Verify correct placement of the nasogastric tube after the initial insertion, before beginning a feeding or instilling medications or liquids, and at regular intervals during continuous feedings (Metheny et al., 2019). This decreases the risk that the tip of the tube is situated in the stomach or intestine, preventing inadvertent administration of substances into the wrong place. A misplaced feeding tube in the lungs or pulmonary tissue places the patient at risk for aspiration, pneumonia, and even death (Lamont et al., 2011, as cited in Anderson, 2018a). Radiographic examination, measurement of tube length and measurement of tube marking, measurement of aspirate pH, and monitoring of carbon dioxide have been suggested to confirm feeding tube placement (Anderson, 2018a; Irving et al., 2018; Metheny et al., 2019). The use of two or more of these techniques in conjunction with each other increases the likelihood of correct tube placement (AACN, 2020; Anderson, 2019; Anderson, 2018a; Dias et al., 2019; Rahimi et al., 2015). An old technique of auscultation of air injected into a feeding tube has been proved unreliable and is not suggested for use (AACN, 2020; Anderson, 2018a; Boeykens et al., 2014; Boullata et al., 2017; Irving et al., 2018; Metheny et al., 2019). Recommendations for use of visual inspection of gastric aspirate are conflicting; this method should be used cautiously if part of policy and procedure guidelines and with consideration to the potential for inaccuracy (AACN, 2020; Dias et al., 2019; Mak & Tam, 2020; Metheny et al., 2019). When bedside methods to check placement suggest the tube has been displaced, a radiograph should be requested to determine the tube's location (AACN, 2020).

Allow a 1-hour interval after the patient has received medication or completed an intermittent feeding before testing pH of gastric fluid. Feedings should never be interrupted solely for the purpose of pH testing; however, if a feeding is interrupted as part of preparation for a test or procedure, testing of the pH may be desired. Fasting gastric pH is usually 5 or less, even in patients receiving gastric-acid inhibitors (AACN, 2020). The pH of feeding tube aspirates is likely to approach fasting levels if nutritional feedings have been off for at least 1 hour (AACN, 2020; Irving et al., 2018). When continuous feedings are in use, pH may become less helpful, because the nutritional formula may buffer the pH of GI secretions (Judd, 2020).

Use of pH test strips calibrated in units of 0.5 and approved for use with human secretions should be used to ensure accuracy in testing gastric pH (Anderson, 2018a; Metheny et al., 2019). There is considerable variation in the evidence guidelines related to the pH values to distinguish between gastric and respiratory aspirates (Metheny et al., 2019). The lower the pH, obviously, the stronger the evidence for placement in the stomach and not the respiratory tract (Metheny et al., 2019). Suggested limits for a safe range to identify gastric secretions vary and include a pH of ≤4.0, ≤5.0, or ≤5.5; suggested limit for respiratory secretions is a pH of ≥6.0 (AACN, 2020; Dias et al., 2019; Metheny et al., 2019). Nurses should be certain to follow facility policy, procedure, and practice guidelines. If placement is in doubt, a radiograph should be obtained to verify tube placement (AACN, 2020; Boullata et al., 2017).

Assessment

Assess for signs of respiratory distress; coughing, choking, dyspnea may occur when a tube is inadvertently positioned in the airway (AACN, 2020). Inspect the abdomen for distention and firmness; auscultate for bowel sounds or peristalsis and palpate the abdomen for distention and tenderness. If the abdomen is distended, consider measuring the abdominal girth at the umbilicus to establish a baseline. Assess the time when the patient last received medication or tube feeding.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

• Risk for Impaired Nutritional Status
• Injury risk
• Aspiration risk

Outcome Identification and Planning

The expected outcomes to achieve when confirming placement of an NG tube are that the tube is located in the patient's stomach without any complications, and the patient does not exhibit signs and symptoms of aspiration.

Implementation

Action	Rationale
1. Gather equipment.	Assembling equipment provides for an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Explain the procedure to the patient, including the rationale for confirming tube placement. Answer any questions as needed.	Explanation facilitates patient engagement.
5. Assemble equipment on the overbed table or other surface within reach.	Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
6. Close the patient's bedside curtain or door. Raise the bed to a comfortable working height (VHACEOSH, 2016). Perform respiratory and abdominal assessments as described above. Drape the chest/work area with a bath towel or disposable pad.	Closing curtains or the door provides for patient privacy. Having the bed at the proper height prevents back and muscle strain. Assessment is vital to detect changes in the patient's condition before initiating the intervention. The protective drape prevents accidental soiling of bed linens and patient clothing with stomach contents.
7. Confirm placement of the nasogastric tube in the patient's stomach using at least two methods. The first method utilized should be measurement of the exposed length of tube.	With the exception of radiographic examination, which is usually done immediately after insertion to verify initial tube placement, the use of two or more of these techniques in conjunction with each other increases the likelihood of correct tube placement (AACN, 2020; Anderson, 2019; Anderson, 2018a; Dias et al., 2019; Rahimi et al., 2015). Any change in the length of the exposed tube may indicate dislodgement (AACN, 2020; Boullata et al., 2017). If a significant change in the external length is observed, use other bedside tests to help determine if the tube has become dislocated (Boullata et al., 2017).
8. Put on gloves. Verify the position of the marking on the tube at the nostril. Measure length of the exposed tube and compare with the documented length (Figure 1).	Gloves prevent contact with blood and body fluids and transfer of microorganisms. The tube should be marked with an indelible marker at the nostril or the centimeter marking on the tube noted at the time it was placed (AACN, 2020; Irving et al., 2018; Judd, 2020). This marking should be assessed at regular intervals and each time the tube is used (AACN, 2020). Tube length should be checked and compared with this initial measurement, in conjunction with pH measurement and visual assessment of aspirate. Any change in the length of the exposed tube may indicate dislodgement (AACN, 2020; Boullata et al., 2017).
9. Verify how much time has elapsed since the patient has received medication or completed an intermittent feeding. Attach a syringe to the end of the tube and aspirate a small amount (5 to 10 mL) of gastric secretions (Figure 2). If unable to obtain a specimen, reposition the patient and flush the tube with an air bolus, then apply negative pressure to the plunger (AACN, 2020). It may be necessary to retry several times. Slowly apply negative pressure to withdraw fluid.	The pH of feeding tube aspirates is likely to approach fasting levels if nutritional feedings have been off for at least 1 hour (AACN, 2020; Irving et al., 2018). However, when continuous feedings are in use, pH may become less helpful, because the nutritional formula may buffer the pH of GI secretions (Judd, 2020). The tube is in the stomach if its contents can be aspirated: the pH of the aspirate can then be tested to determine gastric placement. Difficulty in aspiration may be due to a blocked tube or the tip of the tube not being positioned in fluid. Injecting an air bolus will help remove the blockage, and repositioning the patient will help place the tip of the tube in the fluid. This action may be necessary several times in order to obtain aspirate.
10. Measure the pH of aspirated fluid using pH test strips calibrated in units of 0.5 and approved for use with human secretions (Figure 3). Place a drop of gastric secretions onto the pH test strip or place a small amount of secretions in a plastic cup and dip the pH test strip into it. Within 30 seconds, compare the color on the test strip with the chart supplied by the manufacturer.	The pH of gastric contents is acidic (;5.5). Suggested limits for a safe range are (AACN, 2020; Anderson, 2018a; Dias et al., 2019; Metheny et al., 2019): Stomach: ≤4.0, ≤5.0, or ≤5.5 (depending on evidence source) Intestines: ≥7.0 Respiratory tract: ≥6.0 This method will not effectively differentiate between intestinal fluid and pleural fluid.
11. Use capnography if available. Refer to the General Considerations below.	A carbon dioxide detector is helpful in detecting when a feeding tube is in the tracheobronchial tree but is not sufficiently sensitive and specific to preclude the need for a confirming radiograph before initial use of a feeding tube (AACN, 2020).
12. If it is not possible to aspirate contents, assessments to check placement are inconclusive, the exposed tube length has changed, or there are any other indications that the tube may not be in place, check placement by radiograph (x-ray) of the placement of the tube based on facility policy.	X-ray is considered the most reliable method for identifying the position of the NG tube (AACN, 2020; Boullata et al., 2017).
13. Flush the tube with 30 to 50 mL of water for irrigation. Disconnect the syringe from the tubing and cap the end of the tubing.	Flushing the tube prevents occlusion (Bischoff et al., 2020; Boullata et al., 2017; Drummond Hayes, 2018). Capping the tube deters the entry of microorganisms and prevents leakage onto the bed linens.
14. Clamp the tube and remove the syringe. Cap the tube, reattach it to the feeding delivery set, or attach the tube to suction, based on the circumstances.	Capping or reattachment to the feeding delivery set or reattachment to suction allows for appropriate treatment for individual patients.
15. Remove equipment and return the patient to a position of comfort. Remove gloves. Raise the side rail and lower the bed.	This promotes patient comfort and safety. Removing gloves properly reduces the risk for infection transmission and contamination of other items.
16. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.

Evaluation

The expected outcomes have been met when the tube has been determined to be located in the patient's stomach without complications, and the patient has not exhibited signs and symptoms of aspiration.