Gastrostomy & Enteral Feeding Tube Nursing

Comprehensive clinical reference for GCC nurses — NG tubes, PEG care, feed administration, complications and exam preparation.

Enteral Nutrition PEG / Gastrostomy Patient Safety DHA / DOH / SCFHS Prep

Enteral Feeding Overview

Indications for Enteral Nutrition

Enteral nutrition (EN) is indicated when a patient has a functional gastrointestinal tract but is unable to maintain adequate oral intake to meet nutritional requirements.

Clinical Conditions

  • Stroke with dysphagia (swallowing impairment)
  • Head and neck cancer (surgical/radiotherapy sequelae)
  • Motor neurone disease / ALS
  • Oropharyngeal or oesophageal surgery
  • GI surgery requiring gut rest or bypass
  • Critical illness / prolonged ventilation
  • Malnutrition with severe anorexia or dysphagia
  • Dementia with severe dysphagia (after MDT review)
  • Prematurity / failure to thrive in neonates

MUST Screening

All patients must undergo nutritional screening on admission using the Malnutrition Universal Screening Tool (MUST).

  • Score 0 = low risk (routine care)
  • Score 1 = medium risk (observe and repeat)
  • Score ≥2 = high risk → refer to dietitian
Dietitian referral is mandatory for all patients scoring ≥2 on MUST and for any patient commencing enteral feeding.
Enteral vs Parenteral Nutrition
FactorEnteral (EN)Parenteral (PN)
RouteGut — tube into GI tractCentral/peripheral IV
Gut integrityMaintains intestinal mucosa, reduces bacterial translocationGut atrophy may occur
Infection riskLowerHigher (line sepsis, CRBSI)
CostSignificantly cheaperExpensive (formulas + line care)
IndicationFunctional GI tractNon-functional GI tract, short bowel, fistula
Preferred?Yes — always first choiceOnly when EN not possible/tolerated
Clinical principle: "If the gut works, use it." Enteral feeding preserves gut-associated lymphoid tissue (GALT), supports immune function and reduces the systemic inflammatory response in critical illness.
Tube Types and Selection
Tube TypeDurationPositionKey Indications
Nasogastric (NG)Short-term <4 weeksStomachAcute illness, stroke recovery, short-term supplementation
Nasojejunal (NJ)Short-term <4 weeksJejunum (post-pyloric)Gastroparesis, acute pancreatitis, high aspiration risk
PEGLong-term >4 weeksStomachStroke (long-term), head/neck cancer, MND, neurological conditions
RIGLong-term >4 weeksStomachCannot tolerate endoscopy; severe head/neck obstruction
Surgical gastrostomyLong-termStomachWhen PEG/RIG not feasible; laparoscopic or open
Jejunostomy (PEJ)Long-termJejunumGastroparesis, gastric surgery, high aspiration risk long-term
Nutritional Requirements

Energy Requirements

25–30 kcal/kg/day (standard adult)
  • Hypocaloric feeding: 15–20 kcal/kg (critically ill, obese)
  • Hypermetabolic states (burns, sepsis): up to 35 kcal/kg/day
  • Indirect calorimetry is gold standard where available

Protein

1.0–1.5 g protein/kg/day
  • Critical illness / pressure injuries: 1.5–2.0 g/kg/day
  • Renal failure (non-dialysis): 0.6–0.8 g/kg/day (dietitian to advise)

Fluid Requirements

30–35 mL/kg/day
  • Adjust for fever (+200 mL per degree above 37°C), stoma losses, excessive sweating (GCC climate)
  • Flush water contributes to total fluid input — document on fluid balance chart

Micronutrients

  • Standard formulas contain RDA of vitamins/minerals per 1000–1500 mL
  • Monitor: phosphate, potassium, magnesium, zinc, selenium especially early
  • Vitamin D deficiency common in GCC population — supplement separately

NG Tube Insertion & Position Confirmation

CRITICAL PATIENT SAFETY ALERT — NPSA/2011/PSA002: Misplacement of NG tubes into the bronchial tree with subsequent feeding has caused patient deaths. NEVER commence feeding or give medication until tube position is confirmed by an accepted method. NEVER use the air auscultation (whoosh) test — it is unreliable and no longer acceptable practice.
NG Tube Sizes
TypeSizePurposeNotes
Fine bore6–8 FrFeeding / medicationMore comfortable; requires pH/CXR confirmation; do NOT use stylet after insertion
Wide bore12–16 FrGastric drainage, aspiration of stomach contents, medicationRyles tube; easier aspiration; less comfortable for long-term
Insertion Technique
  1. Explain the procedure, obtain verbal consent, verify patient identity, gather equipment (tube, pH paper/strips, tape, gloves, lubricant, 50 mL syringe, emesis basin).
  2. Position patient upright at minimum 45° (ideally sitting fully upright at 90°). Protect airway.
  3. Assess nostrils — ask patient which side is clearer; inspect for septal deviation or obstruction.
  4. Measure NEX distance: Nose → Earlobe → Xiphisternum. Mark or note length (typically 55–65 cm in adults).
  5. Lubricate distal 10 cm of tube with water-soluble lubricant (not petroleum jelly).
  6. Insert tube horizontally through nostril, aiming posteriorly (not upward) toward nasopharynx.
  7. When tube reaches oropharynx (~15 cm), ask patient to tilt chin to chest (flexion occludes trachea) and take sips of water while you advance the tube.
  8. Advance smoothly to marked NEX length. Stop immediately if: coughing/gagging, cyanosis, inability to speak, or respiratory distress.
  9. Temporarily secure tube, confirm position using accepted method before taping definitively.
  10. Document: date, time, NEX measurement, tube size/type, confirmation method, result, and your name.
Position Confirmation — Accepted Methods

pH Testing (First-Line / Gold Standard)

Aspirate gastric contents using a 50 mL syringe. Apply to CE-marked pH paper/strips (not litmus).

pH ≤5.5 = Gastric position confirmed. Safe to commence feeding/medication. Document pH value and date/time on feeding chart.
pH 5.6–6.0 = Borderline. Do NOT feed. Reposition patient, retry aspiration, or proceed to CXR.
pH >6.0 or unable to aspirate = CXR required. Do not feed until CXR reviewed and documented by a competent person.

Factors Affecting pH Result

  • Proton pump inhibitors (PPIs) and H2-blockers can raise gastric pH above 5.5 — document medication use, lower threshold for CXR
  • Recent antacid administration
  • Recent feeding (may raise pH slightly)
  • Continuous feeding (check during feed break)

Chest X-Ray Confirmation

Required when pH test cannot confirm gastric placement.

Correct CXR Appearance

  • Tube follows midline through oropharynx and oesophagus
  • Passes through the diaphragm
  • Tip visible below the diaphragm in the stomach
  • No looping in the oesophagus or trachea
Incorrect CXR findings — do NOT feed:
Tube tip in bronchus, pleural space, or coiled in oesophagus. Remove tube immediately and reassess.

Documentation of CXR

A competent healthcare professional must interpret the CXR. Document in the feeding chart: CXR date, time, who interpreted, and outcome before feeding commences.

PROHIBITED: Air Auscultation (Whoosh Test) — injecting air and listening with stethoscope is unreliable. A tube in the bronchus or oesophagus can produce similar sounds. This method has been directly implicated in patient deaths and is NOT an accepted confirmation method in any UK, DHA, DOH or SCFHS guideline.
Ongoing Checks & Complications

When to Re-confirm Position

  • Before each feed or medication administration
  • After vomiting or retching
  • After patient repositioning (especially rolling)
  • If tube length at nostril has changed
  • If patient appears distressed or coughing
  • After violent coughing

Complications of Misplacement

  • Bronchial placement: feeding into lung — pneumonia, pneumothorax, death
  • Oesophageal coiling: no gastric drainage, risk of aspiration
  • Intracranial placement: rare — severe facial trauma/skull base fracture (use oral route in this context)
  • Oesophageal perforation: rare — forceful insertion

Interactive NG Tube Position Checker

Step-by-step clinical decision support tool. Not a substitute for clinical judgement or local policy.

pH 4.0
Unable to aspirate — recommended actions:
  • Reposition patient: turn onto left side to bring tube tip into pool of gastric fluid
  • Ask patient to swallow water (if able) and retry
  • Advance tube 5–10 cm and retry aspiration
  • Wait 30 minutes if recently fed (feeding may buffer pH)
  • If still unable to aspirate → request CXR before feeding
CXR Required Before Feeding

Actions:
  • Do NOT commence feeding or give medication
  • Request urgent CXR — document reason as "NG tube position confirmation"
  • A competent healthcare professional must review the CXR
  • Confirm on CXR: tube tip below diaphragm, midline path, no bronchial position
  • Document CXR reference, interpreter, and outcome on feeding chart before proceeding

Escalation: If unable to confirm position, inform senior nurse/medical team. Consider tube replacement.

Reference: NPSA Patient Safety Alert NPSA/2011/PSA002 — Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants.

PEG & Gastrostomy Care

Types of Gastrostomy
TypeMethodKey FeatureReplacement Device
PEGEndoscopic — pull or push techniqueMost common; internal bumper holds tube; external fixator plateBalloon gastrostomy (Mic-Key, Corflo) or low-profile button
RIGRadiological — fluoroscopy-guidedFor patients unable to tolerate endoscopy or sedation; severe head/neck obstructionBalloon gastrostomy
SurgicalLaparoscopic or openWhen endoscopy/radiology not feasible; can be combined with other surgeryBalloon gastrostomy
Low-profile buttonReplacement only (after tract established)Flush with skin; cosmetically preferred; anti-reflux valveReplaced every 6–12 months
PEG Insertion — Nursing Responsibilities

Pre-procedure

  • Verify written informed consent (endoscopy team obtains)
  • Nil by mouth: minimum 6 hours food, 4 hours clear fluids
  • Confirm INR/clotting and platelet count within acceptable range
  • Hold anticoagulants as per endoscopy protocol
  • Antibiotic prophylaxis: cephalosporin (e.g. cefazolin 1–2 g IV) 30–60 min before procedure — reduces stoma site infection
  • Check for penicillin/cephalosporin allergy; alternative: co-amoxiclav or ciprofloxacin
  • Ensure IV access and resuscitation equipment available

Post-procedure (First 24–48 h)

  • Nil by mouth for 4 hours post-insertion (minimum)
  • Monitor vital signs: temperature (infection), BP, HR
  • Assess stoma site: redness, swelling, bleeding, haematoma
  • Check external fixator plate — should allow 5 mm movement (not tight)
  • Document tube length at skin level
  • Commence feeding after 4 hours if no complications, as per dietitian's plan
  • Monitor for peritonitis signs (severe abdominal pain, fever, rigidity)
Ongoing Stoma Care

Daily Stoma Care Routine

  1. Wash hands; non-sterile gloves for established stoma (>5 days).
  2. Clean around stoma with sterile saline or clean water (not hydrogen peroxide or alcohol — damage tissue).
  3. Dry thoroughly — moisture causes maceration and infection.
  4. Inspect for: redness, swelling, discharge (colour/odour), granulation tissue, signs of buried bumper.
  5. After first 5 days: rotate external fixator and tube 360° daily while sliding tube 2–3 cm in and out to prevent buried bumper syndrome.
  6. Ensure external bumper allows 5 mm movement — if tight, loosen to prevent pressure necrosis/buried bumper.
  7. Re-secure and document condition.

Balloon Gastrostomy Specific Care

  • Check balloon volume weekly — use distilled water (not saline, not air)
  • Typical balloon volume: 5–20 mL (check manufacturer spec for specific device)
  • If volume drops consistently: balloon may be leaking — arrange replacement
  • Do not overfill: excess pressure causes stoma widening, pain, granulation tissue
  • Never use a syringe larger than 10 mL to check balloon (risk of overfill)

Tube Displacement

Tube out <8 weeks post-insertion: EMERGENCY — stoma tract closes rapidly (within hours). Do NOT attempt reinsertion at ward level. Call endoscopy/surgical team immediately. Keep stoma site covered with gauze.
Tube out >8 weeks post-insertion: Stoma tract established — insert replacement tube of same size, confirm position before feeding (aspirate pH or brief fluoroscopy).
Buried Bumper Syndrome

The internal disc (bumper) migrates into the gastric wall due to excessive external fixator tension, causing the gastric mucosa to grow over the internal bumper.

Signs

  • Inability to rotate the tube
  • Resistance when pulling tube outward
  • Pain on tube manipulation
  • Gastric leak around tube
  • Inability to advance tube into stomach

Management

  • Do NOT force rotation or extraction
  • Refer to gastroenterology/endoscopy team
  • Endoscopic incision and release (first line)
  • Surgical removal if endoscopy fails
  • Prevention: Daily rotation and correct external fixator tension from day 5

Feed Administration

Enteral Feed Types
Formula TypeExamplesIndicationsGCC Relevance
Standard polymericEnsure, Fortisip, JevityMost patients with intact GI tract; 1–2 kcal/mLFirst-line choice for most patients
Renal formulaNepro, RenilonCKD — low potassium, low phosphate, restricted fluid volumeHigh CKD prevalence in GCC
Diabetic formulaGlucerna, Nutrison DiasonDiabetes — low carbohydrate, modified glucose responseHigh relevance: GCC has very high T2DM prevalence
Hepatic formulaHeparonHepatic encephalopathy — branched-chain amino acids, restricted aromatic AADietitian guidance required
Pulmonary formulaPulmocareRespiratory failure — high fat, low carbohydrate (reduces CO2 production)Ventilated patients
Elemental / semi-elementalPeptamen, Elemental 028Severe malabsorption, IBD, short bowel, pancreatitisPre-digested — absorbed in proximal small bowel
Administration Methods

Continuous Pump Feeding

  • Infused via enteral pump over 20–24 hours
  • Standard in hospital/ICU setting
  • Preferred for: critically ill, NJ/jejunostomy feeding, impaired gastric emptying
  • Pump rate set per dietitian's regimen
  • Feed bag and giving set must be changed every 24 hours
  • Maximum hang time for open feed system: 4 hours (closed system: 24 hours if per manufacturer)

Overnight Feeding

  • Typically 8–12 hours overnight
  • Allows mobility during the day
  • Common in home enteral nutrition (HEN)

Intermittent Bolus Feeding

  • Mimics normal meal pattern — more physiological
  • 4–6 bolus feeds per day (typically 200–400 mL per bolus)
  • Administer by gravity drip or slow syringe push over 20–30 minutes
  • Not suitable for NJ/jejunostomy (risk of dumping syndrome) — continuous only post-pyloric
  • Check gastric residual volume (GRV) before each bolus (if gastrostomy)

Nasojejunal Feeding — Special Considerations

  • Confirm position by pH >6 (intestinal pH) or fluoroscopy/endoscopy
  • Continuous feeding only — no boluses
  • Omit prokinetics (no gastric motility issue)
  • Cannot check gastric residual volumes
Tube Flushing Protocol
Adequate flushing is the single most important action to prevent tube blockage and ensure accurate drug delivery.
TimingVolumePurpose
Before each feed30 mL sterile/cooled boiled waterCheck patency; clear tube
After each feed30–50 mL waterClear feed residue; prevent blockage
Before each medication15–30 mL waterClear tube; prevent drug-nutrient interaction
Between each medication10–15 mL waterPrevent drug-drug incompatibility in tube
After each medication30 mL waterEnsure full drug delivery
Every 4 hours during continuous feed30 mL waterPrevent blockage; contributes to fluid balance
When feed is stopped30 mL waterClear feed before tube is capped

Document all flush volumes on the fluid balance chart. Use sterile water for immunocompromised, ICU, and neonatal patients.

Medication Administration via Feeding Tube

General Principles

  • Always use liquid formulations where available
  • Administer medications separately — flush between each drug
  • Crush only tablets that are safe to crush (confirm with pharmacist)
  • Dissolve crushed tablets in 10–15 mL of water before administration
  • Use oral/enteral syringes (NOT IV syringes) — colour-coded purple or pink
  • Never add medications directly to feed bag

Drugs That Must NEVER Be Crushed

NEVER crush the following formulations:
  • Sustained release: SR, XL, XR, LA, MR, CR, ER preparations
  • Enteric coated: EC, gastro-resistant preparations
  • Cytotoxic / chemotherapy agents (hazardous powder)
  • Antiretroviral medications
  • Sublingual preparations
  • Hormonal/immune-suppressive agents (variable)
Contact pharmacist if in doubt. Many drugs have alternative liquid or dispersible formulations.
Refeeding Syndrome

A potentially fatal metabolic complication occurring when feeding is introduced after a period of starvation or severely reduced intake (>5 days).

Pathophysiology

  • Starvation depletes intracellular phosphate, potassium, magnesium
  • Reintroduction of carbohydrate triggers insulin release
  • Insulin drives glucose, phosphate, K+, Mg into cells
  • Severe hypophosphataemia — most critical electrolyte shift
  • Cardiac arrhythmias, respiratory failure, seizures, death

Risk Factors (NICE 2006)

  • BMI <16 kg/m²
  • Unintentional weight loss >15% in 3–6 months
  • Little or no nutritional intake >10 days
  • Anorexia nervosa, alcoholism, oncology patients

NICE Monitoring Protocol

  • Measure phosphate, potassium, magnesium before feeding commences
  • Correct deficiencies before starting feed
  • Start at low rate: 10 kcal/kg/day, increase over 4–7 days
  • Check electrolytes daily for first 72 hours, then 3x/week
  • Thiamine 200–300 mg/day before and during first 10 days of feeding
Phosphate <0.6 mmol/L: Urgent oral/IV phosphate replacement. Reduce feed rate. Inform medical team immediately. This is a medical emergency.

Monitoring Schedule

  • Electrolytes: daily for 72h, then 3x/week
  • Blood glucose: every 4–6h initially
  • Fluid balance: strict daily
  • Cardiac monitoring if severe risk

Complications & Troubleshooting

Tube Blockage

Prevention

  • Follow flushing protocol strictly (see Tab 4)
  • Flush before and after each medication
  • Never crush medications directly into feed
  • Use liquid formulations where possible
  • Do not mix medications together

Management of Blocked Tube

  1. Use a 50 mL syringe — smaller syringes generate more pressure (risk of tube rupture with <10 mL syringe).
  2. Push-pull technique: gently aspirate and inject 10–20 mL warm water repeatedly. Do NOT use force.
  3. If warm water fails: try carbonated water (CO2 may help dislodge).
  4. Pancreatic enzyme solution (pancrelipase + sodium bicarbonate in water) — dwell for 30 min then flush.
  5. If all fail: tube replacement required.
Never insert wire stylet into an in-situ tube — risk of perforation, especially if tube is soft from prolonged use or positioned in bronchus.
Diarrhoea
CauseAssessmentManagement
Osmotic overloadRelated to feed rate increase or hyperosmolar formulaReduce feed rate; dilute formula; increase rate more gradually
Bacterial contaminationImproper hang time; poor hygieneMaximum open system hang time 4 hours; strict aseptic handling; replace giving set q24h
Clostridium difficileAntibiotic use, hospital-acquired; mucoid stool; feverStool culture urgently; isolate patient; contact precautions; oral vancomycin or fidaxomicin
Osmotic medicationsSorbitol in liquid medications (many liquid drugs contain sorbitol as excipient)Review medications with pharmacist; switch to sorbitol-free formulations
Low fibre formulaProlonged fibre-free enteral feedingSwitch to fibre-containing formula (e.g. Jevity)
Aspiration Risk

Aspiration of enteral feed into the lungs is a serious complication leading to aspiration pneumonia and respiratory failure.

Prevention Strategies

  • Maintain semi-recumbent position 30–45° during and for 1 hour after feeding
  • Check gastric residual volume (GRV) before each bolus feed and every 4 hours during continuous feed
  • GRV >200–250 mL: hold feed for 1 hour, recheck; consider prokinetics
  • GRV >500 mL: hold feed, review by medical team
  • Use prokinetics: metoclopramide 10 mg TDS, domperidone (review QT prolongation risk)
  • Consider post-pyloric feeding (NJ or jejunostomy) for high-risk patients

Signs of Aspiration

  • Sudden cough during or after feeding
  • Cyanosis or oxygen desaturation
  • Feed visible in oropharynx/ET tube
  • New or worsening chest X-ray infiltrates
  • Fever and purulent sputum (aspiration pneumonia)

Management

  • Stop feed immediately; suction airway
  • Oxygen; call senior/anaesthetist
  • CXR and ABG
  • Antibiotics if aspiration pneumonia develops
  • Review feeding route — consider post-pyloric
Stoma Complications

Skin Excoriation & Leakage

  • Causes: gastric leakage around tube, oversized stoma, high-volume gastric acid
  • Apply barrier cream (Cavilon, zinc oxide) to protect skin
  • Absorbent dressing around stoma (change when damp)
  • Check external fixator tension — too loose allows leakage
  • If balloon device: check balloon volume (may need replacing)
  • Proton pump inhibitors to reduce gastric acid volume

Peristomal Infection

  • Local signs: erythema >1 cm from stoma, warmth, swelling, purulent discharge, pain
  • Wound swab for culture
  • Topical antiseptic or systemic antibiotics per sensitivities
  • Systemic infection (fever, cellulitis spreading): IV antibiotics, surgical review

Overgranulation Tissue

  • Hypertrophic tissue around stoma — common complication
  • Appears as moist, red, friable tissue, bleeds easily
  • Treatment: silver nitrate cautery (applied by specialist nurse), topical corticosteroid cream, or Cavilon spray
  • Ensure tube is not too loose (allows movement = granulation trigger)

Tube Leakage

  • Check balloon volume (deflated balloon → leakage)
  • If stoma dilated (common after years): trial of larger device or specialist referral
  • Wound management team referral for complex cases
Home Enteral Nutrition (HEN)

Preparation for Discharge

  • Community dietitian referral — ongoing assessment
  • Patient and carer training: tube care, feeding administration, flushing, emergency procedures
  • Written care plan and emergency contact numbers provided
  • Supply chain arranged: feed, giving sets, syringes, pump on prescription
  • Home assessment: fridge storage for feed, clean workspace, safe pump location

Ongoing Community Support

  • Dietitian review: initially 1–2 monthly, then 3-monthly if stable
  • GP management: prescriptions, blood tests (electrolytes, nutritional markers)
  • HENS (Home Enteral Nutrition Service) or nutrition nurse specialist
  • Supplier contact for equipment faults

Holiday / Travel Planning

  • Letter from team for airport security (feed, pump, syringes)
  • Additional supply for travel days
  • Contact details for local hospital at destination
  • Fridge requirements for feed (check with supplier)

GCC Context & Exam Preparation

GCC-Specific Clinical Context

High-Prevalence Conditions Requiring Gastrostomy

  • Stroke: Leading cause of disability and dysphagia in GCC; high hypertension and diabetes increase stroke risk. NG then PEG is common care pathway.
  • Head & neck cancer: Prevalent; associated with tobacco use, betel nut chewing, and HPV. PEG often placed prophylactically before radiotherapy.
  • Motor neurone disease (ALS): PEG timing crucial — placed while respiratory function is adequate (FVC >50%).
  • Type 2 Diabetes: Extremely high GCC prevalence (~20% Saudi Arabia, UAE). Gastroparesis complication. Diabetic enteral formula selection important.

Islamic Considerations During Ramadan

Enteral Feeding and Fasting: The majority scholarly opinion (including the Islamic Fiqh Academy of the OIC) holds that nasogastric and gastrostomy feeding does NOT break the Sawm (fast), because feeding through a tube is not the normal route of eating for nourishment and carries a therapeutic/medical intent (darurah).

However, families and patients may hold differing personal religious views. Nurses should:

  • Discuss with patient/family sensitively, involve the hospital chaplain or Islamic scholar if needed
  • Document the discussion and decision in the medical record
  • Explore scheduling feeds outside fasting hours if clinically appropriate and patient/family prefer this approach
  • Ensure nutritional adequacy is maintained whatever schedule is agreed
Regulatory Context: DHA / DOH / SCFHS
Regulatory BodyJurisdictionRelevance to Enteral Nutrition
DHA (Dubai Health Authority)Dubai, UAENursing scope of practice includes NG tube insertion, gastrostomy care, and enteral feed management for licensed nurses
DOH (Department of Health)Abu Dhabi, UAENursing competency framework includes nutritional assessment and enteral feeding protocols
SCFHS (Saudi Commission for Health Specialties)Saudi ArabiaSaudi nursing licensing exam includes NG tube safety (NPSA guidance), PEG care, refeeding syndrome recognition, and medication administration via tube
NHRABahrainSimilar nursing scope; internationally-aligned guidelines
QCHPQatarNursing practice standards aligned with international best practice
Key exam themes: NG tube position confirmation safety (NPSA), refeeding syndrome signs and prevention, gastrostomy stoma care (buried bumper, rotation), medication administration rules (what cannot be crushed), and aspiration prevention.
MCQ Practice — 10 Questions

Click an answer to reveal whether it is correct. Review the explanation for learning.

1. A patient's NG tube aspirate has a pH of 6.2. What is the correct nursing action?
  • A. Commence feeding — pH is acceptable
  • B. Re-aspirate and use the whoosh test to confirm
  • C. Do not feed — request CXR to confirm tube position
  • D. Advance the tube 10 cm and re-aspirate
pH >6.0 does not confirm gastric position. CXR is required before feeding can be commenced. The whoosh test is never acceptable (NPSA guidance).
2. Which of the following best describes the rationale for enteral nutrition over parenteral nutrition?
  • A. Parenteral nutrition delivers more precise nutrient quantities
  • B. Enteral nutrition maintains gut integrity and reduces infection risk
  • C. Enteral nutrition is easier to titrate in critically ill patients
  • D. Parenteral nutrition is not suitable for GCC patients
Enteral feeding preserves intestinal mucosal integrity, maintains GALT (gut-associated lymphoid tissue), reduces bacterial translocation, and carries significantly lower infection risk and cost compared to TPN.
3. A PEG tube was inserted 3 weeks ago. The external fixator appears very tight and the nurse cannot rotate the tube. What complication should be suspected?
  • A. Peristomal infection
  • B. Balloon deflation
  • C. Buried bumper syndrome
  • D. Overgranulation tissue
Buried bumper syndrome occurs when the internal disc migrates into the gastric wall due to excessive external fixator tension. The hallmark sign is inability to rotate the tube. Requires endoscopic or surgical management.
4. A patient on enteral feeding via NG tube develops severe hypophosphataemia (phosphate 0.45 mmol/L) 48 hours after recommencing nutrition following 2 weeks of nil by mouth. What syndrome is this consistent with?
  • A. Dumping syndrome
  • B. Aspiration pneumonia
  • C. Refeeding syndrome
  • D. Hyper-osmolar hyperglycaemic state
Refeeding syndrome presents within the first 72 hours of nutrition reintroduction after starvation. Severe hypophosphataemia (<0.6 mmol/L) is the hallmark. Requires urgent phosphate replacement and feeding rate reduction.
5. Which of the following medications should NEVER be crushed for administration via feeding tube?
  • A. Paracetamol (acetaminophen) 500 mg standard tablet
  • B. Amoxicillin 250 mg capsule
  • C. Metoprolol XL 100 mg (extended release)
  • D. Metronidazole 400 mg tablet
Extended-release (XL, SR, MR, CR, ER) preparations must NEVER be crushed — this destroys the controlled-release mechanism and can cause dose-dumping with toxic levels. Consult pharmacy for immediate-release alternatives.
6. What is the recommended minimum head-of-bed elevation during enteral feeding via NG tube to reduce aspiration risk?
  • A. 15°
  • B. 20°
  • C. 30–45°
  • D. 90°
Evidence-based aspiration prevention requires maintaining the patient at 30–45° semi-recumbent position during enteral feeding and for at least 1 hour after feed completion. Flat position significantly increases aspiration risk.
7. A PEG tube falls out 5 weeks post-insertion. What is the priority nursing action?
  • A. Insert a replacement tube of the same size at the ward level
  • B. Insert a Foley catheter to maintain stoma patency and arrange elective replacement
  • C. Cover the stoma with gauze and contact the endoscopy/surgical team as an emergency
  • D. Leave the stoma open and commence NG tube feeding
Before 8 weeks post-insertion, the gastrocutaneous tract is not fully established and can close within hours. This is a clinical emergency requiring urgent contact with the endoscopy or surgical team. Ward nurses should not attempt reinsertion.
8. A patient on continuous NG feeding has a gastric residual volume (GRV) of 320 mL. What action is most appropriate?
  • A. Continue feeding at the same rate — GRV does not affect enteral feeding decisions
  • B. Hold feeding for 1 hour, recheck GRV, consider prokinetics and reduce rate
  • C. Discard the aspirate and resume feeding immediately
  • D. Change the NG tube and continue feeding
GRV >200–250 mL indicates delayed gastric emptying and increases aspiration risk. Hold feed for 1 hour, recheck, and consider prokinetics (metoclopramide). GRV >500 mL requires medical review and consideration of post-pyloric feeding.
9. Which enteral formula would be most appropriate for a GCC patient with Type 2 diabetes on long-term PEG feeding?
  • A. Standard polymeric formula (Jevity)
  • B. Diabetic-specific formula (Glucerna, Nutrison Diason)
  • C. Elemental formula (Peptamen)
  • D. Renal formula (Nepro)
Diabetic-specific enteral formulas have a modified carbohydrate profile (lower glycaemic index, higher fat/fibre) designed to improve glycaemic control. This is particularly relevant in GCC where T2DM prevalence is among the highest in the world. Always confirm with dietitian.
10. When confirming NG tube position by chest X-ray, which finding confirms correct placement?
  • A. The tube tip is visible at the carina level
  • B. The tube is seen curling in the right main bronchus
  • C. The tube follows the midline, passes through the diaphragm, with tip visible below the diaphragm in the stomach
  • D. The tube tip is above the gastro-oesophageal junction
On CXR, a correctly placed NG tube should: pass midline through the oropharynx and oesophagus, cross through the diaphragm, and have its tip clearly below the diaphragm in the gastric shadow. Any deviation from this requires tube removal and reassessment.
Key Exam Summary Points

Must-Know Safety Rules

  • pH ≤5.5 = safe to feed (gastric aspirate)
  • pH >6.0 = CXR required — do NOT feed
  • Whoosh test: NEVER acceptable
  • Tube out <8 weeks = emergency
  • Rotate PEG from day 5 — prevents buried bumper
  • Refeeding: start low, go slow; thiamine before feeding
  • Never crush SR/XL/EC/MR preparations
  • GRV >250 mL: hold and review

Reference Values

  • Energy: 25–30 kcal/kg/day
  • Protein: 1.0–1.5 g/kg/day
  • Fluids: 30–35 mL/kg/day
  • NG short-term: <4 weeks; gastrostomy: >4 weeks
  • PEG antibiotic prophylaxis: cephalosporin
  • Post-PEG nil by mouth: 4 hours
  • Feed bag/giving set change: every 24h
  • Pre/post feed flush: 30–50 mL water
  • MUST score ≥2: dietitian referral