appropriate form to be used in support of these guidelines.

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15.3 Discharge planning for patients with NG tubes from inpatient areas
1. If the patient is being discharged from an inpatient area into the community with an NG

tube in position, and is to receive feeds via the tube, this should only be considered if
the patient or carer is assessed as being competent to manage the feeding at home to
ensure patient safety and compliance with the NPSA 2005 guidance.

2. The potential risks of poor management of an indwelling NG tube are serious and
potentially life threatening and are:

Aspiration of feeds, water or medication into the lungs this can be due to
misplacement of the tube which can occur on initial insertion or due to the patient
coughing or retching after the NG tube is placed.
The tube falling out or the tube becoming blocked this could lead to the inability
to administer the full nutritional requirements, fluids or medication that the patient
requires.

3. Therefore all appropriate measures must be in place for successful patient discharge
as follows:

If appropriate, the community nursing team should also be contacted to check on the
patients ability. to manage at home
Training has been provided to the patient or carer (if appropriate) in all aspects of
feeding to include managing the equipment, management of the tube and simple
problem solving before the discharge is planned.
The discharging nurse should inform the Dietician and pharmacist of the discharge
date 5-7 days prior to patient discharge This is to ensure that the Dietician has time
to arrange home delivery, and to contact the GP regarding feed prescriptions,
arrange pump training for patient/carers and the pharmacist to organise the
appropriate medicines and medication leaflet.
Arrangements are in place to enable the patient to be seen by an appropriate HCP if
there are any problems with the tube placement or ability to administer the feeds.
The patient is provided with the contact details of who to contact if there are any
problems with appropriate 24 hour support.
Prior to discharge the nurse must ensure that the patient is given a 7 day supply of
60ml purple syringes (provided by the ward) and a 7 day supply of giving sets.
Medications must have been ordered and a 7 day supply of feed is sent home.
Arrangements must be in place for an Enteral feeding pump to be supplied (Do not
send ward pump).
An enteral feed regimen has been agreed and a medications leaflet supplied.
The Dietician has put plans in place for ongoing supplies of syringes and giving sets
for the patient in the Community.
A discharge checklist has been fully completed.

16.

Monitoring implementation
1. Monitoring implementation, compliance and effectiveness of this guideline will be

carried out via the respective governance groups in the Trust. Any incidents relevant to
this guideline will be monitored via governance meetings and lessons learned across
relevant clinical areas.
2. Compliance with documentation will be monitored as part of ongoing clinical audit of
records.
The insertion of Nasogastric (NG) tubes, management of feeds and administration of medicines
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17.

References
Anderton, A (2000) Microbial contamination of enteral tube feeds how e can reduce the
risk. Nutricia Clinical Care
BAPEN (2004) Administring Drugs Via Enteral Feeding Tubes A Practical Guide, British
Association for Parenteral & Enteral Nutrition www.bapen.org.uk/pdfs/drugs
%26enteral/practical-guide-poster.pdf
Cannaby A, Evans L, Freeman A (2002) Nursing care of patients with nasogastric feeding
tubes British Journal of Nursing Vol 11, No 6
Clarke J, Cranswick G, Dennis M S, Flaig R et al (2005) Effect of timing and method of
enteral feeding for dysphagic stroke patients (FOOD) : a multicentre randomised
controlled trial The Lancet, Vol 365, Feb 26, 2005
Colgiovanni L (1999) Taking the tube Nursing Times 95 (21) 63-7
Human Rights Act (1998) www.humanrights.gov.uk
General Medical Council (2011) Good practice guidelines End of Life Care: clinically
assisted nutrition and hydration.
Metheney N, McSweeney M, Wehrle M, Wiersema L (1990) Effectiveness of the
auscultation method in prediction feeding tube location Nurse researcher 39, 262-7
Metheney N, Stewart B J, Smith I, Yan H, Diebold M, Clouse R E (1997) pH and
concentrations of pepsin and trypsin in feeding tube aspirates as predictors of tube
placement Journal of Parenteral Enteral Nutrtion 21, 279-85
National Collaborating Centre for Acute Care (2006) Nutrition Support in Adults; Oral nutrition
support, enteral tube feeding and parenteral nutrition. National Collaborating Centre for Acute
Care, London
NICE (2006). Nutrition Support for Adults, Oral Nutrition Support, Enteral Tube Feeding and
Parenteral Nutrition commissioned by NICE.
NPSA (National Patient Safety Agency) (2005). Patient Safety Alert: 21/2/05
NPSA (2005). Patient and Carer Briefing. 21/2/05
NPSA (2007). Patient Safety Alert No 19. 28/3/07
Riley, E. (2002) Establishing Nutritional Guidelines for Critically Ill Patients: Part 1.
Professional Nurse (17) 10
Riley, E. (2002) Establishing Nutritional Guidelines for Critically Ill Patients: Part 2.
Professional Nurse (17) 11
Royal Marsden Manual of Clinical Nursing Procedures (2008) Chapter 24, Nutritional
Support. Blackwell Science

18.

Associated documentation
This guideline should be read in conjunction with:
Relevant NICE and NPSA guidance.
Worcestershire Health and Care NHS Trust Clinical Record Keeping Guidelines.
Worcestershire Health and Care NHS Trust Consent to Treatment Guidelines.
Worcestershire Primary Care Trust Administration of Medicines to patients with
swallowing difficulties and who have either a PEG or an NG tube Guidelines. (These
guidelines will be in place until revised for the new Worcestershire Health and Care
NHS Trust.)

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Appendix 1

NASOGASTRIC TUBE (NG)

Patient Sticker

Care Plan
Problem

The patient is unable to meet their own adequate nutritional needs


orally.

Goal

To meet the patients nutritional needs by using a fine bore


nasogastric tube

Action

Ensure the enteral feeding process is explained to the patient and


family/carers, with consent sought and documented

Review
Date/Time/Sig

Ensure correct tube position prior to each feed or medication


administration by testing aspirate with pH paper and that tube is
secured appropriately. Record gastric aspirate pH level on NG tube
patency sheet at each feed.
Document the tube lot number and expiry date and repeat if tube is
replaced
Change adhesive tape or patch every 24-48 hours and check skin
integrity
Administer feeds at rate and times as prescribed
The tube must be flushed with 30 ml of freshly drawn drinking tap
water, using a 60ml purple enteral syringe before and after each feed
the syringe must be single use only in inpatient settings
If tube becomes blocked flush with a further 30 ml of warm water or if
necessary, replace the tube
Giving set must be changed every 24 hours
Maintain fluid balance chart and monitor and record bowel actions. If
no bowel action for 3 or more monitoring periods, inform medical
team. If the patient suffers from diarrhoea on commencement of
feed, half the rate and contact dietician.
Record patients weight weekly.
Patients head and shoulders should be elevated approx 30o to
reduce risk of aspiration whilst feeding is in underway.
Maintain nasal hygiene and mouthcare.

The insertion of Nasogastric (NG) tubes, management of feeds and administration of medicines
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Appendix 2

NASOGASTRIC TUBE PATENCY CHECK SHEET


Patient sticker
Practice note
If pH > 5.5 do not use tube
Aspirate again 30 minutes later
If pH remains >5.5, inform medical team and refer to Trust NG tube guidelines
DATE:

/ /

TIME

0001

0102

0203

0304

0405

0506

0607

0708

0809

0910

1011

1112

1213

1314

1415

1516

1617

1718

1819

1920

2021

2122

2223

2324

0001

0102

0203

0304

0405

0506

0607

0708

0809

0910

1011

1112

1213

1314

1415

1516

1617

1718

1819

1920

2021

2122

2223

2324

pH reading
Medical advice
sought

x-rayed
Patent
Initials

DATE:

/ /

TIME
pH reading
Medical advice
sought

x-rayed
Patent
Initials

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Appendix 2 cont

Equipment Record
Date/Time

Evaluation
Date/Time

Specific equipment
required and ordered

Evaluation

Date equipment
received

Signature

Signature

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Appendix 3

Competency assessment sheet for registered health care practitioners


for the insertion of a fine bore Nasogastric (NG) tube
Name of practitioner: ----------------------------

Work location: ------------------------------

Aim: To ensure that all practitioners are competent to pass a fine bore NG tube as per the Trust
guidelines.
Learning objectives are as follows;
Understanding of the legal and ethical issues of NG feeding
Understand the procedure in detail
Demonstrate the safe insertion and placement of an NG tube
Training required: attendance at a training session or via e-learning on subject area
Assessment: ability to fully meet objectives and complete an observed successful NG tube
insertion
Underpinning knowledge
To discuss and understand the legal and ethical issues related to NG tube feeding
To discuss and understand the Nutritional guidelines
To explain the factors which need consideration before undertaking the procedure
To identify all necessary equipment required for the procedure
To discuss and understand the importance of establishing correct tube placement prior to and
during feeding
To demonstrate correct techniques to aspirate the tube
To identify risk factors and to the appropriate action to be taken to maintain patient safety

** I confirm that the above named healthcare practitioner has successfully completed the
assessment of competence required for this procedure as detailed above;

Signed:

Print name:

Date: Designation:

**NB: A registered healthcare practitioner who has already achieved competence in this
area of practice is able to confirm the competence of another healthcare practitioner in this
skill or a specialist practitioner in nutritional care or another suitably qualified individual in
an educational field.
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