Nasogastric & Nasojejunal Tube Nursing

Comprehensive Clinical Guide — GCC Edition | Updated April 2026

DHA Aligned MOH UAE/KSA NPSA / NICE Guidance Evidence-Based Practice GCC Cultural Context

● Overview & Tube Types

Fine Bore Tubes (Feeding)

TypeSizeMaterialUse
Fine Bore NGT6–8 FrPolyurethane / SiliconeEnteral feeding, medications
Nasojejunal Tube8–10 FrPolyurethanePost-pyloric feeding
ⓘ
Polyurethane fine bore tubes are softer, more biocompatible, longer dwell time (up to 4–6 weeks). Preferred for enteral nutrition.

Large Bore Tubes (Drainage/Decompression)

TypeSizeFeature
Ryle's Tube / Levin Tube12–18 FrSingle lumen, PVC, rigid
Salem Sump Tube14–18 FrDouble lumen — blue vent prevents vacuum suction injury
⚠
PVC large-bore tubes should be replaced every 7–10 days. Not suitable for long-term feeding due to stiffness and mucosal injury risk.

● Indications

Enteral Feeding

  • Dysphagia (stroke, head & neck surgery)
  • Neurological impairment (reduced GCS)
  • Facial/oral trauma
  • Anorexia / critical illness
  • Chemotherapy-induced mucositis

Gastric Drainage/Decompression

  • Bowel obstruction
  • Post-operative ileus
  • Acute pancreatitis (gastric decompression)
  • Overdose/ingestion (gastric lavage)
  • Upper GI bleeding (aspirate blood)

Medication Administration

  • Unable to swallow tablets/liquids safely
  • Unconscious patients requiring oral medications
  • Certain emergency medications

● Contraindications

Absolute Contraindications

  • Basal skull fracture (risk of intracranial placement)
  • Mid-face / nasofacial trauma or recent surgery
  • Oesophageal varices (risk of haemorrhage)
  • Oesophageal stricture or perforation
  • Recent oesophageal or gastric surgery
  • Suspected epiglottitis
⚠
Basal Skull Fracture: NGT is absolutely contraindicated. Use orogastric route under specialist guidance only.

Relative Contraindications / Caution

  • Severe coagulopathy / thrombocytopaenia
  • Uncooperative/agitated patient
  • Recent nasal surgery (use other nostril or oral route)
  • Deviated nasal septum
  • Altered pharyngeal anatomy (e.g. head & neck cancer)

Nasojejunal Tube Specific Indications

  • Gastroparesis (impaired gastric motility)
  • Acute pancreatitis (post-pyloric reduces stimulation)
  • Post-op patients with high aspiration risk
  • Recurrent high gastric residual volumes on NGT feeds
  • Gastric outlet obstruction

● Tube Measurement & Sizing

NEX Measurement (Nose–Earlobe–Xiphoid)

  1. Measure from the tip of the nose
  2. To the earlobe
  3. Then down to the xiphoid process
  4. Record this length — this is the insertion depth
ⓘ
Expected adult NGT length: 56–65 cm from nostril to gastric position. Mark the tube with tape at the measured length. Document the external mark (cm) at the nose after insertion.

French (Fr) Sizing Guide

ApplicationSize (Fr)
Fine bore feeding (adult)6–8 Fr
Fine bore feeding (paediatric)4–6 Fr
Large bore drainage12–18 Fr
Gastric lavage36–40 Fr
Nasojejunal tube (adult)8–10 Fr
⚠
1 French = 0.33 mm diameter. Larger bore = more mucosal trauma. Always use smallest appropriate size.

● Equipment Preparation

Required Equipment

  • Appropriate NGT (correct size and type)
  • Water-soluble lubricant gel
  • Kidney dish / receiver
  • 50 mL enteral syringe (purple — NEVER Luer)
  • pH indicator strips (CE marked, range 0–6 preferred)
  • Bioclusive / Tegaderm securing tape
  • Gloves (non-sterile), apron, eye protection
  • Cup of water with straw (for conscious patients)
  • Pen torch for nostril assessment
  • Measurement tape / ruler
  • Suction equipment available

Patient Preparation

  • Explain procedure fully — obtain verbal consent
  • Assess nostrils (patency, deviation, trauma)
  • Ask patient to blow nose gently if able
  • Remove dentures if loose
  • Position in High Fowler's (45–90°) if able
  • Place receiver bowl within patient reach
  • Agree on stop signal (e.g. raise hand)
  • Pre-oxygenate if clinically indicated
ⓘ
Nostril selection: Assess both nostrils. Choose the more patent one. If previous NGT in situ, use alternate nostril to prevent pressure injury.

● Insertion Technique — Conscious Patient

  1. Perform NEX measurement. Mark tube at measured length with marker/tape.
  2. Apply water-activated lubricant to the distal 10–15 cm of the tube. Do NOT use petroleum jelly (damages polyurethane).
  3. Introduce tube into selected nostril — advance gently along the floor of the nasal cavity (not upwards). Keep tube horizontal.
  4. At nasopharynx (~15 cm): Ask patient to flex chin to chest — this opens the oesophagus and closes the trachea. Advance during swallowing.
  5. Ask patient to take sips of water through a straw and swallow — advance tube with each swallow. Continue until NEX mark is at nostril.
  6. If resistance is met: Rotate tube slightly and re-attempt. Never force. Withdraw slightly and retry. If persistent resistance — STOP and reassess nostril/route.
  7. Watch for respiratory distress, coughing, cyanosis, SpO2 drop — these suggest tracheal placement. IMMEDIATELY withdraw tube.
  8. Temporarily secure tube to nose with tape once at NEX mark. Confirm position BEFORE proceeding to feeding (see Tab 3).
  9. Secure permanently once position confirmed. Use Bioclusive/Tegaderm across nasal bridge. Avoid pressure on nasal ala.
⚠
Never secure and use tube without confirmed position. Pulmonary misplacement results in aspiration, pneumonia and death.

● Insertion in Unconscious / Intubated Patients

Modified Technique

  1. Position: Head neutral (no flexion hyperextension). If no C-spine precautions — slight neck flexion assists passage.
  2. Advance tube during expiration when trachea is most relaxed and vocal cords apart.
  3. Inflate ETT cuff fully (intubated patients) to reduce tracheal entry risk.
  4. If repeated failure or coiling: consider laryngoscope-assisted insertion with Magill's forceps under direct vision.
  5. If intubated: capnography on NGT can detect tracheal placement (CO2 waveform = airway placement — REMOVE immediately).
  6. Confirm position by pH/CXR before use (same protocol as all patients).

Nasojejunal Tube Placement

■
NJ tube placement requires specialist expertise. Blind bedside placement has variable success. Preferred methods:
  • Fluoroscopy-guided — gold standard, confirms post-pyloric tip position
  • Endoscopy-assisted — direct vision placement
  • Prokinetic protocol — IV metoclopramide or erythromycin prior to blind NJ placement (increases pyloric passage)
  • Stylet removal once tube is past pylorus (confirmed by XR)
  • NJ tube tip should be in duodenum/jejunum — confirm by imaging
⚠
pH confirmation alone is insufficient for NJ tube placement — CXR/fluoroscopy mandatory to confirm post-pyloric position.

● Tube Securing & Pressure Injury Prevention

Securing Method

  • Use Bioclusive or Tegaderm film dressing across nasal bridge
  • Avoid taping directly to nasal ala (alar necrosis risk)
  • Bring tube across the cheek — second anchor tape to cheek
  • Document external mark (cm at nostril) at time of insertion
  • Check external mark at every shift handover
  • Clip tube to gown or bed linen — prevent traction

Pressure Injury Prevention

  • Alternate nostril every 7 days when tube requires replacement
  • Apply thin foam dressing under tube at nasal bridge
  • Assess nasal mucosa and skin daily
  • Reposition tube across nasal bridge if unilateral pressure noted
  • Document any erythema, skin breakdown, mucosal trauma
  • Consider PEG tube if NGT expected beyond 4–6 weeks
⚠
Nasal pressure injuries are largely preventable and are considered avoidable harm under GCC facility governance frameworks.

⚠ NEVER USE AUSCULTATION (WHOOSH TEST) AS SOLE CONFIRMATION

Injecting air and auscultating over the epigastrium is NOT a reliable method of confirming NGT position. This method has been associated with patient deaths from pulmonary misplacement. It is officially retired by NPSA, NICE, and all GCC health authority guidelines.

● NPSA / NICE Confirmation Hierarchy

✓
Method 1: pH Testing (First Line)
Aspirate 0.5–1 mL of gastric fluid. Apply to pH strip.
pH ≤ 5.5 = Gastric position confirmed. Safe to proceed with feeding.
pH > 5.5 = Do NOT feed. Proceed to CXR.
ⓘ
Method 2: Chest X-Ray (Gold Standard)
Indicated when pH is >5.5, unable to aspirate, or pH test result is uncertain.
Tube tip must be clearly visible below the diaphragm in the gastric shadow.
Radiologist report required before feeding commences.
⚠
CO2 Colorimetric Devices
Useful to confirm the tube is NOT in the lungs (CO2 detected = remove tube).
Does NOT confirm gastric position. Oesophageal placement will not trigger CO2 alarm. Not a substitute for pH or CXR.
✖
Methods NOT Acceptable as Sole Confirmation:
  • Auscultation (whoosh test)
  • Observing bubbling in water
  • Tube misting on breathing
  • Assessment of tube length alone
  • Clinical appearance of aspirate colour only

● pH Testing — Practical Guidance

Technique

  1. Wait at least 1 hour after any feed or antacid before testing (reduces false high pH).
  2. Attach 50 mL enteral syringe to NGT. Aspirate slowly with gentle suction.
  3. If no aspirate: try repositioning patient (left lateral / right lateral). Try 10–20 mL air injection then re-aspirate.
  4. Apply 0.5–1 mL aspirate to CE-marked pH strip. Read result within 30 seconds.
  5. pH ≤ 5.5: Document and proceed to feed. pH > 5.5 or unreadable: Do NOT feed. Request CXR.

When pH Testing is Unreliable

ConditionEffect on pHAction
PPI / H2 antagonist useRaises gastric pH > 5.5CXR required
Antacid administrationRaises gastric pH temporarilyWait 1h, retest
AchlorhydriaGastric pH chronically > 5.5CXR required
Continuous feed runningRaises aspirate pHStop feed 1h, retest
Pleural / respiratory fluidMay read pH 6–7CXR mandatory

● When to Re-confirm Position

Mandatory Re-confirmation Before Each Feed

  • Before commencing any new feed session
  • Before administering medications
  • When reconnecting feed after a break

Re-confirm After Any of These Events

  • Episode of vomiting
  • Severe coughing or retching
  • External mark has changed at nostril
  • Patient has been repositioned significantly
  • After any tube manipulation
  • Any respiratory deterioration

Documentation Requirements

  • Method used (pH / CXR)
  • Result (pH value or CXR confirmed gastric)
  • Date and time of confirmation
  • External tube mark (cm at nostril)
  • Name and designation of nurse
  • Action taken (feed commenced / CXR requested / tube removed)

◇ Interactive: NGT Position Confirmation Decision Tool

Enter clinical findings below to receive a feed/no-feed decision with required actions.

AUSCULTATION (WHOOSH TEST) WAS NOT AND MUST NOT BE USED

If auscultation was used as part of this assessment, restart the confirmation process using pH testing and/or CXR immediately.

📋 Documentation Template (copy to nursing notes)

● Starting Enteral Feeding

Starter Regimen Principles

ⓘ
Full-strength formula from day one. Diluting enteral feeds is NOT recommended (does not reduce GI intolerance, reduces caloric delivery, increases infection risk).

Typical Rate Progression

PhaseRateDuration
Initiation20–40 mL/hr4–8 hours
Advancement40–60 mL/hrPer dietitian plan
Target rate60–100 mL/hrMaintain per plan
Bolus (if applicable)200–400 mL over 20–30 min4–6 times daily
⚠
Always follow the individualised dietitian prescription. Rates above are indicative only. ICU patients may have different targets.

Nursing Setup Checklist

  • Confirm NGT position (pH / CXR) — document
  • Check head-of-bed elevation ≥ 30° (ideally 30–45°)
  • Flush tube with 30 mL sterile water before feed
  • Check formula type, rate, and volume per dietitian plan
  • Attach new giving set (change every 24h)
  • Hang formula — label with date, time, feed name
  • Set pump rate as prescribed
  • Document feed commencement time and rate
  • Check GRV at 4–6 hourly intervals
  • Flush tube with 30 mL water after each feed and medications

● Gastric Residual Volume (GRV) Management

Aspiration & Assessment

  1. Stop feed. Aspirate gently with 50 mL syringe every 4–6 hours.
  2. Measure total volume aspirated. Return aspirate to stomach if < 500 mL and not discoloured (reduces electrolyte loss).
  3. Document volume, colour, and consistency.
  4. Restart feed at previous rate if GRV acceptable (see thresholds).
GRV VolumeAction
< 200–300 mLContinue feeding — no action required
200–500 mLHold feed 1–2 hours; re-aspirate; consider prokinetic
> 500 mLStop feed; escalate to medical team; prokinetic; consider NJ tube
Repeated > 300 mLConsider post-pyloric NJ tube placement

Aspiration Risk Reduction

  • Maintain HOB ≥ 30° during feeding and for 30–60 min after bolus feeds
  • Avoid prone or flat positioning during active feeds (unless ventilatory indication)
  • Consider prokinetics: metoclopramide 10 mg IV/oral TDS; erythromycin 125–250 mg IV BD
  • Monitor for signs of aspiration: increased secretions, SpO2 drop, new cough, respiratory deterioration
  • Use NJ tube if recurrent aspiration or high GRV on NGT
⚠
Refeeding Syndrome Risk: In severely malnourished patients — monitor serum phosphate, potassium, magnesium for first 72 hours. Initiate feed at low rate (10–20 mL/hr). Phosphate < 0.6 mmol/L — stop feed and replace electrolytes urgently.

● Medication Administration via NGT

Safe Administration Principles

  1. Confirm NGT position before medication administration.
  2. Flush tube with 10–30 mL sterile water before first medication.
  3. Administer each medication separately — flush 10 mL water between each medication.
  4. Use liquid formulations whenever available.
  5. If crushing is unavoidable — confirm with pharmacist first.
  6. Flush with 30 mL sterile water after last medication.
  7. Document medications administered and flush volumes.

Medications That Must NOT Be Crushed

✖
NEVER crush the following via NGT:
  • Sustained release (SR/XL/XR/MR) formulations
  • Enteric coated (EC) tablets
  • Sublingual / buccal preparations
  • Cytotoxic medications
  • Hormone / immunosuppressant tablets (variable)
  • Capsules containing liquid or pellets — check with pharmacist
⚠
Crushing SR/EC formulations causes dose dumping — sudden release of entire dose with potential toxicity. Always check with pharmacy before crushing any preparation.

● Tube Patency — Flushing Protocol

Routine Flushing

  • 30 mL sterile water every 4–6 hours
  • Before and after each feed session
  • Before and after medications
  • After GRV aspiration

Managing Blockage

  • Warm water flush first (30 mL, gentle pressure/suction cycles)
  • Sodium bicarbonate solution flush (1/4 tsp in 10 mL water)
  • Carbonated water (sparkling water)
  • Enzymatic declogger (Clog Zapper) per protocol
  • If unable to unblock — replace tube. Never use guide wire to unblock in situ tube.

Prevention of Blockage

  • Never mix medications together in syringe
  • Always flush between medications
  • Use liquid formulations preferentially
  • Flush after any period of tube non-use
  • Avoid high-viscosity formulas in fine-bore tubes

● Critical Complications — Misplacement

⚠
Pulmonary misplacement is the most dangerous NGT complication. Feeding into the lungs causes aspiration pneumonia, lung abscess, pneumothorax, respiratory failure, and death. This is a NEVER EVENT under GCC patient safety frameworks.

Signs Suggesting Misplacement During Insertion

  • Severe coughing or choking during insertion
  • SpO2 desaturation
  • Respiratory distress / increased work of breathing
  • Cyanosis
  • Patient unable to speak (tube obstructing airway)
  • Tube is unusually easy to insert (suspect oesophageal coiling)
⚠
Intracranial misplacement: Occurs with basal skull fracture. Absolute contraindication. Requires neurosurgical consultation urgently if inadvertent intracranial placement suspected.

Response to Suspected Misplacement

  1. Stop any feed or medication immediately.
  2. Do NOT remove tube until confirmed with senior clinician.
  3. Call medical team and senior nurse urgently.
  4. Assess airway, breathing, SpO2 — initiate emergency response if needed.
  5. Arrange urgent CXR.
  6. Document incident. Complete patient safety incident report (PSIR).
  7. Clinician decision: remove tube + reassess.

● Complications Reference Table

Complication Risk Factors Recognition Management Prevention
Pulmonary misplacement Unconscious, impaired swallow, inexperienced inserter Respiratory distress, SpO2 drop, pH > 6, CXR shows tube in lung field Stop feed, call team, emergency response, remove tube, treat aspiration pneumonia Proper technique, pH/CXR confirmation, never use auscultation alone
Tube blockage Fine bore tube, poor flushing, crushed medications Unable to aspirate or infuse; resistance on syringe push Warm water flush, sodium bicarb, Clog Zapper, replace if unresolved Regular flushing 4–6 hourly, liquid meds, flush between all medications
Nasal pressure injury Long-term NGT, same nostril, inadequate padding Erythema / ulceration at nasal ala or bridge, patient reports pain Reposition tube, foam dressing, alternating nostril on re-site Daily skin assessment, proper securing, alternating nostril weekly
Aspiration pneumonia HOB < 30°, high GRV, impaired consciousness, reflux Fever, productive cough, new chest findings, SpO2 drop, CXR infiltrate Stop feeds, medical review, antibiotics if confirmed, chest physiotherapy HOB ≥ 30°, GRV monitoring, prokinetics, NJ tube if high risk
Tube migration / displacement Vomiting, coughing, agitation, poor securing External mark change, visible tube loop in mouth/pharynx, patient discomfort Stop feed immediately, do not push tube back — re-site, re-confirm position Regular mark checks, secure anchoring, bite block if agitated
Sinusitis Prolonged NGT (> 2–3 weeks), immunocompromised Facial pain, nasal congestion, fever, purulent nasal discharge Remove NGT or change nostril, ENT review, antibiotics if bacterial Consider PEG tube if NGT expected > 4–6 weeks
Oesophageal erosion Large bore rigid tube, prolonged use, GORD Haematemesis, chest pain, dysphagia, stridor Remove tube, urgent endoscopy, surgical consult Use fine-bore polyurethane tube, replace PVC tubes every 7–10 days

● Incident Reporting — GCC Requirements

Never Events (Mandatory Reporting)

  • Feeding via misplaced NGT (pulmonary / intracranial)
  • Medication via confirmed misplaced NGT
  • Use of Luer-lock syringe on enteral feeding system
⚠
All NGT Never Events must be reported to the facility patient safety department, the DHA/MOH as applicable, and documented in the patient's clinical record with a full incident analysis.

PSIR Trigger Events (Report Within 24h)

  • Any suspected misplacement during or after insertion
  • Aspiration event related to NGT feeding
  • Grade 2+ nasal pressure injury
  • Tube inserted without proper position confirmation
  • Wrong patient / wrong feed type administered

● GCC Regulatory Alignment

Position Confirmation Guidance

AuthorityGuidelineConfirmation Standard
DHA (Dubai)Clinical Practice Guideline: Enteral NutritionpH ≤ 5.5 first line; CXR if pH > 5.5
MOH UAEPatient Safety Circular — NGTpH + CXR confirmation hierarchy adopted
MOH Saudi ArabiaCBAHI Standard NCP.07Aspirate pH / radiological confirmation
MOH Qatar (MOPH)Nursing Care StandardAligned with NPSA 2011 guidance
MOH Bahrain / Oman / KuwaitNational standards reference NPSApH + CXR standard adopted

Enteral Feeding Systems — GCC Compliance

  • ENFit connectors are being adopted across GCC — prevents cross-connection with IV lines
  • Only use purple enteral syringes (ENFit) — NEVER Luer-lock syringes
  • Enteral giving sets must be changed every 24 hours
  • Formula hang time: 4 hours for non-aseptic pour, 8–12 hours for closed system RTH (ready to hang)
  • Closed systems (RTH) preferred in ICU and immunocompromised patients
⚠
Use of IV (Luer-lock) syringe on enteral feeding line is a Never Event in all GCC jurisdictions.

● PEG Tube Decision-Making in GCC

Standard Threshold for PEG Consideration

  • NGT expected to be required for > 4–6 weeks
  • Recurrent NGT displacement / patient pulling tube
  • Grade 2+ nasal pressure injury from NGT
  • Patient/family preference after counselling
  • Neurological condition stable and prognosis allows
ⓘ
Early PEG (within 2–3 weeks) is recommended by ESPEN for stroke patients with persistent dysphagia and good prognosis.

GCC Cultural & Ethical Considerations — PEG

■
Islamic Ethics of Artificial Nutrition:
In GCC, artificial nutrition (NGT/PEG) for patients who cannot maintain independent nutrition is generally considered an obligation (wajib) when there is a reasonable prospect of benefit. Withdrawal in end-of-life scenarios requires senior clinical, family, and Islamic ethics committee review.
  • Family council involvement is expected and required before PEG consent in most GCC hospitals
  • Islamic ethics committees may be consulted in complex neurological ICU cases
  • Document family discussions and decisions in medical/nursing notes
  • For stroke patients: 4–6 week NGT threshold may differ culturally — some families prefer to avoid surgical PEG procedure; engage dietitian, SLT, and medical team in shared decision-making

● Halal Feed Considerations & Ramadan

Halal Status of Enteral Feeds

✓
Most commercially available standard enteral formulas (Ensure, Fresubin, Jevity, etc.) are halal-certified or halal-compatible. The majority do not contain porcine-derived or non-halal animal ingredients.
  • Check individual formula data sheet for gelatin source (porcine vs bovine/fish)
  • Omega-3 enhanced formulas: fish-derived — acceptable in most Islamic rulings
  • Consult hospital dietitian for halal certification verification if family raises concern
  • Document family communication and formula confirmation in nursing notes

NGT Feeding During Ramadan

ⓘ
Islamic Ruling: A patient who is medically required to receive NGT feeding is exempt from the obligation to fast (sawm). NGT feeds via tube bypassing oral intake are considered a medical necessity (darura). Feeding continues uninterrupted 24 hours/day if clinically required.
  • Communicate ruling sensitively to patient/family — involve hospital chaplain or Islamic advisor if requested
  • Document that patient/family have been informed of the exemption
  • Do not modify feed schedule for Ramadan without dietitian and medical team review
  • If patient insists on fasting during Ramadan against medical advice — document informed refusal and involve senior team

● Patient & Family Communication in GCC

Arabic-Language Key Phrases for NGT

EnglishArabic
Nasogastric tubeأنبوب معدي أنفي (Unboob ma'adi anfi)
We need to pass a tube through your nose to your stomachنحتاج إلى إدخال أنبوب عبر أنفك إلى معدتك
This will help you receive nutritionهذا سيساعدك على الحصول على التغذية
You may feel some discomfortقد تشعر ببعض الانزعاج
Please swallow when I tell youمن فضلك ابتلع عندما أخبرك
Raise your hand if you want me to stopارفع يدك إذا أردت مني التوقف
The tube is now in the correct positionالأنبوب الآن في الموضع الصحيح

Family Education — Key Points

  • Explain why NGT is needed and expected duration
  • Reassure that NGT is a standard and safe procedure when managed correctly
  • Explain that tube position is checked before every feed for safety
  • Advise on what to do if tube appears to move (call nurse immediately)
  • Discuss PEG tube option if long-term feeding expected
  • Provide written information in Arabic and English where available

Multilingual Instruction Cards

GCC hospitals should maintain bedside instruction cards in: Arabic English Urdu/Hindi Tagalog covering: tube purpose, when to call nurse, positioning instructions, and feeding schedule.

● Quick Reference — GCC NGT Safety Summary

✓
ALWAYS
  • Confirm position with pH ≤ 5.5 OR confirmed CXR before each feed
  • Use ENFit/purple enteral syringes
  • Maintain HOB ≥ 30° during feeds
  • Document all confirmation steps
  • Report any misplacement incidents
✖
NEVER
  • Use auscultation as sole confirmation
  • Feed if pH > 5.5 without CXR confirmation
  • Insert NGT in confirmed basal skull fracture
  • Use Luer-lock IV syringes for enteral feeds
  • Crush SR/EC/sublingual medications
ⓘ
ESCALATE WHEN
  • pH > 5.5 and CXR not yet done
  • GRV > 500 mL or repeated > 300 mL
  • Suspected pulmonary misplacement
  • Respiratory deterioration during/after insertion
  • Nasal pressure injury developing

GCC Nursing NGT Guide — Compiled April 2026. Based on NPSA (2011), NICE (2023), ESPEN (2023), DHA/MOH UAE/MOH KSA guidelines. For clinical governance use. Always refer to your facility's local policy and individual patient clinical context. This guide does not replace registered professional nursing judgement.