Nasogastric Tube Assessment Form
Complete this form to evaluate the status, placement, tolerance, and clinical observations related to nasogastric tube care.
Tube Placement Verification Method
*
pH aspirate test
Auscultation
X-ray confirmation
Visual inspection
Other
Tube Type and Size
*
Fine bore (≤12 Fr)
Wide bore (>12 Fr)
Other
Date and Time of Last Tube Insertion
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Tube Patency and Function
*
Patent and flushing well
Partially blocked
Completely blocked
Unable to assess
Patient Tolerance to Tube
*
1
2
3
4
5
Tube Exit Site Assessment
*
Clean, dry, and intact
Redness/erythema
Swelling
Discharge present
Other
Gastric Aspirate Appearance
*
Clear
Cloudy
Green
Bloody
Unable to obtain
Feeding Administration Status
*
Feeding administered as prescribed
Feeding withheld (clinical reason)
Feeding interrupted (tube issue)
Complications/Adverse Events Observed
*
None
Dislodgement
Blockage
Aspiration
Nasal erosion
Other
Additional Clinical Observations/Comments
Submit Assessment
Should be Empty: