Nasogastric tube feeding

1. Nasogastric & Orogastric
Tube Feeding
RetDem Guide

2. DEFINITIONS
Nutrition is the integration of dietary materials by living
organisms in order for them to develop, maintain
themselves, and reproduce.
Malnutrition refers to the condition where the body is
deprived of nutrients
Enteral Nutrition is a form of nutrition in liquid or
formula delivered through a tube to the digestive
system.

3. DEFINITIONS
Nasogastric tube is a flexible rubber or plastic tube
that is passed through the nose down through the
throat down to the esophagus and into the stomach
to deliver food and medicine.
Orogastric tube is a tube passed through the mouth
and esophagus into the stomach.

4. Purposes
● Feed the patient with fluids when oral intake is
not possible.
● To avoid aspirating foods or fluids into the lungs.
● To collect the gastric fluid for diagnostic
purposes.

5. Materials
● Stethoscope
● Pen light
● Tongue depressor
● Water-based lubricant
● Hypoallergenic plaster
● Towel / Disposable Pads
● NG tube
● Emesis basin
● Sterile and non-sterile gloves
● Asepto Syringe / 30 cc disposable
syringe
● Medication (for feeding) or
feedings
● Feeding bag (for open system)
● 10-30 cc NSS

6. INSERTION OF NASOGASTRIC OR OROGASTRICTUBE
ASSESSMENT
● Review clients medical history. Medical conditions that may have resulted
in a loss of gag reflex. This is to avoid any errors or complications during
the procedure.
Go to the patient’s room, knock, introduce yourself, explain the purpose of
your arrival. Ask for the patient’s name.
● Check the patency of nares and intactness of nasal tissue. Check for
history of nasal surgeries or deviated septum. The nares with the best
airflow is the easiest to access. This also allows the nurse to know the
history of any nasal or sinus problems of the patient.

7. ● Determine the presence of gag reflex. Gag reflex
is used to guide intubations since a loss of gag
reflex may have a risk of aspiration, pneumonia
or may trigger intubation. (use tongue depressor)
● Assess the mental status or ability to understand.
Patient understanding can reduce anxiety and
increase cooperation. This also ensures
responsiveness during the procedure.

8. PREPARATION
● Determine the size of tube to be inserted and whether or not the
tube is to be attached to a suction. To help determine the
appropriate amount of tube to be inserted. For the neonates, fr 6
(french 6); for infants to 5 years old, fr 8 (french 8); and children
over 5 years old is fr 8-10 (french 8-10).
● Assist client to a high fowler's position, if his/her condition
permits, and support the head with a pillow. Facilitates the
passage of the tube into the stomach. This also prevent
aspiration. (Place pillow at the back of the baby this also
prevent back strain).
● Place a towel or disposable pads across the chest. To
prevent soiling of bodily fluids.

9. PROCEDURE
● Explain the procedure and develop a hand signal.
Reduce the anxiety of the patient to facilitate
cooperation and promote client safety. Since the
procedure is uncomfortable, developing a hand
signal in order for us to pause if the patient feels any
discomfort during the procedure.
● Wash hands and don sterile gloves. Reduce the
transmission of microorganisms.
● Provide client’s privacy. Reduce shame and
embarrassment.

10. ● Assess the client’s nares. Ask the client to hyperextend
the head and using a penlight, observe the intactness
of the tissues of the nostrils, including any irritations
or abrasions. This allows a clear view of the nasal area
to check for any signs of infection or skin breakdowns.
● Examine the nares for any obstructions or deformities.
Have the client blow the nose one nostril one at a
time. This Determines which nares is more susceptible
for the tube insertion.
● Select the nostril that has the greater airflow.
Determine the nostril that’s more patent to facilitate
insertion.

11. ● Prepare the tube: If a rubber tube is being used, place it on ice
for 5-10 mins. To stiffen the rubber tube and make the insertion
easier. If a plastic tube is to be used, place it in a warm water.
Minimizes the stiffness of the plastic tube for easier insertion.
● Determine how far to insert the tube: Measure the distance from
the tip of the nose to the tip of the earlobe and then from the tip
of the earlobe then to the xiphoid process of the sternum. To
help determine the appropriate length of the tube to be
inserted.
● Mark this length with adhesive tape, if the tube has no markings.
This provides accurate markings to allow the accurate length to
be inserted.

12. ● Lubricate the first 4 inches of the tube w/ water-soluble lubricant. To
facilitate easier tube passage across potentially dry tissue and minimize
trauma to the mucosa. (place lubricant in the hand and lather on the tube)
● Ask the client to slightly flex the neck backward. Opens the esophagus
and assists in the tube insertion as this facilitates a smooth passage from
the nose to the stomach.
● Gently insert the tube, with its natural curve towards the selected nostril.
Promotes passage of the tube with minimal trauma to the mucosa.
● Ask the client to tip head forward, and gently advance the tube towards
the nasopharnyx - this is usually where the client start to gag. If the client
starts to gag, stop the movement. Assists in the tube insertion as this
opens the esophagus and reduces the risk of the tube from entering the
trachea.

13. ● Advance the tube several inches at a time as the client swallow
until the taped mark is reached. Allows a quick and accurate
tube insertion.
● If gag reflex is present, have the client swallow water or ice
chips as tube is advanced. Tube may follow the swallow
mechanism and aid insertion.
● If the tube meets resistance, lubricate it and insert the tube in
the other nostril. Prevents any trauma and avoid excessive
pushing as this causes more damage.
● Withdraw the tube immediately if there are signs of respiratory
distress. This signals that tube may be inserted in the
respiratory tract.

14. ● Wipe or wash body oil off tip of the nose and allows it
to dry. Prevents friction and aids in the adhesiveness
of the tape.
● Split a 4-inch strip of tape lengthwise 2 inches.
Secure the tube with a tape by placing the wide
portion of the tape on the bridge of the nose and
wrapping the split ends around the tube. Avoid
pressure from the tube against the mucosa by
securing the tube properly.

15. ● Check the placement of the tube: Aspirate for gastric content.
Assess the color and quality. If required, measure with pH
indicator strip. Ensures proper placement of tube in the stomach.
A pH that’s less than 5.5 points to correct placement and values
while a pH that’s more than 5.5 require radiological confirmation.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6896807/)
● Auscultate air insufflations by placing stethoscope over the
epigastrium and injecting 10-30 ml of air into the tube while
listening for a whooshing sound. If air is difficult to hear, tube may
not be in the stomach. This verifies that air entering the stomach
which ensures correct placement of the tube.
● Prepare the client for x-ray, if prescribed. Confirms the tube
placement.

16. ● Attach the distal end of the tube to suction, draining bag, or
adapter according to the purpose of this nursing intervention. To
have an appropriate pathway for the nursing intervention.
● Secure the tube with tape, or rubber band and safety pin to
client's gown or bed sheet. Prevents the tube from becoming
dislodged and make it secured.
● Remove gloves, dispose of contaminated materials in proper
contained and wash hands to prevent cross-contamination.
(remove pads first then gloves)
● Position client comfortably. Promotes comfort and safety.
● Document relevant information. Provides a timely and accurate
documentation which ensures client safety and ensures the
continuity of care.

17. ADMINISTERING TUBE FEEDINGS
PREPARATION
● Assist the client to a fowler’s position in bed or a
sitting position on as chair, the normal position for
eating. If sitting is contraindicated, a slightly elevated
right side lying position is acceptable. This reduce the
risk of pulmonary aspirations in the event that the
client will vomit or regurgitates the formula.

18. PROCEDURE:
● Explain the procedure. Reduces
anxiety; promotes client's cooperation.
● Wash hands and don clean gloves.
Reduces spread of microorganisms.
● Provide client’s privacy. Ensure safety
to client and reduce embarrassment.

19. PROCEDURE:
● Assess the placement of the tubing either by any of the
following procedures: 1st is the Aspiration of gastric
contents and test pH with pH indicator strip. This aids in
the prediction of proper placement of the tube in the
stomach.
● 2nd is the Auscultation for “whooshing” sound in the
epigastrium upon introduction of air in the tube. If air is
difficult to hear, the tube may not be in the stomach. This
ensures that the tube is inserted all the way through the
stomach. (inject 10-30 ml air then listen to whooshing sound)

20. ● Prepare the feeding: 1st is to check for expiration
date of feeding. This promotes client safety by
ensuring that the formula is safe to be consumed.
● Warm feeding to room temperature. To avoid
stomach cramping.
● If using an open system, clean the top of the
feeding container with alcohol and rinse with clean
water the syringe to be used. Prevents
contamination and maintains sterility.

21. FEEDING BAG (OPEN SYSTEM)
● Hang the bag from an infusion pole about 30 cm (12in) above the
tube’s point of insertion to the client. This height allows the gravity
to promote infusion of the formula.
● Clamp the tubing and add the formula to the bag. Prevents the air
from entering the tubing while adding formula to the bag.
● Open the clamp, run the formula through the tubing and re-clamp.
To allow the formula to fill the tubing, removing all the air.
● Attach the bag to the nasogastric or orogastric tube and regulate
the drip by adjusting the clamp to the drop factor of the bag.
Allows the gravity to control the flow rate reducing the risk of
diarrhea from bolus feeding.

22. SYRINGE (OPEN SYSTEM)
● Remove the plunger from the barrel of the syringe and
connect the tip of the syringe to a pinched or clamped
nasogastric or orogastric tube. Pour feeding formula to
the barrel of the syringe. Prevent air from entering the
tubing; provides a system to deliver feeding. Allows
gravity to control flow rate.

23. ● Permit the feeding to flow in slowly at the
prescribed rate or by gravity. Raise or lower the
syringe to adjust flow as needed. This is to
administer the feeding at the right flow rate and
reduce the risk of the formula from being
introduced quickly.
● Pinch or clamp the tubing to stop the flow for a
minute, if the client feels discomfort. Reduces the
risk of aspiration and other complications.
● Remove gloves…

24. REMOVING NASOGASTRIC OR OROGASTRICTUBE
PREPARATION:
● Confirm the physician’s order for tube removal. Prevents
wrong procedure since a doctor’s order is required to
remove the tubing.
● Assist client in high fowler’s position or to a sitting
position, if health permits. Allows easy removal of the
tube and for the patient’s comfort.

25. ● Place the disposable pads across the client’s
chest. Prevents soiling the linens and patient’s
clothes.
● Have the client hold emesis basin and a towel or
tissue to wipe the nose and mouth while the
tube is removed. To catch and wipe off
secretions as the tube is removed.

26. PROCEDURE:
● Identify client, assess client’s consciousness and explain
the procedure. Reduces anxiety and promotes
cooperation.
● Wash hands and (clean) don gloves. Prevents the spread
of microorganisms.
● Prepare the environment, provide privacy. Reduces
shame and embarrassment which puts the client at ease.
● Prepare the equipment. Facilitate a smooth flow and
accurate skill performance of the procedure.

27. ● Detached the tube: 1st is to disconnect the
tube from any attachments. Avoids suction
and potential trauma to the tissues as the
tube is removed.
● Then, remove the adhesive tape securing the
tube to the nose and safely pin from the
clients gown. This allows the tube to be
removed easily.

28. ● Removing the tube: 1st, pinch the tube with the gloved
hand. Secures the tube and prevents any leaks while
tube is being removed.
● Ask client to take a deep breath and hold still while
pulling the tube out, (coil the tube around your hand as
you are pulling). This prevents aspiration as holding the
breath closes the epiglottis.
● Remove the tube slowly but evenly over the course of 3
to 6 seconds. Prevents residual feeding from flowing out
as the tube is being removed and minimize discomfort as
the tube is being removed.

29. ● Observe intactness of the tube. An evidence
of the tube damage warrants further
investigation.
● Place the tubing in a plastic bag and handled
with biohazard precaution. For proper
disposal of the tubings.
● Dispose of contaminated materials in proper
container, remove gloves, and wash hands.
Prevents cross-contamination.

30. ● Ensure client's comfort: Provide oral hygiene to relieve the
dryness of the mouth. (Let the client gargle water and spit in
the emesis basin. Then wipe off the mouth. Discard the used
materials.)
● Assist the client to clean the nares. Ascertains that damage
has not occurred in the nasal area and clears the passage of
any secretions. (Use pen light to assess the nares)
● Document the NG tube removal, amount of drainage and
client's response. To have an accurate documentation of the
procedure done according to agency policy and for the
continuity of care.

31. The end.