Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults

PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES
Section 3.11
TITLE REFERENCE NUMBER MANAGER / COMMITTEE RESPONSIBLE DATE ISSUED
PHT POLICY FOR THE INSERTION AND MAINTENANCE OF FINE BORE NASO-GASTRIC FEEDING TUBES IN ADULTS
3.11 CLINICAL NUTRITION NURSE SPECIALISTS
04.03.2008
VERSION
REVIEW DATE
Equality Impact Assessment has been applied to this policy
December 2009 Joanne Pratt - Lead Clinical Nutrition Nurse Specialist Jo Pratt and Gillian Fraser - Clinical Nutrition Nurse Specialists
AUTHOR
RATIFIED BY Amendments record: Date 15th Dec 2007 24 Nov 2007 15 Dec 2007 19TH Dec 2007 6th Jan 2008 14th Jan 2008
PROFESSIONAL ADVISORY COMMITTEE 06.02.2008
Page throughout 5 7,12, 13 16 17 19 20 -22
Comments Syringe changed to enteral syringe Updated references Use of blackcurrant drink NG tube position chart Updated competency Updated starter regimen
Approved By: CNNS, NST, MATRONS, Debbie Knight CNNS,NST, MATRONS, Debbie Knight CNNS, NST MATRONS, Debbie Knight CNNS, NST, MATRONS, Debbie Knight
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
Section 3.11
CONTENTS:
1. 2. 3. 4. 5. 6. 7. 8. 9. INTRODUCTION / BACKGROUND STATUS PURPOSE SCOPE/AUDIENCE DEFINITIONS PROCESS DUTIES AND RESPONSIBILITIES TRAINING ASSOCIATED DOCUMENTATION
APPENDICES:
1. 2. 3. 4. 5. 6. 7. PROTOCOLS FOR PRACTICE PRODUCT INFORMATION / TUBE SELECTION ANATOMY + PHYSIOLOGY OF SWALLOWING CONFIRMING THE CORRECT POSITION OF NASOGASTRIC FEEDING TUBES IN ADULTS (FLOWCHART) NG TUBE POSITION CHART NG COMPETENCY STARTER REGIMEN FOR ADULTS
1. INTRODUCTION / BACKGROUND Nasogastric 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 nasogastric tube (NGT) placement as studies have shown this method to be inaccurate. NG tubes should be aspirated and tube position confirmed using ph indicator strips BDH (0-6) (See Appendix 1 & 2) X-rays should not routinely be used. (9). 2. STATUS This is a clinical policy. 3. PURPOSE This 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/AUDIENCE These 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-gastric feeding tube. For administration of medication via a fine bore nasogastric feeding tube please refer to Administration of Drugs 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.
PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES A. INDICATIONS Indication for feeding Unconscious patient Swallowing disorder Example Head injury, ventilated patient Post-CVA, multiple sclerosis, motor neurone disease. Liver disease (particularly with ascities) Oesophageal stricture Postoperative ileus inflammatory bowel disease, short bowel syndrome. Cystic fibrosis, renal disease, critical illness Severe depression or anorexia nervosa Cerebrovascular accident.
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Evidence 1.
Physiological anorexia Upper GI obstruction Partial intestinal failure Increased nutritional requirements Psychological problems GI, gastrointestinal:
B CONTRADINDICATIONS Fractured Base of skull Bleeding Oesophageal Varices Perforated oesophagus Perforated pharyngeal pouch C 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
Insertion Nasal damage, intracranial insertion, pharyngeal/oesophageal pouch perforation, bronchial placement, variceal bleeding. Discomfort, erosions, fistulae, and strictures. Post insertion trauma 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
Evidence
Displacement Reflux GI intolerance Metabolic
*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 Specialists for assessment.
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5. DEFINITIONS Fine 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 (stomach end = 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 nasopharynx 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 is usually a short- term intervention (4-6 weeks). A route for permanent enteral access should be considered if enteral 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. Competency level 2 and above (Appendix 6). Maintenance of a Nasogastric tube: Includes correctly checking tube position, and maintaining the patency of that tube. Ongoing management includes 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 to manage risk. 7. DUTIES AND RESPONSIBILITIES
Doctors The 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 is unable to confirm tube position at the bedside it is the Doctors responsibility to request and review a chest xray 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 of competency (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 above practitioner in a safe and competent manner (see Appendix 6: NG Competency).
PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES Aspect of Care/Outcomes 1. NGTs are inserted by a competent level 2 and above practitioner. NGTs are safely maintained by level 2 and above practitioners 2. All ward areas use pH indicator strips BDH 0 - 6 to test aspirate when confirming NG position. 3. NG Tube is not used if inadvertently placed in the lungs 4. CxR requested on placement only when aspirate is unobtainable. 5. The position of NG tube is checked as per Policy and documented on NG Tube Position Chart (see appendix 5). 8. TRAINING Expected Standard Target
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Source of Data Collection
100%
Review of medical notes. Staff Interviews.
100%
Audits
100%
Risk Incident Forms Audit x-ray Review of medical notes Review of patient notes. Audit of use of NG Tube Position Chart
100%
100%
Liaison with Ward Managers, Practice Development Nurses, Clinical Educators and Modern Matrons to 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 Hospital Patients. 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 literature Review. 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.
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10. Great Britain National Patient Safety Agency (2007). Promoting safer measurement and administration of liquid medicines via oral and other enteral routes. 11. Portsmouth NHS Trust (2005). Administration of Drugs to Adult Patients with feeding tubes. Drug Therapy Guideline No 52.01, p1-25. 12. Metheny, N., et.al. (2005). Indicators of Tubesite during Feedings. Journal of Neuroscience Nursing 37 (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
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APPENDIX 1: PROTOCOLS FOR PRACTICE
List of Equipment for Procedure: Clean tray or trolley 1 x fine bore feeding tube 6 - 8fg 1 x glass of water and straw 1x 10ml enteral syringe filled with tap water 1 x 50ml enteral syringe Bioclusive/Hypafix pH Indicator strips ACTION
1. Explain procedure to patient. 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. 3. Wash hands and apply gloves. Assemble required equipment, select appropriate tube.
RATIONALE
To obtain patients consent and cooperation. This position allows easy swallowing and ensures that the epiglottis is not obstructing the oesophagus. To ensure a clean procedure is maintained throughout. Consider gauge required dependent on diagnosis. Patient may have one nostril which is clearer than the other e.g. deviated nasal septum To gain an approximate length for that patient. This will ensure that the guide wire can be easily removed once placed. This will facilitate easy passage when inserting the tube. There are two distinct stages when passing the tube. a. nose pharynx stop and swallow b. pharynx stomach. 1
EVIDENCE
Appendix 3. Appendix 2. Infection Control Policy 2 1 1 2 1 2 4 12
4. Check nose and mouth for any signs of Obstruction and ensure both are clean. Check nasal patency by sniff with each nostril occluded in turn. 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). 6. Flush the tube with 1-2mls of water Ensure guidewire moves freely. 7. Lubricate the NG tube by immersing end of tube in water. 8. Insert the tube into the clearest nostril and slide backwards 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. 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.
Manufacturers guidelines 2 Appendix 3
The passing of the NGT can be coordinated with observing for laryngeal movement. During this phase the epiglottis covers the airway and NGT can pass into oesophagus.
Appendix 3.
14
Risk of aspiration.
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ACTION
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. 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. 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. 12. Follow steps A-C to obtain aspirate and verify 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. 13. If unable to obtain aspirate or pH of aspirate is 5 or above follow flowchart See 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
RATIONALE
EVIDENCE
This reduces the risk of aspirating fluids.
1 14
One nostril may be clearer than the other. Smaller gauge or weighted tube may be easier to pass on specific patients. 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. 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.
Appendix 2 1 2 8 2 8
3, 13 4 5 10
3, 9, 12, 13
9, 13
Appendix 4. 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. 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.
X-ray request forms need to document that CXR is to verify NG tube position, as a specific density is required.
4 5 13
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.
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SUBSEQUENT VERIFICATION OF NGT POSITION As 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
1. 2. 3. 4. 5. Each bolus feed or drug administration. At least once every 24hrs when continuous feeds are used. If the patient complains of discomfort or feed reflux into the mouth. After vomiting or violent retching. After severe coughing bouts/respiratory distress. After endotracheal or tracheostomy tube suctioning. If tube has obviously displaced on checking measurement. On receipt of patient being transferred prior to using tube.
RATIONALE
To confirm correct position prior to use. To ensure tube has not displaced. To ensure tube has not displaced. Tube may be coiled in back of throat. To ensure tube has not displaced. To ensure tube has not displaced. Check back of throat to ensure that tube is not coiled. To ensure tube has not displaced.
EVIDENCE
4, 6, 8, 14 4, 6, 8 4, 6, 8 4, 6, 8 4, 6, 8 4, 6, 8 4, 6, 8 4, 6, 8
6. 7. 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
1. Check that level 2 Practitioner has followed guidance on flowchart (appendix 4). Obtain patient history: Check measurement at nose Has patient vomited, coughed, or complained of feed reflux? If tube position has not moved, inject 5/10mls of water into NG tube. Attempt to re-aspirate using a 10ml enteral syringe. Aspirate visualisation: -
RATIONALE
To ensure correct procedure has been followed. 14
EVIDENCE
2.
To check if tube has moved. To ensure tube has not displaced.
3.
This has been shown to ease the process for obtaining aspirate Altered feed may indicate gastric digestion. Bile may indicate stomach or small bowel position. 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.
4.
12
5.
Consider auscultation to give further supportive information.
8, 9, 13
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ONGOING MANAGEMENT ACTION

Skin 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. Maintaining Patency Flush tube with 30-50mls water before and after feed using a 50ml enteral syringe.
RATIONALE
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.
EVIDENCE
2, 14
To ensure tube does not become blocked. Use 50ml enteral syringe to prevent tube rupture or collapse
3, 6, 7
If fluid restricted may need to reduce these amounts. If continuous feeding flush every 46hrs as above. Administration of medications Where possible medications should be given in liquid/dispersible form with a water flush in between.
To ensure fluid balance in 24hr period does not exceed restriction.
To avoid blockage of tube.
4, 6, 11
PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES APPENDIX 2: PRODUCT INFORMATION / TUBE SELECTION / ENTERAL SYRINGES PRODUCT Flocare 8fg (non weighted) Merck 6fg (weighted) Merck 8fg (weighted) BDH 0-6 Indicator Strips PRODUCT Flocare 8fg (non weighted) Merck 8fg (weighted) Merck 6fg (weighted) Catheter tip 60ml enteral syringe 60ml enteral syringe (female luer lock) 20ml enteral syringe (female luer lock) 10ml enteral syringe (female luer lock) ORDER NO. 35243 090120004 090120012 315052J CONCENTRATED FEED

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COST 5.35 each 10.03 each 10.03 each 3.19 pack THICK MEDICATION
HOW TO ORDER UK Procure FWM 040 UK Procure FWM 243 UK Procure FWM 301 UK Procure HHD 046 DIFFICULT INSERTION
PE60B PE60 PE20 PE10
39p each (box of 55) 39p each (box of 60) 23p each (box of 80) 18p each (box of 100)
FTA 048 FTA 047 FTA 046 FTA 044
PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES APPENDIX 3: ANATOMY + PHYSIOLOGY OF SWALLOWING
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Upper Oesophageal sphincter contracted Pass NG tube into Pharynx
Upper Oesophageal sphincter relaxed When patient swallows upper Oesophageal sphincter relaxes, epiglottis closes over trachea sealing off airway, therefore NG tube more likely to pass into Oesophagus.
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APPENDIX 4: CONFIRMING THE CORRECT POSITION OF NASOGASTRIC FEEDING TUBES IN ADULTS
PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES IF YOU ARE UNABLE TO OBTAIN ASPIRATE
A. Turn patient onto their side Aspirate tube B. If tube measurement is less than 60cm advance tube 5 10cm Aspirate tube C. If tube measurement is more than 70cm withdraw tube 5 10cm Aspirate tube D. Is patient on any medication that increases stomach emptying: i.e. metoclopramide 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 not appropriate an x-ray must be requested.
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This will allow the tip of the tube to enter the gastric fluid pool. Tube may be in oesophagus advancing tube may allow it to pass into the stomach. Tube may be inserted past the stomach into small bowel. Withdrawing tube may bring tube back into the stomach. May result in little or no fluid within the stomach. Seek senior advice. 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.
It is inappropriate/unsafe to repeatedly send patients F. For subsequent checking of tube for x-ray to verify tube position. position Seek senior advice. x-ray should not be routinely used. 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. 2. On subsequent check of tube position if pH 5 5.5 a) Is patient on medication that could elevate pH of gastric contents? b) Was an x-ray taken on placement that confirmed stomach position? To confirm gastric placement
If yes to a and b and there is no indication that tube has moved it is likely to be in stomach Use Tube (see Appendix 1)
3. Aspirate appears to contain feed. Wait 60 minutes
Feed in stomach will elevate pH. If pH remains elevated. Aspirate tube Seek senior advice.
4. If tube measurement is more than 70cm withdraw Possible small bowel position of tube tip. tube 5 10cm Withdrawing tube will bring it back into stomach. Aspirate tube 5. Bile Aspirated (green/yellow colour) 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 Bile can indicate either small bowel or gastric placement. Seek senior advice. a. To confirm gastric placement. b. Seek senior advice.
PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES APPENDIX 5. NG TUBE POSITION CHART
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NG TUBE POSITION CHART

Name: Date of birth: Hospital Number: .
On initial NGT placement size/type of NGT . Date Time Length of NGT in cms at tip of nose If Aspirate obtained pH value If No Aspirate Action Taken
If pH less than 5 use Tube If pH not less than 5 Action Taken Signature and print name
*If unsure seek senior guidance and refer to policy for The Insertion and Maintenance of Fine Bore Naso-Gastric Feeding Tubes in Adults * Use BDH 0 6 Indicator strips Order No: HHD 046 - 315052J CLINICAL NUTRITION NURSE SPECIALISTS 023 9228 6000 Ext 5918 Bleep 1484/1813

Name
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APPENDIX 6: NG COMPETENCY: Competency Statement: Competency Statement: Care of a patient with a fine bore Naso-gastric feeding Tube
Competency Indicators 1st Level After obtaining consent from the patient (as appropriate)
a) Correctly undertake initial Achieved Assessor Signature
Competency Indicators 2nd Level After obtaining consent from the patient (as appropriate) Level 1+ a) Interpret information from initial nursing assessment and identify risk factors. b) Implement and evaluate relevant nutritional plan. c) Involve patient, relative and significant other, informing them of plan and potential outcomes. d) Following medical consultation including consideration of ethical issues. Correctly insert the appropriate Naso-gastric tube, checking that it is positioned correctly. e) Demonstrate knowledge of complications associated with an NG tube and NG feeding
Achieved Assessor Signature
Competency Indicators 3rd level After obtaining consent from the patient (as appropriate) Level 1 and 2+ a) Manage and ensure that all nutritional interventions are provided by the appropriate Health Care Professional b) Evaluate treatment and instigate further interventions as required. c) Lead multi-disciplinary discussion involving patient, relative and significant others, in the ethical issues and the appropriateness of planned intervention. d) Able to manage difficult tube insertions on a range of patients.
Competency Indicators 4th level After obtaining consent from the patient (as appropriate) Level 1, 2 and 3+ a) Act as a resource to support and lead the multi-disciplinary team in the planning of further treatment and intervention.
b) Undertake audit, set
nutritional assessment Weight Height BMI

b)
Inform Health Care Professional of patients nutritional assessment as required.
c) Record information/
intervention accurately in patients record d) Keep patient, relatives and significant others informed of all actions e) Report significant changes and refer to relevant Health Care Professional.
Trust wide standards and policies for the care of the patient with a fine bore feeding tube, based on expert knowledge, relevant research and experience. c) Lead regular reviews of equipment in use and update as required

Competency Indicators 1st Level
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Competency Indicators 2nd Level
Competency Indicators 3rd level e) Utilising experience and knowledge, manage any complications, referring to Specialist Practitioner as required. Co-ordinate discharge plan, supporting the patient in self management or involve carers as required Document all interventions in the patients records Facilitate learning and practice development within clinical area. Initiate a feeding regimen at weekends and over Bank Holidays using Starter regimen, provided in NGT Policy
Competency Indicators 4th level

d) Act as an expert
Utilising an holistic approach, understand the implications for a patient having a NG eg altered body image. g) Assist Health Care Professional with the insertion of the NasoGastric Tube h) Maintain patient comfort and safety. i) Maintain correct infection control procedures j) Inform Health Care Professional of any change in patients condition/status Can access and maintain relevant supplies at ward level
f)
Subsequently check the position of the Naso-gastric Tube before administering feed and medication. g) Demonstrate ability to maintain patency and ensure correct feeding regime is maintained. h) Correctly administer medication via Naso-gastric tube (if already competent at administering medication) i) Initiate discharge planning, involving relevant Health Care Professionals.
f)
resource advising, teaching and supporting members of the Portsmouth NHS Trust.
e) Act as an expert
f)
g)
practitioner with patient case load supporting and advising patients and carers both in PHT and within the community.
h)
i)
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Education resources to support your development - Policy & Guidelines for gaining - Web Site: - Guidelines for enteral feeding in Consent British Association of Enteral & Parental Nutrition (BAPEN) www.bapen.org.uk Adult Hospital Patients by Stroud, Contact Practice Development Nurses and or Clinical Educators for information on Policy & Guidelines for The Duncan & Nightingale 2003 in GUT Insertion and Maintenance of Fine available relevant courses. 52 (suppl. V111) V11-1 V11-12 bore Naso-gastric Feeding Tubes Opportunity for bi-annual education via in Adults. nutrition link study days - Nutrition Benchmark (Essence of Care) - Policy and guidelines for infection control Access Clinical Nutrition Nurse Specialists Contact No 023 9228 6000 ext 5918
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 your achievement in the boxes below.
Level 1 Level 2 Level 3 Level 4
Date Signature of Educator/ Trainer Date: Signature of Assessor Signature of Assessor
Date Signature of Educator/ Trainer Date: Signature of Assessor
Date Signature of Educator/ Trainer Date: Signature of Assessor
Date Signature of Educator/ Trainer Date:
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References to Support Competency 1. Cannaby, A et al. (2002) Nursing Care of Patients with Nasogastric Tubes British Journal of Nursing 11 (6) 366-372 2. Christensen, M. (2001) Bedside Methods of Determining Nasogastric Tube Placement: A literature review. Nursing in Critical Care 6 (4) 192-199 3. Colagiovanni, l. (1999). Taking the Tube Nursing Times 95 (21) 63-71 4. 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 of Human 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
PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES APPENDIX 7: STARTER REGIMEN FOR ADULTS DEPARTMENTS OF NUTRITION AND DIETETICS AND CLINICAL NUTRITION
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STARTER REGIMEN FOR 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 an individualised Feeding Regimen see telephone extensions on page 2 or use OrderComms 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 Specialists DATE: June 2006 REVIEWED: Reviewed and Updated July 2007 and December 2007 REVIEW DATE: December 2009 Portsmouth Hospitals NHS Trust 1
Section 3.11
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 DAY 1 DAY 2 DAY 3 Feed Type Water Fresubin Original Water Fresubin Original Water Fresubin Original Rate (ml/hour) 30 20 30 30 50 50 Duration (hours) 4 20 4 20 4 20 Volume (ml) 120 400 120 600 200 1000
Patient may require additional intravenous fluids* - please assess fluid balance
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 feeding has stopped Feeding tubes should be flushed before and after medication and whenever the feed is started/stopped with 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 and ongoing care, please contact the Nutrition Nurses. Further information: - Policy on Insertion and Maintenance of Fine Bore Naso-gastric feeding Tubes in Adults, Clinical Guidelines, 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) - 2 Drug Therapy Guideline No: 52.01 Administration of Drugs to Adult Patients with Feeding Tubes - 3 Drug Therapy Guideline No: 46.00 Guidelines for the Prevention and treatment of Adult Patients At Risk of Developing Refeeding Syndrome.
Dietitians x 7700 6150 QAH x 7701 3720 SMH 2 2
Nutrition Nurses x 7700 5918

FOR ADULT PATIENTS AT RISK OF REFEEDING SYNDROME
Section 3.11
Ward:... Name:.. DOB:. DATE:.. Sheet No:.. 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 A history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics 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 daily orally 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. F l u i d B a l a n c e s
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/Day Feed Type Rate Duration number (ml/hour) (hours) Day 1 Water 30 4 Fresubin Original 15 20 Day 2 Water 30 4 Fresubin Original 20 20 Day 3 Water 30 4 Fresubin Original 25 20 Patient will require additional intravenous fluids*
Volume (ml) 120 300 120 400 120 500
SEE INFORMATION REGARDING DAILY PATIENT MANAGEMENT WHILST FEEDING ON PAGE 2 of this appendix

Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults

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PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES

TITLE REFERENCE NUMBER MANAGER / COMMITTEE RESPONSIBLE DATE ISSUED

PROFESSIONAL ADVISORY COMMITTEE 06.02.2008

Page throughout 5 7,12, 13 16 17 19 20 -22

PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES

Displacement Reflux GI intolerance Metabolic

PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES

Source of Data Collection

Review of medical notes. Staff Interviews.

PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES

PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES

APPENDIX 1: PROTOCOLS FOR PRACTICE

Appendix 3. Appendix 2. Infection Control Policy 2 1 1 2 1 2 4 12

Manufacturers guidelines 2 Appendix 3

PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES

This reduces the risk of aspirating fluids.

Trust Policy and Protocol for the Management of Records (2005)

17. Implement NG tube position chart (Appendix 5) at bedside

To ensure documentation of NG position check.

PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES

To check if tube has moved. To ensure tube has not displaced.

Consider auscultation to give further supportive information.

PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES

ONGOING MANAGEMENT ACTION

To ensure fluid balance in 24hr period does not exceed restriction.

To avoid blockage of tube.

PE60B PE60 PE20 PE10

FTA 048 FTA 047 FTA 046 FTA 044

Upper Oesophageal sphincter contracted Pass NG tube into Pharynx

PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES

APPENDIX 4: CONFIRMING THE CORRECT POSITION OF NASOGASTRIC FEEDING TUBES IN ADULTS

3. Aspirate appears to contain feed. Wait 60 minutes

NG TUBE POSITION CHART

PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES

Achieved Assessor Signature

Achieved Assessor Signature

Achieved Assessor Signature

nutritional assessment Weight Height BMI

Inform Health Care Professional of patients nutritional assessment as required.

PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES

Competency Indicators 2nd Level

Achieved Assessor Signature

Achieved Assessor Signature

Competency Indicators 4th level

Achieved Assessor Signature

PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES

Date Signature of Educator/ Trainer Date: Signature of Assessor Signature of Assessor

Date Signature of Educator/ Trainer Date: Signature of Assessor

Date Signature of Educator/ Trainer Date: Signature of Assessor

Date Signature of Educator/ Trainer Date:

PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES

STARTER REGIMEN FOR NASO-GASTRIC TUBE FEEDING IN ADULTS

PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES

For patients 40kg weight and over

Dietitians x 7700 6150 QAH x 7701 3720 SMH 2 2

Nutrition Nurses x 7700 5918

PORTSMOUTH HOSPITALS NHS TRUST CLINICAL POLICIES

REFER PATIENT TO DIETITIAN AS SOON AS POSSIBLE

Volume (ml) 120 300 120 400 120 500

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