- THIS PROCEDURE IS TYPICALLY PERFORMED BY A REGISTERED NURSE. The use of this procedure guideline assumes that the registered nurse has the nursing education and skills to perform this task.
- This procedure guideline does not replace nursing clinical judgment.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
- Some children may have a NG bridle to help with NG tube securement
- An NG bridle is a securement method used to discourage pulling on the nasogastric feeding tube
- 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
- Verification should be used to verify placement prior to using NG tube for feeding or medication administration
- It is important not to use the auscultatory method or examination of gastric fluid as the sole methods of NG tube tip verification, as these methods are unreliable.
- 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
- If there are no markings, check the cm measurement on the tube to compare to initial placement depth per health care provider’s orders.
- 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
- The ink mark on the tube that was placed to measure the length of the tube to be inserted should always be seen at the nose.
- That mark should be the same every time and should be documented in the student’s health care record every time a feeding or medication is administered.
- If the mark is not at the nose, the feeding or medication should not be administered. Contact the parents/guardians and health care provider, if necessary.
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 ENFit/enteral 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 healthcare provider’s medical order
- Parent/guardian authorization form
Procedure:
- 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
- Review student’s allergy status
- Ensure proper documentation of parent/guardian authorization to administer the feeding
- Explain the procedure to the student at their level of understanding
- Wash hands
- Put on gloves
- Gather equipment and place on clean surface
- Confirm that you have the correct formula
- Check expiration date on the formula
- Note the integrity of the formula container
- Position student 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
- 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
- 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
- Check pH of gastric contents:
NOTE: Be sure to wait at least one hour after administering feedings or medications before assessing pH because the pH level of gastric aspirate is often elevated by either medication or enteral feeding formulas - Attach an ENFit/enteral syringe of the appropriate size to the end of the NG tube
- Pull back gently on the plunger of the ENFit/enteral syringe
- Aspirate about 1 mL of fluid or amount ordered by the health care provider
- If you have rinsed water in the tube it can change the pH
- Withdraw 2-3 mL and discard this fluid prior to checking pH
- Saturate the pH paper with aspirated gastric secretions
- Follow pH strip/paper manufacture instructions to interpret results
- Gastric fluids should be at a level of 5.5 or less
- If pH level is ≤5.0, continue with NG feeding
- For pH level >5.0 (or per health care provider’s order) contact parent/guardian and health care provider, DO NOT administer medication or feeding
- Strategies to obtain aspirate:
- Use a larger-sized ENFit/enteral syringe (to decrease the pressure created by the plunger)
- Reposition the student on the left side for 10-15 minutes (to move the NG tube away from the stomach wall)
- Instill 3mL flush of air (to move the NG tube away from the stomach wall)
- Watch for breathing problems (i.e. coughing, choking, or difficulty breathing)
- If instillation of air is unsuccessful, the NG tube may be kinked or dislodged, the school nurse should contact parent/guardian and health care provider
- If unable to obtain aspirate to check pH level, do not use NG tube, contact parent/guardian and health care provider
To continue with NG tube feeding: - Shake the feeding container/can
- If feeding is in a can, clean the top of the feeding (formula) can with an alcohol wipe or soapy cloth
- Measure prescribed amount of enteral formula to be infused into clean graduated measuring cup or ENFit/enteral syringe
- Observe the appearance of the formula for any abnormalities
- Prepare the enteral formula per health care provider’s order
- Remove cap/plug from NG tube
- Attach 60-mL ENFit/enteral syringe, without plunger, to NG tube
- Pour feeding into ENFit/enteral syringe until about one-half full
- Elevate the ENFit/enteral syringe above the level of the stomach
- Open clamp on NG tubing
- Allow feeding to run in slowly, over prescribed amount of time
- The higher the ENFit/enteral syringe is held, the faster the feeding will flow
- Lower the ENFit/enteral syringe if the feeding is going too fast
- Refill the the ENFit/enteral syringe before it empties to prevent air from entering the stomach
- Continue to add until feeding is completed over prescribed time
- Monitor student during feeding for any signs of intolerance or complications
- Stop feeding immediately for gagging, vomiting, coughing, abdominal distension, change in skin color, or difficulty breathing, etc.
- Make feeding like mealtime: allow student to sit with other students during mealtime
- After feeding is complete flush NG tube with prescribed amount of water
- Pinch or clamp NG tubing
- Disconnect the ENFit/enteral syringe
- Clamp and/or cap NG tube
- Make sure NG tube is secured to face and appropriate secured to clothing to prevent dislodgement
- Keep the student in feeding (upright) position for at least 30 minutes after completing feeding
- Wash the ENFit/enteral syringe with soap and warm water and place in home container
- The ENFit/enteral syringe can be used repeated times for up to 24 hours
- Remove gloves
- Wash hands
- Document assessment, steps taken to verify tube placement, feeding, other interventions and outcomes in student’s health care record
- Follow up, as needed, with parents/guardian and health care provider
References:
American Society for Parenteral and Enteral Nutrition (ASPEN). (2018). Pediatric NG tube placement/verification video for professionals. . Retrieved June 22, 2023, from https://www.youtube.com/watch?v=k8aH0TyJYhc
Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., McGinnis, C., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii-Wolfe, C., Sullivan, J., Wood, A., Malone, A., Guenter, P., & ASPEN Safe Practices for Enteral Nutrition Therapy Task Force, American Society for Parenteral and Enteral Nutrition. (2017). ASPEN safe practices for enteral nutrition therapy [Formula: see text]. JPEN. Journal of parenteral and enteral nutrition, 41(1), 15–103. https://doi.org/10.1177/0148607116673053
Lynn, P. (2019). Administering a tube feeding. In Skill checklists for Taylor’s clinical nursing skills. A nursing process approach. (5th ed.). (pp. 253-255).
Lynn, P. (2019). Confirming placement of a nasogastric tube. In Skill checklists for Taylor’s clinical nursing skills. A nursing process approach. (5th ed.). (pp. 251-252).
Perry, A. G., Potter, P.A., Ostendorf, W., & Laplante, N. (2021). Skill 32.2 verifying placement of a feeding tube. In Clinical nursing skills and techniques. (10th ed.). (pp. 959-963). St. Louis, MO: Elsevier.
Perry, A. G., Potter, P.A., Ostendorf, W., & Laplante, N. (2021). Skill 32.4 administering enteral nutrition: Nasogastric, nasointestinal, gastrostomy, or jejunostomy tube. In Clinical nursing skills and techniques. (10th ed.). (pp. 965-972). St. Louis, MO: Elsevier.
Spratling, R., Chambers, R., Lawrence, P., & Faulkner, M.S. (2021). Best practices with use of feeding tubes for children at home. Pediatric Nursing, 47(1), 7-10.
Page last reviewed: February 18, 2025
Page last updated: February 18, 2025
The information and materials presented in this Website are intended for informational purposes only and are not designed to diagnose or treat a health problem or disease, or assist in diagnosis or treatment of the same. The information is not intended to substitute for, supplement or replace clinical judgment. If there are any concerns or questions about or relating to a nursing or medical procedure, contact the individual’s healthcare provider. The information provided on this Website is not intended to be a substitute for medical orders and persons without the proper education, training, supervision and/or licensure should not perform the procedures.