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 [126], 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.
   The patient is often less frightened if they feel that they have some control over the procedure. E
3. 3.Show
   Assist the patient to sit in a semi‐upright position in the bed or chair. Support the patient's head with pillows. Note: the head should not be tilted backwards or forwards (Rollins [156]).
   To allow for easy passage of the tube. This position enables easy swallowing and ensures that the epiglottis is not obstructing the oesophagus (NCCAC [108], C).
4. 4.Show
   Decontaminate hands and apply personal protective equipment.
   To reduce the risk of cross‐contamination (NHS England and NHSI [115], C).
5. 5.Show
   Select the appropriate distance mark on the tube by measuring performing a NEX measurement: 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 (Action figure 8.27). Mark this position on the tube with a permanent pen or a piece of tape.
   To ensure that the appropriate length of tube is passed into the stomach (NHSI [116], C).

Procedure

1. 6.Show
   Wash hands with soap and water or an alcohol‐based handrub, and assemble the equipment required.
   Hands must be cleansed before and after patient contact to minimize cross‐infection (NHS England and NHSI [115], C).
2. 7.Show
   Follow manufacturer's instructions to activate the lubricant on the tip of the tube, for example dip the end in tap water or lubricate the proximal end of the tube with lubricating jelly.
   To lubricate the tube, assisting its passage through the nasopharynx. E
3. 8.Show
   Check that the nostrils are patent by asking the patient to sniff with one nostril closed. Repeat with the other nostril.
   To identify any obstructions liable to prevent intubation. E
4. 9.Show
   Insert the rounded end of the tube into the clearer nostril and slide it backwards and inwards along the floor of the nose to the nasopharynx. If any obstruction is felt, withdraw the tube and try again in a slightly different direction or use the other nostril.
   To facilitate the passage of the tube by following the natural anatomy of the nose. E
5. 10.Show
   As the tube passes down into the nasopharynx, unless swallowing is contraindicated, ask the patient to start swallowing and sipping water. If the patient is unable to drink safely but has capacity, ask them to perform a dry swallow.
   To focus the patient's attention on something other than the tube. A swallowing action closes the glottis and the cricopharyngeal sphincter opens, enabling the tube to pass into the oesophagus (Lamont et al. [78], E; NNNG [128], C).
6. 11.Show
   Advance the tube through the pharynx as the patient swallows until the predetermined mark has been reached (NEX measurement). If the patient shows signs of distress, for example gasping or cyanosis, remove the tube immediately. Do not flush any fluid down the nasogastric tube until the position has been checked.
   The tube may have accidentally been passed down the trachea instead of the pharynx. Distress may indicate that the tube is in the bronchus. However, absence of distress is not a reliable indicator of a correctly placed tube. (NHSI [116], C). There is a risk of introducing fluid into the lungs if the tube is incorrectly positioned (NHSI [116], C).
7. 12.Show
   Secure the tube to the nose with either adherent dressing tape or an adhesive nasogastric stabilization/securing device. Alternatively, hypoallergenic tape can be applied to the cheek to secure the nasogastric tube. Ensure the nasogastric tube is not putting pressure on the nares.
   To hold the tube in place. To ensure patient comfort. E

   Prolonged pressure from the tube to the nasal tissues could cause medical‐device‐related pressure damage. E

Post‐procedure

1. 13.Show
   Measure the external (visible) part of the tube from the tip of the nose and record this and the NEX measurement in the care plan. Mark the tube at the exit site (nares) with a permanent marker pen or piece of tape.
   To provide a record to assist in detecting movement of the tube (Metheny and Titler [102], E; NHSI [116], C).

   It is good practice to measure the external length in the case the markings become faded. E
2. 14.Show
   Check the position of the tube to confirm that it is in the stomach by using the following methods. Note: placement devices (e.g. nasoendoscope or electromagnetic technology) do not replace the following checks (NHS England [112]).
   No fluids must be given via the tube until the correct position of the tube has been confirmed (NHSI [116], C).

   To confirm that the tube is in the correct position (NHS England [112], C).

   Note: the following methods must not be used to test the position of a nasogastric feeding tube: auscultation (introducing air into the nasogastric tube and checking for a bubbling sound via a stethoscope, also known as the ‘whoosh test’), use of litmus paper or absence of respiratory distress.
3. 15.Show
   First‐line test method: pH paper: aspirate 0.5–1 mL of stomach contents and test its pH on indicator strips (NHSI [116]) (see Box 8.6 for methods of aspiration). When aspirating fluid for pH testing, wait at least 1 hour after a feed or medication has been administered (either orally or via the tube). Before aspirating, flush the tube with 20 mL of air to clear other substances. A pH level of between 1 and 5.5 is unlikely to be pulmonary aspirates and it is considered appropriate to proceed to feed through the tube (NHSI [116]). Regular proton pump inhibitors or altered anatomy (e.g. gastric sleeve) may affect readings of aspirates. Risk management should be taken in these cases to ensure safe feeding. See Problem‐solving table 8.14.
   pH indicator strips should have gradations of 0.5 or paper with a range of 0–6 or 1–11 to distinguish between gastric acid and bronchial secretions. They must be CE marked and intended to check gastric aspirate (NHSI [116], C).

   To prove an accurate test result because the feed or medication may raise the pH of the stomach (NHSI [116], C).
4. 16.Show
   If a pH of 6 or above is obtained or there is doubt over a result in the range of pH 5–6 then feeding must not commence until a second competent person has checked the reading or retested the aspirate. The nasogastric tube may need to be repositioned or checked with an X‐ray.
   There is less certainty over the correct placement of the tube if the pH is above 6 (NHSI [116], C).
5. 17.Show
   Second‐line test method: X‐ray confirmation: take an X‐ray of the chest and upper abdomen. The X‐ray request form should clearly state that the purpose of the X‐ray is to establish the position of the nasogastric tube for the purpose of feeding (NHSI [116]).
   X‐ray of radio‐opaque tubes is the most accurate way of confirming position and is the second‐line method of choice in patients for whom it is not possible to confirm correct placement with gastric aspirate and pH indicator strips (NHSI [116], C). Clearly stating the purpose of the X‐ray will ensure the correct image is obtained by the radiographer. E
6. 18.Show
   X‐rays must only be interpreted and the position confirmed by someone assessed as competent to do so. When the position is confirmed, the person interpreting the X‐ray must document the tip's position in the patient's notes in an entry that is signed with the date and time.
   To record the position and document that it is safe to feed through the nasogastric tube (NHSI [116], C; NMC [126], C).
7. 19.Show
   Once placement of the nasogastric tube is confirmed, the guidewire/stylet can be removed following the manufacturer's guidelines; this can include the need to activate the internal lubricant of the tube immediately before removal.
   To facilitate easy removal of the guidewire/stylet (NHS England [112], C).
8. 20.Show
   Remove and dispose of any equipment.
   To reduce the risk of cross‐infection. E
9. 21.Show
   Record the procedure in the patient's notes.
   To maintain accurate records (NMC [126], C).