This document provides guidelines for inserting a Nasal Retaining Loop (NRL), also known as a nasal loop or bridle, to secure nasogastric feeding tubes in patients who repeatedly remove them. It outlines: 1) The purpose, scope, definitions, responsibilities, process, training, and monitoring for NRL insertion. 2) The indications, contraindications, and considerations for NRL insertion. 3) Instructions for daily care of a patient with an NRL and for removing the NRL if necessary. The overall aim is

1. Guideline for Insertion of NGT Retaining Loop (Nasal Loop / Bridle)
Version 2
Name of responsible (ratifying) committee Nutrition Support Group
Date ratified 12.01.2010
Gillian Fraser Clinical Nutrition Nurse Specialist
Document Manager (job title)
Jo Pratt Lead Clinical Nutrition Nurse Specialist
Date issued 15.02.2010
Review date February 2012
Electronic location Corporate Clinical Guidelines
Policy for the Insertion and Maintenance of Fine Bore
Related Procedural Documents
Nasogastric Feeding Tubes in Adults
NGT Fixation; Nasal Bridle; Nasal Loop Forcible
feeding; Feeding practices; Feeding behaviour; Ethnic
Key Words (to aid with searching) differences; Cultural factors; Patient restraint; Patient
compliance; Patient cooperation; Artificial feeding;
Parenteral feeding
Guideline for Insertion of NGT Retaining Loop (Nasal Loop / Bridle). Issue 2.15.02.2010 Page 1 of 9
(Review date February 2010) 14/01/2011

2. CONTENTS:
1. QUICK REFERENCE GUIDE
2. INTRODUCTION
3. PURPOSE
4. SCOPE
5. DEFINITIONS
6. DUTIES AND RESPONSIBILITIES
7. PROCESS
8. TRAINING REQUIREMENTS
9. ASSOCIATED DOCUMENTATION
10. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS
APPENDICES:
1. PICTURES
2. INDICATIONS/ CONTRAINDICATIONS /CONSIDERATIONS
3. CARE OF PATIENT WITH NASAL RETAINING LOOP
1. QUICK REFERENCE GUIDE
1. Patients who repeatedly remove Nasogastric Tubes are referred to the CNNS/CNSC team
for NRL assessment.
2. Patients are assessed for appropriateness of NRL insertion by CNNS/CNCSs
3. Appropriate consent is obtained prior to NRL insertion and is documented in patients notes
4. Ward staff are issued with NRL care guidelines and educated on how to care for NRL
5. All patients with NRL insitu are reviewed weekly by CNNS team
6. NRL can be removed if absolutely necessary to prevent damage to the nasal septum
Guideline for Insertion of NGT Retaining Loop (Nasal Loop / Bridle). Issue 2.15.02.2010 Page 2 of 9
(Review date February 2010) 14/01/2011

3. 2. INTRODUCTION
The use of naso-gastric tubes (NGT) is a common procedure across many different specialties.
This procedure is documented in the PHT Policy for Insertion and Maintenance of Fine Bore
Feeding Tubes in Adults.
Naso-gastric tubes become displaced for a variety of reasons and a small group of patients
appear to be particularly intolerant of the tube and require a NGT to be re-passed frequently.
This can be distressing for the patient, their family and detrimental to their recovery and/or
treatment.
An alternative fixing device has been developed called the Nasal Retaining Loop (AMT Bridle).
This provides a means of securing the NGT to prevent accidental or intentional tube removal by
the patient.
Using this device is potentially an ethically sensitive decision and is recognised as a form of
restraint. This guideline has been written to enable designated practitioners to follow an agreed
decision making, assessment and procedural process.
3. PURPOSE
This guideline is designed to enable Clinical Nutrition Nurse Specialists (CNNS), Consultant
Nurse Stroke Care (CNSC) to place Nasal Retaining Loops in patients who repeatedly remove
NG tubes.
4. SCOPE
The Nasal Retaining Loop will solely be inserted by the CNNS/CNSC who will act as
gatekeepers for this procedure. Supplies of this device are held only by the CNNS/CNSC.
Insertion will follow assessment and multidisciplinary consultation.
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’
5. DEFINITIONS
Nasal Retaining Loop (NRL): Is a method of preventing inadvertent displacement or removal of
fine-bore nasogastric feeding tubes in patients requiring enteral administration of feed, fluid or
medication. It comprises of a rigid probe and a flexible probe with a tape attached. The flexible
probe has a removable guidewire. Each probe has a magnet at the end. The probes are
inserted into each nostril until the magnets join at the back of the nose. The rigid probe is then
pulled out of the nostril bringing the flexible probe and the loop of tape around the back of the
nasopharynx and exiting from each nostril. The tapes from each nostril are then secured to the
NGT with a clamp, reducing the risk of inadvertent removal.
Fine bore naso-gastric feeding tube: -
Defined as between a 6fg - 8fg tube. The length of the tube is measured in cms starting at the
distal tip (stomach end = “0”cms). Measurements are seen along the length of the tube, the
tube length will vary depending on manufacturer. The tube is made of silicone or polyurethane
which is passed through the nostril via the naso-pharynx into the oesophagus, then stomach.
An 8fg NGT needs to be in situ to place a NRL.
6. DUTIES AND RESPONSIBILITIES
Doctors: It is a medical decision to commence enteral feeding.
Healthcare professionals: It is the responsibility of those caring for the patient to assess
whether they have capacity to consent for this procedure. If the patient is deemed to lack
capacity then a best interests decision should be made.
Registered Nurse: It is the nurses’ responsibility to care for the NGT and NRL as per Trust
Policy/Guideline and assist the CNNS/CNSC in NRL placement.
Guideline for Insertion of NGT Retaining Loop (Nasal Loop / Bridle). Issue 2.15.02.2010 Page 3 of 9
(Review date February 2010) 14/01/2011

4. CNNS/CNSC: It is the CNNS/CNSC responsibility to assess the patient for NRL insertion and
maintain competency in inserting the NRL. All patients with a NRL in situ will be reviewed
weekly by the CNNS.
7. PROCESS
Equipment:-
Gloves/Apron
Nasal Retaining Loop
8fg NGT (if not already in situ)
Mouthcare swabs
Tissues
Scissors
Clinical Practice Guideline
Lubricating Jelly
pH indicator strips
enteral syringe
1. Following a referral the CNNS/CNCS will assess the patient for appropriateness for nasal loop
insertion.(Appendix 2)
2. If the patient has capacity the procedure should be explained to gain consent. If the patient is
deemed to lack capacity then a best interests decision should be made and documented in the
medical notes.
3. The patient should be positioned appropriately according to assessment, to enable ease of
placement.
4. Wash hands and apply gloves and apron in preparation for procedure.
Open and prepare equipment (as above).
5. Check nose for any signs of obstruction and that both the nose/mouth are clean as this may
impede insertion.
6. Lubricate rigid blue probe and insert into the nostril following the anatomy of the nose. If NGT in
situ insert rigid blue probe into the NGT nostril. Advance up to the 2nd groove on the probe and
maintain probe position.
If blue probe will not advance try the other nostril (as patient may have deviated nasal septum or
obstruction in that nostril)
See Appendix 1 – Picture 1.
7. When rigid blue probe is in situ-insert the flexible white probe (with tape) into the opposite nostril
and withdraw the guidewire 1-2 cms.
This allows flexibility of the white probe and easier connection with the magnet of the rigid blue
probe. Some manipulation of the flexible white probe may be required until the magnets from both
the rigid blue probe and the flexible white probe unite within the nasopharynx.
OR
Fully insert the flexible white probe and completely remove the guidewire, very gently withdraw the
rigid blue probe until taped white probe and magnets unite.
If the magnets have joined then the flexible white probe will be able to be pulled through by the
rigid blue probe. (May also hear a click or feel the magnets joining)
(See Appendix 1 - Picture 3)
8. When confirmed that the magnets are joined- remove guidewire from flexible white probe (if still
in situ) prior to pulling through nostril.
Guideline for Insertion of NGT Retaining Loop (Nasal Loop / Bridle). Issue 2.15.02.2010 Page 4 of 9
(Review date February 2010) 14/01/2011

5. 9. Slowly withdraw the rigid blue probe from one nostril- pulling the flexible white probe with
attached tape up from the other nostril and over the nasal septum. Pull all the way out until only
the tape is visible protruding from both nostrils.
See Appendix 1 - Picture 4.
10. Using scissors cut the flexible white probe from the tape leaving only the tape in the nose.
Insert NGT if not already in situ. The assistant is responsible for ensuring the nasal retaining loop
remains insitu.
11. If inserting NGT at time of nasal retaining loop placement-check NGT position as per Trust
Policy prior to securing the clamp from the nasal retaining loop to the NGT.
Once confirmed to be in correct position –knot tapes securely under the nose, and place NGT in
the groove in the clamp near to the nose.
12. Put one of the tapes in the clamp with the NGT and fold the two halves of the clamp together
and press firmly to secure the NGT in the clamp.
13. After the clamp has been closed – verify that it will not slip or re-open. Knot the tapes together
under the clamp and trim excess tape. See Appendix 1 – Picture 6.
14. Document procedure with outcome in medical notes leaving clear instructions re ongoing
management for nursing staff. (Appendix 3)
15. The ward cost code will be obtained so that the cost of equipment used can be recharged to
the clinical area.
8. TRAINING REQUIREMENTS
The CNNS and CNSC are responsible for training new in post nurses within the Clinical
Nutrition Nurse Specialist team and the Consultant Nurse Stroke Care Team respectively.
The CNNS team are responsible for educating ward staff re care of a patient with a NRL insitu
9. REFERENCES AND ASSOCIATED DOCUMENTATION
Anderson M.R., O’Connor M. Mayer, P. et al (2004). The nasal loop provides an alternative to
percutaneous gastrostomy in high risk dysphagic stroke. Clinical Nutrition. 23(4)
Eisenberg P, Spies M, Metheny N., (1987). Characteristics of patients who remove their
nasal feeding tubes. Clinical Nurse Specialist.1(3):94-98.
Great Britain National Patient Safety Agency (2005). Patient Safety Alert 05. Reducing the
harm caused by misplaced nasogastric tubes. NPSA, London.
Meer, J.A. (1989). A new nasal bridle for securing naso enteral feeding tubes. Journal of
Parenteral and Enteral Nutrition. 13(3) p331-34.
Norton B. et al. (1996). A randomised prospective comparison of percutaneous endoscopic
gastrostomy and nasogastric tube feeding after acute dysphagic stroke. British Medical
Journal.; 312:13-16.
Pancorbo-Hidalgo, P.L., Fernandez, F.P., Rimirez-Perez, C. et al (2001). Complications
associated with enteral nutrition by nasogastric tube in an internal medicine unit. Journal of
Clinical Nursing. 104 p482-90.
Guideline for Insertion of NGT Retaining Loop (Nasal Loop / Bridle). Issue 2.15.02.2010 Page 5 of 9
(Review date February 2010) 14/01/2011

6. Popovich, M.J. Lockrem, J.D., Zivot, J.B. (1996). Nasal bridle revisited: an improvement in
the technique to prevent unintentional removal of small bore nasoenteraic feeding tubes.
Critical Care Medicine. 24(3) p429-31.
Royal College of Nursing (2004). Restraint Revisited – rights, risks and responsibility RCN
London.
The FOOD Trial Collaboration (2005). Effect of timing and method of Enteral tube feeding for
dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. The Lancet.
365:764-72.
Williams J. (2005) Using an alternative fixing device for naso-gastric tubes. Nursing Times.
101(34):26-27.
Acknowledgements
Derby Hospitals NHS Foundation Trust (2005). Proposal for the change in practice relating to
the securing of naso-gastric tubes utilising nasal bridles within a specified group of adult
patients.
Winchester and Eastleigh Healthcare NHS Trust (2006). Nasal Tube Retaining System
(nasal loop): guidelines for use
The AMT Bridle. Nasal tube retaining system. Product information leaflet.
10. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS
Patients requiring assessment for NRL are referred to the CNNS team.
Appropriate consent is obtained prior to NRL insertion.
Weekly review of all patients with NRL insitu by CNNS team
NRL care guideline is adhered to by ward staff
CNNS team are responsible for monitoring compliance with this guideline.
Guideline for Insertion of NGT Retaining Loop (Nasal Loop / Bridle). Issue 2.15.02.2010 Page 6 of 9
(Review date February 2010) 14/01/2011

7. APPENDIX 1: PICTURES
Picture 1
Picture 2 Picture 3 Picture 4
Picture 5 Picture 6 Picture 7
Guideline for Insertion of NGT Retaining Loop (Nasal Loop / Bridle). Issue 2.15.02.2010 Page 7 of 9
(Review date February 2010) 14/01/2011

8. APPENDIX 2: INDICATIONS/CONTRAINDICATIONS FOR INSERTION OF NASAL RETAINING
LOOP
INDICATIONS:
Persistent removal of NGT in patient who requires enteral feeding.
CONTRAINDICATIONS:
Abnormal clotting e.g raised INR, low platelets.
Excessive agitation
# base of skull +/- facial trauma
Grossly deviated nasal septum
Mechanical obstruction-i.e nasopharyngeal airway in situ
CONSIDERATIONS;
Nasal polyps/deformity/anatomically challenging.
History of epistaxis
Ethnic variations
Ethical/cultural issues
Mental capacity act
Use of Mittens
Guideline for Insertion of NGT Retaining Loop (Nasal Loop / Bridle). Issue 2.15.02.2010 Page 8 of 9
(Review date February 2010) 14/01/2011

9. APPENDIX 3: CARE OF PATIENT WITH NASAL RETAINING LOOP.
Patient Name: Date NG & NRL Inserted:
DAILY:
• Check the nasal loop tapes and clip are secure.
• Ensure the tapes are not over-tight.
• Check that the clip is not causing any pressure to under-lying skin.
• Inspect the skin around the nostrils for any signs of soreness/pressure necrosis.
• Clean around nostrils to prevent build-up of any crusting and reduce the risk of
skin becoming sore.
• Apply skin barrier as required.
Refer to the Nutrition Nurses for advice if you have any concerns. The Nutrition
Nurses will review patient on a weekly basis otherwise.
NASAL RETAINING LOOP REMOVAL.
If the patient becomes very agitated and is pulling aggressively at the NG tube you may have
to remove the NRL to prevent damage to the nasal septum. Please contact the Nutrition
Nurses for assessment during normal working hours.
Out of hours ward staff can remove the NRL if it becomes absolutely necessary, but please
consider:
• Other methods of maintaining the NRL e.g. mittens.
• How will the patient receive nutrition if the NRL and NG are removed?
How To Remove NRL:
With scissors cut the white
tape here. Pull the NGT (with
clamp and tape attached)
from the opposite nostril until
the whole tube is removed.
Guideline for Insertion of NGT Retaining Loop (Nasal Loop / Bridle). Issue 2.15.02.2010 Page 9 of 9
(Review date February 2010) 14/01/2011