Upload
setanpikulan
View
221
Download
0
Embed Size (px)
Citation preview
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
1/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 1 of 22
Control Date: 09/10/2008
TITLEPHT POLICY FOR THE INSERTION AND MAINTENANCE OF FINEBORE NASO-GASTRIC FEEDING TUBES IN ADULTS
REFERENCE
NUMBER3.11
MANAGER /
COMMITTEERESPONSIBLE
CLINICAL NUTRITION NURSE SPECIALISTS
DATE ISSUED 04.03.2008
VERSION 4
REVIEW DATE December 2009
Equality Impact
Assessment has been
applied to this policyJoanne Pratt - Lead Clinical Nutrition Nurse Specialist
AUTHOR Jo Pratt and Gillian Fraser - Clinical Nutrition Nurse Specialists
RATIFIED BY PROFESSIONAL ADVISORY COMMITTEE 06.02.2008
Amendments record:
Date Page Comments Approved By:
15th Dec 2007 throughoutSyringe changed toenteral syringe
CNNS, NST, MATRONS,Debbie Knight
24 Nov 2007 5 Updated referencesCNNS,NST, MATRONS,Debbie Knight
15 Dec 2007 7,12, 13 Use of blackcurrant drinkCNNS, NST MATRONS,Debbie Knight
19TH Dec 2007
6th Jan 200814th Jan 2008
16
17 1920 -22
NG tube position chart
Updated competencyUpdated starter regimen CNNS, NST, MATRONS,Debbie Knight
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
2/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 2 of 22
Control Date: 09/10/2008
CONTENTS:1. INTRODUCTION / BACKGROUND2. STATUS3. PURPOSE
4. SCOPE/AUDIENCE5. DEFINITIONS6. PROCESS7. DUTIES AND RESPONSIBILITIES8. TRAINING9. ASSOCIATED DOCUMENTATION
APPENDICES:1. PROTOCOLS FOR PRACTICE2. PRODUCT INFORMATION / TUBE SELECTION3. ANATOMY + PHYSIOLOGY OF SWALLOWING
4. CONFIRMING THE CORRECT POSITION OF NASOGASTRIC FEEDING TUBES IN ADULTS(FLOWCHART)
5. NG TUBE POSITION CHART6. NG COMPETENCY7. STARTER REGIMEN FOR ADULTS
1. INTRODUCTION / BACKGROUNDNasogastric tube feeding is common practice and many tubes are inserted daily without incident. However,there is a small risk that the tube can become misplaced into the lungs during insertion, or move out of the
stomach at a later stage. Auscultation must not be used as the sole method for checking correct nasogastrictube (NGT) placement as studies have shown this method to be inaccurate. NG tubes should be aspiratedand tube position confirmed using ph indicator strips BDH (0-6) (See Appendix 1 & 2) X-rays should not
routinely be used. (9).
2. STATUSThis is a clinical policy.
3. PURPOSEThis policy is designed to guide all Healthcare Professionals in the safe insertion and maintenance of fine
bore naso-gastric feeding tubes in adults.
4. SCOPE/AUDIENCEThese guidelines apply to all competent healthcare professionals inserting and/or maintaining fine bore
naso-gastric feeding tubes in Portsmouth Hospitals NHS Trust.They are applicable to adult patients who require short term (4-6weeks) feeding via a fine bore naso-gastricfeeding tube.
For administration of medication via a fine bore nasogastric feeding tube please refer to Administration ofDrugs to Adult Patients with Feeding Tubes guideline (11).
For fine/wide bore naso-gastric feeding tubes or orogastric feeding tubes inserted other than at the bedside(ie endoscopy, imaging, theatres) this policy should be adhered to for verification of tube position.Patients in the Department of Critical Care are excluded from this Policy. The Department of Critical Care is
responsible for producing its own speciality specific guidelines to Trust Standards.
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
3/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 3 of 22
Control Date: 09/10/2008
A. INDICATIONS
Indication for feeding Example Evidence
Unconscious patientSwallowing disorder
Physiological anorexia
Upper GI obstructionPartial intestinal failure
Increased nutritional requirements
Psychological problems
GI, gastrointestinal:
Head injury, ventilated patientPost-CVA, multiple sclerosis, motor neurone
disease.
Liver disease (particularly with ascities)
Oesophageal stricturePostoperative ileus inflammatory bowel disease,short bowel syndrome.
Cystic fibrosis, renal disease, critical illness
Severe depression or anorexia nervosa
Cerebrovascular accident.
1.
B CONTRADINDICATIONS Fractured Base of skull Bleeding Oesophageal Varices Perforated oesophagus Perforated pharyngeal pouchC CONSIDERATIONS NGT insertion may be problematic if the patient is known to have: - Head & Neck malignancy/obstruction Upper Gastrointestinal Malignancy/obstruction/surgery i.e. Gastrectomy Pharyngeal pouch Hiatus Hernia Fractured cervical spine
COMPLICATIONS
Type Complication EvidenceInsertion
Post insertion trauma
Displacement
Reflux
GI intolerance
Metabolic
Nasal damage, intracranial insertion,
pharyngeal/oesophageal pouch perforation,
bronchial placement, variceal bleeding.
Discomfort, erosions, fistulae, and strictures.
Tube falls out, bronchial administration of
feed. *See below.Potential aspiration pneumonia.
Oesophagitis, aspiration
Nausea, bloating, pain, diarrhoea.
Refeeding syndrome, hyperglycaaemia, fluid
overload, electrolyte disturbance.
1
*In a patient with a functioning Gastro-Intestinal Tract, who repeatedly displaces NGTs it may be possible to
insert a nasal bridle, which will prevent displacement. Please contact the Clinical Nutrition Nurse Specialistsfor assessment.
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
4/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 4 of 22
Control Date: 09/10/2008
5. DEFINITIONSFine bore naso-gastric feeding tube: -Defined as between a 6fg - 8fg. The length of the tube is measured in cms starting at the distal tip (stomachend = 0cms). Measurements are seen along the length of the tube, the tube length will vary depending on
manufacturer. The tube is made of silicone or polyurethane which is passed through the nostril via the naso-pharynx into the oesophagus, then stomach. (Appendix 2)Nasogastric tube feeding: -
The administration of artificial nutrition via a fine bore nasogastric tube. Feeding via a naso-gastric tube isusually a short- term intervention (4-6 weeks). A route for permanent enteral access should be considered ifenteral support is required for longer than this. (Appendix No 8)
Healthcare Professionals: -A registered or trained competent member of staff including doctors, nurses and midwives. Competencylevel 2 and above (Appendix 6).
Maintenance of a Nasogastric tube: -
Includes correctly checking tube position, and maintaining the patency of that tube. Ongoing managementincludes skin care, checking tube position.
Enteral Syringe:-Purple single use non I.V. compatible syringe for enteral use only.
6. SEE APPENDIX 1 FOR PROTOCOLS FOR PRACTICE
Critical reporting within Clinical Nutrition and completion of Trust risk forms will be the systems used tomanage risk.
7. DUTIES AND RESPONSIBILITIES
DoctorsThe decision to commence artificial nutrition via a nasogastric tube is a medical decision to be made in
conjunction with the patient, the patients family and the MDT members. If the Healthcare Professional isunable to confirm tube position at the bedside it is the Doctors responsibility to request and review a chest x-ray to establish gastric placement. It should be noted that nasogastric tubes as stated in Appendix 2 are
radio opaque.
Healthcare Professionals -
a) Healthcare Professionals are responsible for establishing the gastric placement of NGTs prior to their use.
b) It is the responsibility of the Healthcare Professional to develop and maintain their own level ofcompetency (Appendix 6).
Clinical Nutrition Nurse Specialists are responsible for the development and review of the policy.Clinical Nutrition Nurse Specialists in conjunction with Modern Matrons, Ward Managers, Practice Development Nurses and Clinical
Educators are responsible for the management and implementation of this policy.
It is expected that fine bore nasogastric tubes will be inserted and maintained by a level 2 and abovepractitioner in a safe and competent manner (see Appendix 6: NG Competency).
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
5/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 5 of 22
Control Date: 09/10/2008
Aspect of Care/OutcomesExpected Standard
TargetSource of Data Collection
1. NGTs are inserted by a competent level 2
and above practitioner.
NGTs are safely maintained by level2 and above practitioners 100%
Review of medical notes.
Staff Interviews.
2. All ward areas use pH indicator strips BDH0 - 6 to test aspirate when confirming NGposition.
100% Audits
3. NG Tube is not used if inadvertently placedin the lungs 100% Risk Incident Forms
4. CxR requested on placement only when
aspirate is unobtainable. 100% Audit x-rayReview of medical notes
5. The position of NG tube is checked as perPolicy and documented on NG Tube Position
Chart (see appendix 5).
100%Review of patient notes.
Audit of use of NG Tube Position
Chart
8. TRAINING
Liaison with Ward Managers, Practice Development Nurses, Clinical Educators and Modern Matronsto ensure policy is adhered to at ward level.
Clinical Nutrition Nurse Specialists to maintain a high profile in clinical areas to support
implementation of this policy. Dissemination via Clinical Nutrition Nurse Specialists in ongoing training programmes.
9. ASSOCIATED DOCUMENTATION
Note all documents that support the policy and include further reading if required.
1. Stroud, M., Duncan, H., & Nightingale, J. (2003). Guidelines for Enteral Feeding in Adult HospitalPatients. Gut, 52 (suppl. Vii), vii-vii 12.
2. Burnham, P. (2000). A Guide to Nasogastric Tube Insertion. Nursing Times Plus 96 (8), 6-7.3. Reid, W. (2002). Clinical Governance: Implementing a Change in Workplace Practice. Nasogastric Tube
Placement. Professional Nurse, 17(12), 734-737.4. Cannaby, A., Evans, L. & Freeman, A. (2002). Nursing Care of Patients with Nasogastric Feeding
Tubes. British Journal of Nursing, 11(6), 366-372
5. Christensen, M. (2001). Bedside Methods of Determining Nasogastric Tube Placement: A literatureReview. Nursing in Critical Care 6 (4), 192-199.
6. Colagiovanni, L. (1999). Taking the Tube. Nursing Times 95 (21), 63 - 71.7. Colagiovanni, L. (2000). Preventing and Clearing Blocked Feeding Tubes. Nursing Times Plus, 96 (17),
3 - 4.8. Metheny, N. & Titler, M.G. (2001). Assessing Placement of Feeding Tubes. American Journal of
Nursing, 101(5), 36 - 45.9. Great Britain National Patient Safety Agency (2005). Reducing the harm caused by misplaced
Nasogastric Feeding Tubes.
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
6/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 6 of 22
Control Date: 09/10/2008
10.Great Britain National Patient Safety Agency (2007). Promoting safer measurement and administrationof liquid medicines via oral and other enteral routes.
11.Portsmouth NHS Trust (2005). Administration of Drugs to Adult Patients with feeding tubes. DrugTherapy Guideline No 52.01, p1-25.
12.Metheny, N., et.al. (2005). Indicators of Tubesite during Feedings. Journal of Neuroscience Nursing37(b), 320-325.13.Taylor, S. & Clemente, R. (2005). Confirmation of Nasogastric tube position by pH testing. Journal of
Human Nutrition and Dietetics 18 371-375.14.Great Britain. National Institute for Health and Clinical Excellence (2006). Nutrition Support in Adults
(Clinical Guideline 32) London : NICE
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
7/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 7 of 22
Control Date: 09/10/2008
APPENDIX 1: PROTOCOLS FOR PRACTICE
List of Equipment for Procedure: -Clean tray or trolley1 x fine bore feeding tube 6 - 8fg
1 x glass of water and straw1x 10ml enteral syringe filled with tap water1 x 50ml enteral syringe
Bioclusive/HypafixpH Indicator strips
ACTION RATIONALE EVIDENCE
1. Explain procedure to patient. To obtain patients consent and co-operation. 1
2a. Where possible the patient should be sitting in
a semi-upright position supported with pillows.
2b. For the semi-conscious patient it is often
easier to be in a lying position.
This position allows easy swallowing and
ensures that the epiglottis is not obstructing
the oesophagus.
Appendix 3.
3. Wash hands and apply gloves. Assemble
required equipment, select appropriate tube.To ensure a clean procedure is maintained
throughout.
Consider gauge required dependent on
diagnosis.
Appendix 2.
Infection Control
Policy
2
1
4. Check nose and mouth for any signs of
Obstruction and ensure both are clean.
Check nasal patency by sniff with each nostriloccluded in turn.
Patient may have one nostril which is
clearer than the other e.g. deviated nasalseptum
1
2
5. Estimate the length of NG tube by measuring
from the xiphisternum to the tip of the nose, and
from the tip of the nose to the ear lobe.
(Measurement approx 50-60cm).
To gain an approximate length for that
patient.
1 12
2
4
6. Flush the tube with 1-2mls of water
Ensure guidewire moves freely.This will ensure that the guide wire can be
easily removed once placed.
Manufacturers
guidelines
7. Lubricate the NG tube by immersing end of
tube in water.This will facilitate easy passage when
inserting the tube.2
8. Insert the tube into the clearest nostril and slidebackwards and inwards along the floor of the
nose to the nasopharynx approx 10cm and STOP
If any obstruction is felt withdraw tube slightly
and try again at a slightly different angle.
There are two distinct stages when passingthe tube.
a. nose pharynx stop and swallowb. pharynx stomach.
Appendix 3
9a. If the patient can swallow coincide
passing NGT with swallowing a sip of
water.
9b. If the patient is dysphagic but can
swallow own secretions - trickle 1-2mls
of water into the mouth using a syringe
to elicit a swallow.
Repeat the water/swallow and advance until
estimated length is reached.If swallowing reflex is not initiated DO NOT
continue with this method.
The passing of the NGT can be co-
ordinated with observing for laryngeal
movement. During this phase the epiglottis
covers the airway and NGT can pass into
oesophagus.
Risk of aspiration.
Appendix 3.
14
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
8/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 8 of 22
Control Date: 09/10/2008
ACTION RATIONALE EVIDENCE
9c. If the patient is dysphagic and unable to
swallow secretions or the above fails attempt to
pass the tube unaided to the estimated
measurement.
NB Advancing chin forwards and/or turning head
to one side may facilitate tube advancement.
This reduces the risk of aspirating fluids.1
14
10. If you are unsuccessful repeat above
procedure in other nostril. Consider smaller bore
and/or weighted tube. Do not repeat procedure
more than 3 times.
One nostril may be clearer than the other.
Smaller gauge or weighted tube may be
easier to pass on specific patients.
Appendix 2
1
2
8
11. Remove guide wire and secure naso-gastric
tube in place using hypafix/bioclusive across side
of face. Do not apply tape to nose.
Mark NGT with pen at point of entry into nostril.
Most fine bore NGTs are radio- opaque
and do not require the guide wire to be in
situ for x-ray (see manufacturers
guidelines).
This will provide an easily identifiable
mark as a baseline.
2
8
12. Follow steps A-Cto obtain aspirate andverify
correct NGT position.
.
A. Using a 50ml enteral syringe insufflate up to
30mls of air via NGT.
B. Attempt to gain aspirate from NGT.
If aspirate obtained check using ph indicator
strips. (See appendix 2)
C. If pH is less than 5, use tube - x-ray is not
required.
Gastric secretions have a pH of less than 5.
This confirms that tube is in the stomach.
This clears tube of debris and forces end of
the tube away from the stomach mucosa.
The pH of aspirate should be measured
using pH indicator strips in the range 0-6
with 1/2 point gradations.
Litmus paper must not be used as it does
not indicate the degree of acidity.
3, 13
4
5
10
3, 9, 12, 13
9, 13
13. If unable to obtain aspirate or pH of aspirate
is 5 or above follow flowchart See Appendix 4.Appendix 4.
14. If the patients swallow is intact and aspirate
cannot be obtained, ask patient to drink 200mls of
blackcurrant, then aspirate this via NGT
If tip of NGT is in gastric fluid pool
blackcurrant will be aspirated USE
TUBE X-RAY IS NOT REQUIRED.
DO NOT USE THIS METHOD UNLESS
PATIENTS SWALLOW IS INTACT.
13
15. In the absence of a positive aspirate test a
chest x-ray will be required to confirm tube
position.
NB Confirmation of tube position by x-ray is only
correct at the time of x- ray. Subsequent
checking of position by aspirate test must be
carried out at the bedside. See below.
X-ray request forms need to document that
CXR is to verify NG tube position, as a
specific density is required.
4
5
13
16. Following insertion and confirmation of
correct position document procedure - including
pH of aspirate obtained +/or confirmed by x-ray,
and measurement of tube at nose.
Position of tube on x-ray must be confirmed by a
level 4 competent practitioner or medic and
documented in medical notes.
Accountability for checking the tube
position before use lies with the competent
Healthcare Professional.
Recording the procedure is a requirement
in law and provides a baseline for future
measurement.
This is a legal requirement.
Trust Policy and
Protocol for the
Management of
Records (2005)
Care of a Patient with a
Fine Bore Nasogastric
Feeding Tube (2005)
Competency Appendix
6.17. Implement NG tube position chart
(Appendix 5) at bedside
To ensure documentation of NG position
check.
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
9/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 9 of 22
Control Date: 09/10/2008
SUBSEQUENT VERIFICATION OF NGT POSITIONAs the accountable practitioner caring for the patient with an NGT it is your responsibility to ensure the tube is in the
correct position.
Tube position should be checked by aspiration before: -
ACTION RATIONALE EVIDENCE1. Each bolus feed or drug administration. To confirm correct position prior to use. 4, 6, 8, 14
2. At least once every 24hrs whencontinuous feeds are used.
To ensure tube has not displaced. 4, 6, 8
3. If the patient complains of discomfort orfeed reflux into the mouth.
To ensure tube has not displaced. Tube
may be coiled in back of throat.4, 6, 8
4. After vomiting or violent retching. To ensure tube has not displaced. 4, 6, 8
5. After severe coughing bouts/respiratorydistress.
To ensure tube has not displaced. Check
back of throat to ensure that tube is not
coiled.
4, 6, 8
6. After endotracheal or tracheostomy tubesuctioning.
To ensure tube has not displaced. 4, 6, 8
7. If tube has obviously displaced onchecking measurement.
4, 6, 8
8. On receipt of patient being transferredprior to using tube.
4, 6, 8
Use NG Tube Position Chart (Appendix 5) to document subsequent checking of tube position.
It is recognised that obtaining aspirate for subsequent checking may at times be difficult.
In the absence of aspirate of a pH below 5 it is the responsibility of the most senior Health Care Professional to use
their clinical judgement to determine if the tube is safe to use.
The following is provided to assist in your decision making.
ACTION RATIONALE EVIDENCE1. Check that level 2 Practitioner has
followed guidance on flowchart
(appendix 4).
To ensure correct procedure has been
followed.14
2. Obtain patient history:Check measurement at nose
Has patient vomited, coughed, or
complained of feed reflux?
To check if tube has moved.
To ensure tube has not displaced. 4
3. If tube position has not moved, inject
5/10mls of water into NG tube. Attemptto re-aspirate using a 10ml enteral
syringe.
This has been shown to ease the process for
obtaining aspirate3
4. Aspirate visualisation: - Altered feed may indicate gastric digestion.Bile may indicate stomach or small bowel
position.12
5. Consider auscultation to give furthersupportive information.
Auscultation has some benefit as an ancillary
method for checking tube placement. It must
not be used as the sole method of determining
tube location.
8, 9, 13
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
10/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 10 of 22
Control Date: 09/10/2008
ONGOING MANAGEMENT
ACTION RATIONALE EVIDENCESkin Care
Daily:
* Check that tape securing tube is
intact and not in need of replacement
* Check around nostril for any signs
of pressure necrosis.
If patient is NBM ensure mouth care
is maintained 2 hourly.
To ensure tube is safely secured in position.
Tape may need to be changed to secure tube in a
different position.
To ensure oral hygiene is maintained reducing risk of
opportunistic infections.
2, 14
Maintaining Patency
Flush tube with 30-50mls water
before and after feed using a 50ml
enteral syringe.
If fluid restricted may need to reduce
these amounts.
If continuous feeding flush every 4-
6hrs as above.
Administration of medications
Where possible medications should
be given in liquid/dispersible form
with a water flush in between.
To ensure tube does not become blocked.
Use 50ml enteral syringe to prevent tube rupture or
collapse
To ensure fluid balance in 24hr period does not exceed
restriction.
To avoid blockage of tube.
3, 6, 7
4, 6, 11
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
11/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 11 of 22
Control Date: 09/10/2008
APPENDIX 2: PRODUCT INFORMATION / TUBE SELECTION / ENTERAL SYRINGES
PRODUCT ORDER NO. COST HOW TO ORDER
Flocare 8fg (non weighted) 35243 5.35 each UK Procure FWM 040
Merck 6fg (weighted) 090120004 10.03 each UK Procure FWM 243Merck 8fg (weighted) 090120012 10.03 each UK Procure FWM 301
BDH 0-6 Indicator Strips 315052J 3.19 pack UK Procure HHD 046
PRODUCT CONCENTRATED FEED THICK MEDICATION DIFFICULT INSERTION
Flocare 8fg (non weighted)
Merck 8fg (weighted)
Merck 6fg (weighted)
Catheter tip 60ml enteralsyringe PE60B 39p each (box of 55) FTA 048
60ml enteral syringe
(female luer lock)PE60 39p each (box of 60) FTA 047
20ml enteral syringe
(female luer lock)PE20 23p each (box of 80) FTA 046
10ml enteral syringe(female luer lock)
PE10 18p each (box of 100) FTA 044
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
12/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 12 of 22
Control Date: 09/10/2008
APPENDIX 3: ANATOMY + PHYSIOLOGY OF SWALLOWING
Upper Oesophageal sphincter contractedPass NG tube into Pharynx
Upper Oesophageal sphincter When patient swallows upper Oecloses over trachea sealing off ai
ass into Oeso ha us.
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
13/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 13 of 22
Control Date: 09/10/2008
APPENDIX 4: CONFIRMING THE CORRECT POSITION OF NASOGASTRIC FEEDING TUBES IN ADULTS
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
14/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 14 of 22
Control Date: 09/10/2008
IF YOU ARE UNABLE TO OBTAIN ASPIRATE
A. Turn patient onto their side Aspirate tube
This will allow the tip of the tube to enter the gastric
fluid pool.
B. If tube measurement is less than 60cm
advance tube 5 10cm Aspirate tube
Tube may be in oesophagus advancing tube may
allow it to pass into the stomach.C. If tube measurement is more than 70cm
withdraw tube 5 10cm Aspirate tubeTube may be inserted past the stomach into small
bowel. Withdrawing tube may bring tube back into
the stomach.
D. Is patient on any medication that increasesstomach emptying: i.e. metoclopramide
May result in little or no fluid within the stomach.
Seek senior advice.
E. If swallow is intact ask patient to drink 200mls
blackcurrant and attempt to aspirate via NGT.
On initial NGT placement if aspirate is
unobtainable and/or blackcurrant test is notappropriate an x-ray must be requested.
Aspiration of blackcurrant via NG indicates that
NGT is in stomach.
To confirm gastric placement. To give baseline
information for subsequent checking.Seek senior advice prior to requesting x-ray.
F. For subsequent checking of tubeposition
x-ray should not be routinely used.
It is inappropriate/unsafe to repeatedly send patients
for x-ray to verify tube position.
Seek senior advice.
IF ASPIRATE HAS A pH of 5 or above (if swallow intact refer to E above)
1. On initial NGT placement an x-ray must be
requested.
To confirm gastric placement
2. On subsequent check of tube positionif pH 5 5.5
a) Is patient on medication that could elevatepH of gastric contents?
b) Was an x-ray taken on placement thatconfirmed stomach position?
If yes to a and b and there is no indication that tubehas moved it is likely to be in stomach
Use Tube (see Appendix 1)
3. Aspirate appears to contain feed.
Wait 60 minutes Aspirate tube
Feed in stomach will elevate pH. If pH remains
elevated.
Seek senior advice.
4. If tube measurement is more than 70cm withdrawtube 5 10cm
Aspirate tube
Possible small bowel position of tube tip.Withdrawing tube will bring it back into stomach.
5. Bile Aspirated (green/yellow colour) Bile can indicate either small bowel or gastricplacement.
Seek senior advice.
6. No reason for pH.a. On initial placement of NGT an x-ray must
be obtained.
b. For subsequent checking of tube position it
is inappropriate to x-ray
a. To confirm gastric placement.
b. Seek senior advice.
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
15/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 15 of 22
Control Date: 09/10/2008
APPENDIX 5. NG TUBE POSITION CHART
NG TUBE POSITION CHART
Name: Date of birth: Hospital Number:
On initial NGT placement size/type of NGT . If pH less than 5 use Tube
Date Time Length of NGT in
cms at tip of nose
If Aspirate
obtainedpH value
If No Aspirate
Action Taken
If pH not less than
Action Taken
*If unsure seek senior guidance and refer to policy for The Insertion and Maintenance of Fine Bore Naso-Gastric Feeding T* Use BDH 0 6 Indicator strips Order No: HHD 046 - 315052J CLIN
023
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
16/22
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
17/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 17 of 22
Control Date: 09/10/2008
Competency Indicators1st Level
Achieved
Assessor
Signature
CompetencyIndicators2nd Level
Achieved
Assessor
Signature
CompetencyIndicators3rd level
Achie
Asses
Signat
f) Utilising an holisticapproach, understandthe implications for apatient having a NG eg
altered body image.g) Assist Health Care
Professional with theinsertion of the Naso-Gastric Tube
h) Maintain patient comfortand safety.
i) Maintain correct infectioncontrol procedures
j) Inform Health CareProfessional of anychange in patientscondition/status
Can access and maintainrelevant supplies at wardlevel
f) Subsequently check theposition of the Naso-gastricTube before administeringfeed and medication.
g) Demonstrate ability tomaintain patency andensure correct feedingregime is maintained.
h) Correctly administer
medication via Naso-gastrictube (if already competent at
administering medication)i) Initiate discharge planning,
involving relevant HealthCare Professionals.
e) Utilising experience and
knowledge, manage anycomplications, referringto Specialist Practitioneras required.
f) Co-ordinate dischargeplan, supporting thepatient in selfmanagement or involvecarers as required
g) Document allinterventions in the
patients recordsh) Facilitate learning andpractice developmentwithin clinical area.
i) Initiate a feeding regimenat weekends and over
Bank Holidays usingStarter regimen,provided in NGT Policy
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
18/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 18 of 22
Control Date: 09/10/2008
Education resources to support your development
- Policy & Guidelines for gainingConsent
- Policy & Guidelines for TheInsertion and Maintenance of Fine
bore Naso-gastric Feeding Tubesin Adults.
- Nutrition Benchmark (Essence ofCare)
- Policy and guidelines for infectioncontrol
Access Clinical Nutrition Nurse SpecialistsContact No 023 9228 6000 ext 5918
- Guidelines for enteral feeding inAdult Hospital Patients by Stroud,Duncan & Nightingale 2003 in GUT52 (suppl. V111) V11-1 V11-12
Opportunity for bi-annual education vianutrition link study days
- Web Site:British Association of Enteral & Pa
Contact Practice Development Nursavailable relevant courses.
Author: Gillian Fraser/Chris Caws Department: Nutrition/Gen. Surgery Review Date: Sept 2009
Record of Achievement.
To verify competence please ensure that you have the appropriate level signed as a record of yLevel 1 Level 2 Level 3 Level 4
Date
Signature of Educator/ Trainer
Date
Signature of Educator/ Trainer
Date
Signature of Educator/ Trainer
Date:
Signature of Assessor
Date:
Signature of Assessor
Date:
Signature of Assessor Signatu
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
19/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 19 of 22
Control Date: 09/10/2008
References to Support Competency
1. Cannaby, A et al. (2002) Nursing Care of Patients with Nasogastric Tubes British Journal of Nursing
11 (6) 366-3722. Christensen, M. (2001) Bedside Methods of Determining Nasogastric Tube Placement: A literature
review. Nursing in Critical Care 6 (4) 192-1993. Colagiovanni, l. (1999). Taking the Tube Nursing Times 95 (21) 63-714. Great Britain National Patient Safety Agency (2007). Promoting safer measurement and
administration of liquid medicines via oral and other enteral routes.5. Portsmouth NHS Trust (2005). Administration of Drugs to Adult Patients with feeding tubes. Drug
Therapy Guideline No 52.01, p1-25.6. Metheny, N., et.al. (2005). Indicators of Tubesite during Feedings. Journal of Neuroscience Nursing
37 (b), 320-325.
7. Taylor, S. & Clemente, R. (2005). Confirmation of Nasogastric tube position by pH testing. Journal ofHuman Nutrition and Dietetics 18 371-375.8. Great Britain. National Institute for Health and Clinical Excellence (2006). Nutrition Support in adults
(Clinical Guideline 32) London : NICE
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
20/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 20 of 22
Control Date: 09/10/2008
APPENDIX 7: STARTER REGIMEN FOR ADULTS
DEPARTMENTS OF NUTRITION AND DIETETICS AND CLINICAL NUTRITION
STARTER REGIMENFOR NASO-GASTRIC TUBE FEEDING IN ADULTS
The following instructions have been devised to enable competent Healthcare Professionals
(level 3) to commence artificial feeding via a naso-gastric tube.
Refer patient as soon as possible to the Dietitians for assessment and anindividualised Feeding Regimen see telephone extensions on page 2 or useOrderComms if you have access.
The decision to commence artificial feed is a medical decision and if a naso-gastric tube has been inserted for feeding it is not
acceptable to withhold feed because a Dietitian is not available to provide a feeding regimen.
The aim of the starter regimen is not to meet the patients total nutritional requirements but to avoid starvation and to introduce feed
slowly and safely so as not to cause harm to the patient.
Prior to commencement of feed you must request review by medical team to ensure there are no contraindications or special
measures that may need to be applied (for example: renal failure/congestive cardiac failure/fluid restricted patients/gastro-intestinal
obstruction).
You will need to assess if the patient is at risk of Refeeding Syndrome. If the patient is at risk you must use the feeding regimen on
page 3. Please see PHT Guidelines for the Prevention and Treatment of Adult Patients at Risk of Developing Refeeding Syndrome
for further details.
If the patient is not at risk proceed to use the regimen on page 2.
If the patient is very underweight i.e. less than 40kg you must follow the Refeeding regimen as the patient will need to be fed very
small amounts to start with.
The following starter regimens have been designed to be used at the end of the patients bed as a stand-alone document outside of
this policy.
PRODUCED BY Registered Dietitians and Clinical Nutrition Nurse SpecialistsDATE: June 2006REVIEWED: Reviewed and Updated July 2007 and December 2007REVIEW DATE: December 2009Portsmouth Hospitals NHS Trust
1
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
21/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 21 of 22
Control Date: 09/10/2008
Portsmouth Hospitals NHS Trust Departments of Nutrition and Dietetics AND Clinical Nutrition
NASOGASTRIC TUBEFEEDING STARTER REGIMEN FOR ADULTS
Ward:... Name:.. DOB:. DATE:.. Sheet No:..
Fluid Balance should be closely monitored. Feed should be delivered within the context of careful fluid balance with
intravenous fluids being reduced or discontinued as required*. Biochemistry (within last 48 hours) should be checked before starting and regularly monitored during feeding
Recommended rates are for guidance and not to contravene medical opinion.
REFER PATIENT TO DIETITIAN AS SOON AS POSSIBLE
For patients 40kg weight and over
(if patient less than 40kg use regimen for Refeeding Syndrome see over)Date/Day number Feed Type Rate
(ml/hour)Duration(hours)
Volume(ml)
DAY 1 Water 30 4 120
Fresubin Original 20 20 400
DAY 2 Water 30 4 120
Fresubin Original 30 20 600
DAY 3 Water 50 4 200
Fresubin Original 50 20 1000
Patient may require additional intravenous fluids* - please assess fluid balance
Dietitians x 7700 6150 QAH x 7701 3720 SMH Nutrition Nurses x 7700 5918
2
2
Continue as Day 3 until Dietetic Review
Ensure the patients head is elevated to at least 30 degrees during feeding, and for one hour after feedinghas stopped
Feeding tubes should be flushed before and after medication and whenever the feed is started/stoppedwith 30ml water
Giving sets should be changed daily
If symptoms of intolerance occur (vomiting, abdominal distension, diarrhoea etc) consult medical staff.
If problems with tube management occur eg tube choice, insertion techniques, position check andongoing care, please contact the Nutrition Nurses.
Further information:
- Policy on Insertion and Maintenance of Fine Bore Naso-gastric feeding Tubes in Adults, ClinicalGuidelines, PHT Intranet. This Starter Regimen is Appendix 6 of this Clinical Policy.
- Marsden Manual Chapter 27 pp385-401 Nutrition Support- located on ward and PHT Intranet- NICE Clinical Guideline 32 Nutrition Support in Adults - (URI on PHT Intranet)- 2Drug Therapy Guideline No: 52.01 Administration of Drugs to Adult Patients with Feeding Tubes- 3Drug Therapy Guideline No: 46.00 Guidelines for the Prevention and treatment of Adult Patients At
Risk of Developing Refeeding Syndrome.
7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults
22/22
PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES
Insertion and maintenance of fine bore naso gastric feeding tubes in adults policy Issue 4 04 03 2008 Page 22 of 22
FOR ADULT PATIENTS AT RISK OF REFEEDING SYNDROME
Ward:... Name:.. DOB:. DATE:.. Sheet No:..
Fl
u
i
d
B
a
l
a
n
c
e
s
hould be closely monitored. Feed should be delivered within the context of careful fluid balance with intravenous fluids
being reduced or discontinued as required. * Thiamine -100 mg three times daily (the first dose 30 minutes prior to starting feeding3) either orally OR crushed via
feeding tube2
AND Vigranon B 5ml three times daily via feeding tube.2 3 OR Vitamin B compound strong - 1 tablet three times dailyorally
AND Sanatogen Gold 1 tablet daily either crushed via feeding tube.2 3 or orally.
Biochemistry should be closely monitored BEFORE STARTING (within last 24 hours) and DAILY during feeding,especially Potassium, Magnesium, Phosphate, and Corrected Calcium. If any of these are low do not increase feed rate
do inform medical staff and dietitian when available.
Recommended rates are to guide but not contravene medical opinion. Recommend not to start nutritional supplement drinks (eg Fresubin Energy, Provide Xtra etc) at same time as
starter regimen if patient at risk of Refeeding syndrome
REFER PATIENT TO DIETITIAN AS SOON AS POSSIBLE
Feeding must be increased slowly in accordance with the regimen below following thiamine administration, see above.
For patients At Risk of Refeeding Syndrome or below 40 kg in weight
Date/Daynumber
Feed Type Rate(ml/hour)
Duration(hours)
Volume(ml)
Day 1 Water 30 4 120
Fresubin Original 15 20 300
Day 2 Water 30 4 120Fresubin Original 20 20 400
Day 3 Water 30 4 120
Fresubin Original 25 20 500
Patient will require additional intravenous fluids*
SEE INFORMATION REGARDING DAILY PATIENT MANAGEMENT WHILST FEEDINGON PAGE 2 of this appendix
Occasionally patients will be at risk of Refeeding Syndrome. They can be identified from the following list.Patients with:
ONE OR MORE OF THE FOLLOWING:
Little or no nutritional intake for more than 10 days
Unintentional weight loss greater than 15% within the last 3-6 months
Body Mass Index less than 16
Low levels of potassium, phosphate or magnesium prior to feeding
TWO OR MORE OF THE FOLLOWING:
Little or no nutritional intake for more than 5 days
Unintentional weight loss greater than 10% within last 3-6 months
Body Mass Index less than 18.5