Insertion of ngt retaining device nasal loop bridle

Guideline for Insertion of NGT Retaining Loop (Nasal Loop / Bridle)

Version 2

Name of responsible (ratifying) committee Nutrition Support Group

Date ratified 12.01.2010

Document Manager (job title)Gillian Fraser Clinical Nutrition Nurse Specialist Jo Pratt Lead Clinical Nutrition Nurse Specialist

Date issued 15.02.2010

Review date February 2012

Electronic location Corporate Clinical Guidelines

Related Procedural DocumentsPolicy for the Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults

Key Words (to aid with searching)

NGT Fixation; Nasal Bridle; Nasal Loop Forcible feeding; Feeding practices; Feeding behaviour; Ethnic differences; Cultural factors; Patient restraint; Patient compliance; Patient cooperation; Artificial feeding; Parenteral feeding

Guideline for Insertion of NGT Retaining Loop (Nasal Loop / Bridle). Issue 2.15.02.2010 of 9 (Review date February 2010) 08/04/2023

CONTENTS:1. QUICK REFERENCE GUIDE2. INTRODUCTION 3. PURPOSE4. SCOPE 5. DEFINITIONS6. DUTIES AND RESPONSIBILITIES7. PROCESS8. TRAINING REQUIREMENTS9. ASSOCIATED DOCUMENTATION10. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL

DOCUMENTS

APPENDICES:

1. PICTURES2. INDICATIONS/ CONTRAINDICATIONS /CONSIDERATIONS3. CARE OF PATIENT WITH NASAL RETAINING LOOP

1. QUICK REFERENCE GUIDE

1. Patients who repeatedly remove Nasogastric Tubes are referred to the CNNS/CNSC team for NRL assessment.

2. Patients are assessed for appropriateness of NRL insertion by CNNS/CNCSs

3. Appropriate consent is obtained prior to NRL insertion and is documented in patients notes

4. Ward staff are issued with NRL care guidelines and educated on how to care for NRL

5. All patients with NRL insitu are reviewed weekly by CNNS team

6. NRL can be removed if absolutely necessary to prevent damage to the nasal septum


2. INTRODUCTION

The use of naso-gastric tubes (NGT) is a common procedure across many different specialties. This procedure is documented in the PHT Policy for Insertion and Maintenance of Fine Bore Feeding Tubes in Adults. Naso-gastric tubes become displaced for a variety of reasons and a small group of patients appear to be particularly intolerant of the tube and require a NGT to be re-passed frequently. This can be distressing for the patient, their family and detrimental to their recovery and/or treatment. An alternative fixing device has been developed called the Nasal Retaining Loop (AMT Bridle). This provides a means of securing the NGT to prevent accidental or intentional tube removal by the patient. Using this device is potentially an ethically sensitive decision and is recognised as a form of restraint. This guideline has been written to enable designated practitioners to follow an agreed decision making, assessment and procedural process.

3. PURPOSE

This guideline is designed to enable Clinical Nutrition Nurse Specialists (CNNS), Consultant Nurse Stroke Care (CNSC) to place Nasal Retaining Loops in patients who repeatedly remove NG tubes.

4. SCOPE

The Nasal Retaining Loop will solely be inserted by the CNNS/CNSC who will act as gatekeepers for this procedure. Supplies of this device are held only by the CNNS/CNSC. Insertion will follow assessment and multidisciplinary consultation.

In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

5. DEFINITIONS

Nasal Retaining Loop (NRL): Is a method of preventing inadvertent displacement or removal of fine-bore nasogastric feeding tubes in patients requiring enteral administration of feed, fluid or medication. It comprises of a rigid probe and a flexible probe with a tape attached. The flexible probe has a removable guidewire. Each probe has a magnet at the end. The probes are inserted into each nostril until the magnets join at the back of the nose. The rigid probe is then pulled out of the nostril bringing the flexible probe and the loop of tape around the back of the nasopharynx and exiting from each nostril. The tapes from each nostril are then secured to the NGT with a clamp, reducing the risk of inadvertent removal.

Fine bore naso-gastric feeding tube: -Defined as between a 6fg - 8fg tube. The length of the tube is measured in cms starting at the distal tip (stomach end = “0”cms). 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.An 8fg NGT needs to be in situ to place a NRL.

6. DUTIES AND RESPONSIBILITIES

Doctors: It is a medical decision to commence enteral feeding.

Healthcare professionals: It is the responsibility of those caring for the patient to assess whether they have capacity to consent for this procedure. If the patient is deemed to lack capacity then a best interests decision should be made.

Registered Nurse: It is the nurses’ responsibility to care for the NGT and NRL as per Trust Policy/Guideline and assist the CNNS/CNSC in NRL placement.


CNNS/CNSC: It is the CNNS/CNSC responsibility to assess the patient for NRL insertion and maintain competency in inserting the NRL. All patients with a NRL in situ will be reviewed weekly by the CNNS.

7. PROCESS

Equipment:-Gloves/ApronNasal Retaining Loop8fg NGT (if not already in situ)Mouthcare swabs TissuesScissorsClinical Practice GuidelineLubricating JellypH indicator stripsenteral syringe

1. Following a referral the CNNS/CNCS will assess the patient for appropriateness for nasal loop insertion.(Appendix 2)

2. If the patient has capacity the procedure should be explained to gain consent. If the patient is deemed to lack capacity then a best interests decision should be made and documented in the medical notes.

3. The patient should be positioned appropriately according to assessment, to enable ease of placement.

4. Wash hands and apply gloves and apron in preparation for procedure. Open and prepare equipment (as above).

5. Check nose for any signs of obstruction and that both the nose/mouth are clean as this may impede insertion.

6. Lubricate rigid blue probe and insert into the nostril following the anatomy of the nose. If NGT in situ insert rigid blue probe into the NGT nostril. Advance up to the 2nd groove on the probe and maintain probe position.If blue probe will not advance try the other nostril (as patient may have deviated nasal septum or obstruction in that nostril) See Appendix 1 – Picture 1.

7. When rigid blue probe is in situ-insert the flexible white probe (with tape) into the opposite nostril and withdraw the guidewire 1-2 cms. This allows flexibility of the white probe and easier connection with the magnet of the rigid blue probe. Some manipulation of the flexible white probe may be required until the magnets from both the rigid blue probe and the flexible white probe unite within the nasopharynx.

ORFully insert the flexible white probe and completely remove the guidewire, very gently withdraw the rigid blue probe until taped white probe and magnets unite.If the magnets have joined then the flexible white probe will be able to be pulled through by the rigid blue probe. (May also hear a click or feel the magnets joining)

(See Appendix 1 - Picture 3)

8. When confirmed that the magnets are joined- remove guidewire from flexible white probe (if still in situ) prior to pulling through nostril.


9. Slowly withdraw the rigid blue probe from one nostril- pulling the flexible white probe with attached tape up from the other nostril and over the nasal septum. Pull all the way out until only the tape is visible protruding from both nostrils.

See Appendix 1 - Picture 4.

10. Using scissors cut the flexible white probe from the tape leaving only the tape in the nose.Insert NGT if not already in situ. The assistant is responsible for ensuring the nasal retaining loop remains insitu.

11. If inserting NGT at time of nasal retaining loop placement-check NGT position as per Trust Policy prior to securing the clamp from the nasal retaining loop to the NGT.Once confirmed to be in correct position –knot tapes securely under the nose, and place NGT in the groove in the clamp near to the nose.

12. Put one of the tapes in the clamp with the NGT and fold the two halves of the clamp together and press firmly to secure the NGT in the clamp.

13. After the clamp has been closed – verify that it will not slip or re-open. Knot the tapes together under the clamp and trim excess tape. See Appendix 1 – Picture 6.

14. Document procedure with outcome in medical notes leaving clear instructions re ongoing management for nursing staff. (Appendix 3)

15. The ward cost code will be obtained so that the cost of equipment used can be recharged to the clinical area.

8. TRAINING REQUIREMENTS

The CNNS and CNSC are responsible for training new in post nurses within the Clinical Nutrition Nurse Specialist team and the Consultant Nurse Stroke Care Team respectively.

The CNNS team are responsible for educating ward staff re care of a patient with a NRL insitu

9. REFERENCES AND ASSOCIATED DOCUMENTATION

Anderson M.R., O’Connor M. Mayer, P. et al (2004). The nasal loop provides an alternative to percutaneous gastrostomy in high risk dysphagic stroke. Clinical Nutrition. 23(4)

Eisenberg P, Spies M, Metheny N., (1987). Characteristics of patients who remove their nasal feeding tubes. Clinical Nurse Specialist.1(3):94-98.

Great Britain National Patient Safety Agency (2005). Patient Safety Alert 05. Reducing the harm caused by misplaced nasogastric tubes. NPSA, London.

Meer, J.A. (1989). A new nasal bridle for securing naso enteral feeding tubes. Journal of Parenteral and Enteral Nutrition. 13(3) p331-34.

Norton B. et al. (1996). A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. British Medical Journal.; 312:13-16.

Pancorbo-Hidalgo, P.L., Fernandez, F.P., Rimirez-Perez, C. et al (2001). Complications associated with enteral nutrition by nasogastric tube in an internal medicine unit. Journal of Clinical Nursing. 104 p482-90.


Popovich, M.J. Lockrem, J.D., Zivot, J.B. (1996). Nasal bridle revisited: an improvement in the technique to prevent unintentional removal of small bore nasoenteraic feeding tubes. Critical Care Medicine. 24(3) p429-31.

Royal College of Nursing (2004). Restraint Revisited – rights, risks and responsibility RCN London.

The FOOD Trial Collaboration (2005). Effect of timing and method of Enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. The Lancet. 365:764-72.

Williams J. (2005) Using an alternative fixing device for naso-gastric tubes. Nursing Times. 101(34):26-27.

AcknowledgementsDerby Hospitals NHS Foundation Trust (2005). Proposal for the change in practice relating to the securing of naso-gastric tubes utilising nasal bridles within a specified group of adult patients. Winchester and Eastleigh Healthcare NHS Trust (2006). Nasal Tube Retaining System (nasal loop): guidelines for useThe AMT Bridle. Nasal tube retaining system. Product information leaflet.

10. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL DOCUMENTS

Patients requiring assessment for NRL are referred to the CNNS team.Appropriate consent is obtained prior to NRL insertion. Weekly review of all patients with NRL insitu by CNNS teamNRL care guideline is adhered to by ward staffCNNS team are responsible for monitoring compliance with this guideline.


APPENDIX 1: PICTURES

Picture 1

Picture 2 Picture 3 Picture 4

Picture 5 Picture 6 Picture 7


APPENDIX 2: INDICATIONS/CONTRAINDICATIONS FOR INSERTION OF NASAL RETAINING LOOP

INDICATIONS: Persistent removal of NGT in patient who requires enteral feeding.

CONTRAINDICATIONS:Abnormal clotting e.g raised INR, low platelets.Excessive agitation# base of skull +/- facial traumaGrossly deviated nasal septumMechanical obstruction-i.e nasopharyngeal airway in situ

CONSIDERATIONS;Nasal polyps/deformity/anatomically challenging.History of epistaxisEthnic variationsEthical/cultural issuesMental capacity actUse of Mittens


http://www.porthosp.nhs.uk/Clinical-Policies/Hand%20control%20mittens%20usage%20in%20adult%20patients.doc

APPENDIX 3: CARE OF PATIENT WITH NASAL RETAINING LOOP.

Patient Name: Date NG & NRL Inserted:

DAILY: Check the nasal loop tapes and clip are secure. Ensure the tapes are not over-tight. Check that the clip is not causing any pressure to under-lying skin. Inspect the skin around the nostrils for any signs of soreness/pressure necrosis. Clean around nostrils to prevent build-up of any crusting and reduce the risk of

skin becoming sore. Apply skin barrier as required.

Refer to the Nutrition Nurses for advice if you have any concerns. The Nutrition Nurses will review patient on a weekly basis otherwise.

NASAL RETAINING LOOP REMOVAL.

If the patient becomes very agitated and is pulling aggressively at the NG tube you may have to remove the NRL to prevent damage to the nasal septum. Please contact the Nutrition Nurses for assessment during normal working hours.

Out of hours ward staff can remove the NRL if it becomes absolutely necessary, but please consider:

Other methods of maintaining the NRL e.g. mittens. How will the patient receive nutrition if the NRL and NG are removed?

How To Remove NRL:


With scissors cut the white tape here. Pull the NGT (with clamp and tape attached) from the opposite nostril until the whole tube is removed.

Insertion of ngt retaining device nasal loop bridle

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