Nasogastric Tube Bolus Feeding

<< DIGESTIVE


  • Note that this information does not replace clinical judgment. If there is any concern that tube is not in the stomach, do not feed or give medications and contact provider
  • The use of the auscultatory method to verify NG tube placement has long been proven unreliable and should not be used!
  • The most significant risk with tube feedings is aspiration of feeding into the lungs, be sure the student is positioned properly

Considerations:

  • Be sure to take steps to ensure patient privacy when performing procedure
  • The most significant risk with tube feedings is aspiration of feeding into the lungs, be sure the student is positioned properly with head elevated at least 30 degrees
  • The use of the auscultatory method to verify NG tube placement has long been proven unreliable and should not be used!
  • Orders from the healthcare provider should indicate how placement should be verified prior to feeding or medication administration
    • If there is no order, follow up with healthcare provider prior to using NG tube in the school setting
    • pH monitoring, visual characteristics of gastric aspirate and observing and documenting proper location of external tube markings and comparing to tube length measurements obtained after initial placement of the NG tube
    • Verification should be used to verify placement prior to using NG tube for feeding or medication administration
    • Because the pH level of gastric aspirate is often elevated by either medication or enteral feeding formulas, pH testing is not always a reliable indicator of gastric placement and other methods to verify placement should be used
    • Visual characteristics of feeding tube aspirate can be helpful in distinguishing between gastric and intestinal content but is of little value in differentiating between gastrointestinal and respiratory placement
  • Current practice dictates that at the time of radiographic confirmation of tube site location, the tube should be marked with indelible ink or adhesive tape where it exits the nares. The measurement from marking/nare to end of tube should be documented at insertion and with each subsequent use of the NG tube
    • On subsequent feedings, if the nurse notes that more of the tube is exposed, the position of the tip should be questioned
    • This method should never be the sole means of determining tube placement, because tubes that appear to be securely taped can still migrate
    • Migration is more likely with the commonly used small-bore tubes
  • Strategies to Obtain Aspirate:
    • Use a larger-sized syringe (to decrease the pressure created by the plunger)
    • Reposition the patient (to move the NG tube away from the stomach wall)
    • Instill a small amount of air (to move the NG tube away from the stomach wall)
    • If instillation of air is unsuccessful, the NG tube may be kinked or dislodged, RN should contact parent/guardian and healthcare provider

Supplies:

  • pH indicator strips with 0.5 gradations or pH paper with a range of 0 to 6 or 1 to 11, if ordered
  • 60 ml catheter-tip feeding syringe
  • Adapter with tubing and clamp
  • Graduated measuring cup
  • Prescribed diet at room temperature
  • Tap water, if ordered
  • Towel or wash cloth
  • Non-sterile gloves
  • Student’s Individualized Health Plan (IHP) and/or healthcare provider’s medical order
  • Cap and clamp for tubing

procedure download skill competency

  1. Review student’s medical order including:
    • the type of formula
    • amount
    • infusion type and rate
    • frequency and timing of administration
    • residual volume checks
    • amount of water used to flush the tube
  2. Explain the procedure to the student at his/her level of understanding
  3. Wash hands
  4. Gather equipment and place on clean surface
  5. Position child either sitting or supine with head up at least 30 degrees
    • The most significant risk with tube feedings is aspiration of feeding into the lungs, be sure the student is positioned properly
  6. Inspect nares for discharge or irritation, or skin breakdown
    • Clean any residue or discharge from nares or tubes using a cotton-tipped applicator moistened with water
    • Reposition tape/secure to minimize pressure on nares from the tube, being cautious to not dislodge tube
  7. Check for proper NG placement:
    • Observe and document proper location of external tube markings and compare to tube length measurements obtained after initial placement of the NG tube
    • Visualize gastric contents
      • Remove NG cap or plug from NG tubing
      • Connect 60 ml syringe to NG tubing
      • Aspirate gastric contents
      • Assess color and characteristics of gastric content
        • Gastric aspirates are described as being grassy green or colorless, often with sediment.
        • Intestinal aspirates are often yellow or bile stained and either clear or cloudy.
        • Pleural aspirates are described as watery and straw colored, while tracheobronchial fluid is off-white or tan and often mixed with mucus
      • If residual amount checks are ordered continue to gently draw back on the plunger to remove any liquid or medication that may be left in the stomach
      • Note the amount withdrawn from tube feeding
      • Return residuals to stomach (if ordered), keeping 1-5 ml of gastric content in the syringe to complete pH test
    • Check pH of gastric contents
      • NOTE:  Be sure to wait at least one hour after administering feedings or medications before assessing pH
      • Pinch or clamp NG tubing
      • Disconnect syringe
      • Connect cap or plug to NG tubing
      • Saturate pH paper with presumed gastric contents
      • Follow pH strip/paper manufacture instructions to interpret results
        • If pH level is ≤5, continue with NG feeding
        • For pH level >5 (or per healthcare provider’s order) contact parent/guardian and healthcare provider, DO NOT administer medication or feeding

To continue with NG tube feeding:

  1. Remove cap/plug
  2. Attach syringe without plunger to NG tube
  3. Pour 30-40 mls of  feeding into syringe
  4. Open clamp on NG tubing, allows feeding to run in slowly (the higher the syringe is held, the faster the feeding will flow)
  5. Add more formula when liquid is at 5 mls mark
  6. Continue to add until feeding is completed over prescribed time (lowers syringe if flow is too fast)
  7. Make feeding like mealtime:
    • offer and/or provide oral care to older students
    • provide feeding while child is around other children
  8. After feeding is complete flush NG tube with prescribed amount of water
  9. Pinch or clamp NG tubing
  10. Disconnect syringe
  11. Clamp and/or cap NG tube
  12. Make sure NG tube is secured to face and appropriate secured to clothing to prevent dislodgement
  13. Keep the child in feeding position for at least 30 minutes after completing feeding
  14. Wash syringe with soap and warm water and puts in home container
    • Catheter tip syringe can be used repeated times for up to 24 hours
  15. Document assessment, steps taken to verify tube placement, feeding, other interventions and outcomes in student’s healthcare record
  16. Follow up, as needed, with parents/guardian and healthcare provider

References:

Bankhead, R., Boullata, J., Brantley, S., Corkins, M., Guenter, P., Krenitsky, J., Lyman, B., Metheny, N.A., Mueller, C., Robbins, S., Wessel, J.  (2009).  Monitoring enteral nutrition administration. In: A.S.P.E.N. enteral nutrition practice recommendations.   Journal of Parenteral and  Enteral Nutrition, 33(2), 162-6.

Bowden, V. R., & Greenberg, C. S. (2012). Pediatric nursing procedures (Third Edition). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Cincinnati Children’s Hospital Medical Center. (2011).  Best evidence statement (BESt). Confirmation of nasogastric/orogastric tube (NGT/OGT) placement. Available at: http://guideline.gov/content.aspx?id=35117&search=ng+tube+placement

Cirgin Ellett, M.L., Croffie, J.M.B., Mervyn , C.D. & Perkins, S.M.  (2005). Gastric Tube Placement in Young Children.  Clinical Nursing Research, (14), 238-52.

Farrington, M., Lang, S., & Cullen, L.  (2009).  Nasogastric Tube Placement Verification In Pediatric and Neonatal Patients.  Pediatric Nursing, (35)1, 17-24.

National Patient Safety Agency.  (2005)  How to confirm the correct position of nasogastric feeding tubes in infants, children and adults.  Available at: http://www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=3399

Richardson, D.S., Branowicki, P.A., Zeidman-Rogers, L., Mahoney, J., MacPhee, M.  (2006).  An Evidence-Based Approach to Nasogastric Tube Management: Special Considerations.  Journal of Pediatric Nursing (21)5: 388-93.

Simons, S.R. & Abdallah, L.M.  (2012).  Bedside Assessment of Enteral Tube Placement: Aligning Practice with Evidence.  American Journal  Nursing,  (112)2, 40-46.

Stewart Huffman, S., Jarczyk, K.S., O’Brien, E., Pieper, P., & Bayne, A.  (2004).  Methods to Confirm Feeding Tube Placement: Application of Research in Practice.  Pediatric Nursing, (30), 1.


Acknowledgment of Reviewers:

Lori A. Duesing, MSN, RN, CPNP-AC
Advanced Practice Nurse
Department of Gastroenterology
Children’s Hospital of Wisconsin

Kathy Leack, MS, RN, CNS
Advanced Practice Nurse
Children’s Hospital of Wisconsin


Page last updated: April 7, 2015