Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [178], C).
2. 2.Show
   Arrange a signal by which the patient can communicate if they want the nurse to stop, for example by raising their hand.
   To maintain communication and minimize discomfort and trauma to the patient during the procedure. E
3. 3.Show
   Assist the patient to sit in a semi‐upright position in the bed or chair. Place a pillow behind their head for support. Note: the head should be in a neutral position (not tilted backwards or forwards).
   To maintain a suitable position during the procedure to help with the correct insertion of the tube (Fan et al. [75], R).
4. 4.Show
   Wash hands with soap and water or an alcohol‐based handrub, and assemble the equipment required. Apply personal protective equipment.
   To ensure the procedure is as clean as possible (NHS England and NHSI [161], C).
5. 5.Show
   Select the appropriate distance mark on the tube by performing a NEX measurement. To do this, using the tube, measure the distance from the patient's nose to their earlobe plus the distance from the earlobe to the bottom of the xiphisternum (see Action figure 5 in Procedure guideline 8.10: Nasogastric intubation with tubes using an internal guidewire or stylet).
   To identify the approximate length of tube that needs to be inserted to ensure it is in the correct position. E

Procedure

1. 6.Show
   Check the nostrils are patent by asking the patient to sniff with one nostril closed. Repeat with the other nostril.
   To avoid any blockages or anatomical abnormalities. E
2. 7.Show
   Lubricate about 15–20 cm of the tube with a thin coat of lubricating jelly that has been placed on a gauze swab.
   To make insertion of the tube easier. E
3. 8.Show
   Ensure the receiver is placed beneath the end of the tube.
   To prevent spillage and reduce the risk of infection (Fraise and Bradley [81], E).
4. 9.Show
   Insert the proximal end of the tube into the clearer nostril and slide it backwards and inwards along the floor of the nose to the nasopharynx. If an obstruction is felt, withdraw the tube and try again in a slightly different direction or use the other nostril.
   To avoid unnecessary trauma to the nose and nasopharynx. E
5. 10.Show
   As the tube passes down into the nasopharynx, ask the patient to start swallowing. Offer sips of water (if they are able to take oral fluids).
   To help ensure that the tube passes easily into the oesophagus. E
6. 11.Show
   Advance the tube through the pharynx as the patient swallows until the predetermined mark (NEX measurement) has been reached. If the patient shows signs of distress, for example gasping or cyanosis, remove the tube immediately.
   Reaching the NEX measurement on the tube indicates that it should have advanced far enough down the oesophagus to be correctly positioned in the stomach. If there are signs of respiratory distress, this may indicate that the tube is incorrectly positioned in the bronchus. E
7. 12.Show
   Secure the tube to the nostril with adherent dressing tape or an adhesive nasogastric stabilization/securing device. An adhesive patch (if available) will secure the tube to the cheek.
   To ensure the tube remains in the correct position. E
8. 13.Show
   Use the syringe to gently aspirate any stomach contents and then attach the tube to a drainage bag.
   Aspiration and/or drainage of stomach contents or bile will indicate that the tube is in the correct position in the stomach. E
9. 14.Show
   Assist the patient to find a comfortable position.
   To ensure comfort following the procedure. E

Post‐procedure

1. 15.Show
   Use the pH below to check the position of the nasogastric drainage tube. To carry out the test, aspirate 0.5–1 mL of stomach contents and test its pH on indicator strips (NPSA [181]). Nothing should be instilled into the nasogastric tube until placement has been confirmed.
   To ensure correct placement into the stomach. E

   A pH level of between 1 and 5.5 reflects the acidity of the stomach, so aspirate with this level is unlikely to be pulmonary (Metheny and Meert [147], R; NPSA [181], C). If a pH of 6 or above is obtained, then a second person should retest the sample or a chest X‐ray should be ordered.
2. 16.Show
   Remove gloves and apron and dispose of all equipment safely. Wash hands using soap and water or an alcohol‐based handrub.
   For infection prevention and control (NHS England and NHSI [161], C).
3. 17.Show
   Record the procedure, NEX measurement, length of visible portion of the tube from tip of nose, and tip position in the patient's notes.
   To maintain accurate documentation (NMC [178], C).
4. 18.Show
   Assess the skin integrity of the nostril in which the tube is placed every 2–4 hours and carefully reposition as required.
   To maintain skin integrity and relieve pressure from the plastic tubing. E
5. 19.Show
   Reassess tube length and pH if there is any suspicion that the tube may have moved or migrated.
   To ensure the tube remains in the stomach. E