NGT Procedure

Adult Nasogastric Tube Insertion Procedure & Management Policy

Document Status FINAL

Version V2

Document Change History

Version DATE Comments (i.e. Viewed, reviewed amended or approved by person or Committee

Draft V1.1 04/12/2009 Reviewed and agreed by Alex Mayor

Draft V2.1 23/08/2011 Reviewed and amended by Emma Tyler and Julie Morley Nutrition Nurse Specialist Nurses in accordance with NPSA Alert Mar 2011

Draft V2.2 23/08/2011 Approved by the Clinical Governance Steering Group

Authors (s) Julie Morley & Emma Tyler - Nutrition Nurse Specialists, Paula Wooldridge - Practice Educator.

Approver Clinical Governance Steering Group

Names & Roles of Contributors

Mark Sair, ICU Consultant, Paula Chudleigh Staff Nurse Critical Care, Rosemarie Taylor and Jeanette Snowden, Radiographers.

Relevant to: Staff Groups Medical, Nursing, AHP

Document Reference: TRW/CLI/POL/395/2

Review date October 2014 or sooner as necessary

EIA Not Required

Links to other Policies & Procedures

Adult Enteral Tube Feeding Guidelines. Consent to Examination Treatment Policy, Mouth Care Procedure

Distribution Full ;

TRW.CLI.POL.395.2 Adult Nasogastric Tube Insertion Procedure & Management Policy


2

Trust Commitment to Valuing People PHNT is committed to creating a fully inclusive and accessible service. By making equality and diversity an integral part of the business, it will enable us to enhance the services we deliver and better meet the needs of patients and staff. We will treat people with dignity and respect, promote equality and diversity, and eliminate all forms of discrimination regardless of (but not limited to) age, disability, gender reassignment, race, religion or belief, sex, sexual orientation, marriage/civil partnership and pregnancy/ maternity.

An electronic version of this policy is available on the TrustDocuments Network

Share Folder:

G:\TrustDocuments

Larger text, Braille and Audio versions can be made available upon request to the Human

Resources Department.



3

Contents Contents .................................................................................................................. 31. Introduction ........................................................................................................ 42. Policy Statement ............................................................................................... 4

2.1 Purpose ...................................................................................................... 42.2 Accountability, Authorisation and Responsibility ......................................... 52.3 Consent ...................................................................................................... 52.4 Risk Assessment & Contra-indications ....................................................... 6

3. Nasogastric Tube Selection Adult patients ..................................................... 64. Procedure for the Insertion of a Nasogastric Tube for the Adult ........................ 75. Post insertion care and management of Nasogastric Tubes once insitu ......... 156. Enteral Feeding ............................................................................................... 157. Administration of Medicines via a Nasogastric Tube ....................................... 168. Review and Revision ....................................................................................... 169. Audit & Monitoring ........................................................................................... 16

9.1 Document Control ..................................................................................... 169.2 Dissemination and Implementation ........................................................... 16

10. References ................................................................................................... 1711. Appendices .................................................................................................. 20 Appendix A Checklist for the Review and Approval of Procedural Document Appendix B Plan for Dissemination of Procedural Documents Appendix 1 Competency Assessment Process Insertion and Care of Nasogastric Tubes for Adults Supporting Information for Assessors and Managers Appendix 2 Insertion and Care of Nasogastric Tubes for Adults Competency Assessment Process for Registered Healthcare Professionals Appendix 3 Decision Tree for Nasogastric Tube Placement Check in Adults Appendix 4 Record of Insertion of Nasogastric Tube Sticker Appendix 5 Nasogastric Tube Position Record and Care Plan Appendix 6 Ongoing Post Insertion Care and Management of Nasogastric Tubes Appendix 7 Audit Form



4

1. Introduction The NPSA has published a list of never events which are specific serious untoward incidents that can cause serious harm but should be avoidable if national guidance is followed. One Never Event relates to: Naso tubes placed in the respiratory tract rather than the gastrointestinal tract and not detected prior to commencement of feeding or other use. This policy has been written to comply with the latest guidance from the National Patient Safety Agency. The insertion of a nasogastric (NGT) tube is defined as the passage of a nasogastric tube via the nostril into the stomach.. This policy and procedure gives information and instruction regarding safe and effective placement and confirmation of tube placement to reduce risk in line with current Clinical Governance. The document has been developed to support staff in the ongoing management of nasogastric tubes once a tube has been inserted. This policy is intended for use in the adult patient (aged over 16 years).

2. Policy Statement Plymouth Hospitals NHS Trust aims to deliver safe and effective care to all its patients. The insertion, tube position check and subsequent management of nasogastric tubes will be safe, effective and comfortable for the patient. Staff engaged in the process of inserting, checking and managing the use of nasogastric tubes are expected to be competent to do so and comply with this policy. 2.1 Purpose The procedures described below are intended to support staff in complying with the stated Trust policy and to ensure care is safe and effective. The purpose of a nasogastric tube is to:

a) allow drainage of the contents of the stomach when indicated b) allow removal of air from the stomach when indicated c) Provide a safe access route to the gastrointestinal tract for the

administration of fluids, medicines and or nutrients



5

Fig 1. Examples of Indications for use of a Nasogastric Tube INDICATION ACTION RATIONALE Paralytic Ileus Gastrointestinal disease Gastrointestinal surgery

Leave tube on free drainage Aspirate as indicated or requested Check tube position

To allow drainage of accumulated gastric contents and facilitate gastric motility To avoid aspiration of gastric contents

To provide nutrition for the patient To hydrate the patient To administer medication

Check tube position before the introduction of any substance into the tube

To confirm the correct placement of the tube in order to avoid aspiration of gastric contents and subsequent complications

2.2 Accountability, Authorisation and Responsibility Staff should only undertake this procedure if they are appropriately trained (by completing the Insertion and Care of Nasogastric Tubes Competency Assessment Process. See section 6.0 and 7.0, and must be either: Registered Adult Nurses, Midwives and Health Visitors Registered Childrens Nurse Registered Medical Staff Nurses/Medical staff in training supervised by one of the above

All practitioners are personally responsible for updating their practice to maintain competencies and skills.

It is recommended that this is done 12 monthly if not undertaking procedure regularly.

Accept accountability for their practice. Informal carers i.e. those individuals who have undertaken daily care

regimes for the patient on a routine basis and have been appropriately trained by a practitioner named above.

2.3 Consent Consent for the procedure should be sought under the guidance of the Policy for Consent to Examination and Treatment (available on the intranet under PHNT Trust documents TRW.CGW.POL.216)



6

2.4 Risk Assessment & Contra-indications An individual risk assessment should be conducted and documented by a competent person that balances the risks and difficulties of nasogastric tube insertion. The following group of patients are at a high risk of incorrect tube positioning, dislodgement and aspiration and appropriate specialist advice should be taken if the patient has:

Maxillo-facial disorders, surgery or trauma Skull fractures confirmed or suspected Laryngectomy Recent radiotherapy to head and neck Any disorder of the oesophagus e.g. varices, stricture. Oro-pharyngeal tumours or oro-phayrngeal surgery Unstable Cervical Spinal Injuries Nasal C.P.A.P.

Oro-gastric positioning may be indicated following head injury or neuro-surgery. High Risk also includes patients who: -

Are comatose/semi-comatose Are ventilated/sedated Have a swallow dysfunction Have recurrent retching/vomiting Need to be nursed prone

3. Nasogastric Tube Selection Adult patients There are two types of nasogastric tubes available. These have been chosen to due to their radio-opaqueness, should X-ray be needed. Polyvinyl Chloride (PVC) for short term use up to 30 days (e.g. Ryles tubes) usually used within PHNT for gastric drainage (and for feeding in the Critical Care setting only) Polyurethane (PUR) Fine bore tubes used within PHNT for the administration of nasogastric feed and medications. The nasogastric tube should be selected that is appropriate for its purpose. Various lengths and lumen diameters are available for adult patients.

Patients with nasogastric tubes inserted under direct vision. Most patients who are unconscious or sedated have nasogastric tubes inserted routinely for drainage of gastric aspirate and/or feeding. The patient is usually sedated or anaesthetised or has an altered conscious level. They will have an endotracheal tube in situ and have the nasogastric tube placed under direct vision into the oesophagus. The tube is then advanced until green/yellow/brown contents are freely aspirated.



7

If a tube is inserted under direct vision (as outlined above), the tube can be confirmed to be in the stomach at the time of insertion. Documentation of the insertion should be completed in the perioperative pathway and completion of the Record of insertion of nasogastric tube sticker (Appendix 4). Subsequent checks of the tube position must follow the Decision Tree for nasogastric tube placement checks in adults (Appendix 3) unless repeat direct visualisation of the tube position in the stomach is carried out.

4. Procedure for the Insertion of a Nasogastric Tube for the Adult

Equipment required: 1. Clinically clean tray 2. Fully Radio-opaque Nasogastric tube which is appropriate for its designated

use 3. Topical Gauze 4. Tape to secure E.g. Nasofix 5. 60ml purple enteral syringe 6. pH indicator strips (CE marked for human aspirate) 7. Disposable receiver 8. Spigot/Drainage Bag (if necessary) 9. Glass of water, straw (only if able to swallow) 10. Mouth sponges 11. Non sterile gloves and apron 12. Record of Insertion of Nasogastric Tube Sticker 13. Nasogastric Tube Position Record Form and Care Plan 14. A pen

ACTION RATIONALE EVIDENCE 1 Before a decision is made to insert

a nasogastric tube, an assessment is undertaken to identify the reason for the nasogastric tube insertion:

a) for drainage only b) for drainage and possible

feeding (Critcal Care ONLY)

c) for feeding and medication The rationale for any decisions are recorded in the patients medical notes, including purpose and type of nasogastric tube to be inserted.

To ensure that the nasogastric tube insertion is necessary, avoiding putting the patient through an unnecessary procedure and potential complications.

NPSA (2011)



8

2 Check patient ID and explain the procedure to the patient. Ensure patient is in agreement with the procedure and that verbal/informed consent is gained and documented.

To obtain the patients consent and co-operation. To be able to document consent. If patient is unable to consent then capacity must be established and action is in best interests.

Price (2009) DOH (2001) Mensforth and Nightingale (2001) Mallett and Dougherty (2000) Mental Capacity Act (2005)

3 The patient should be monitored closely throughout the procedure by nursing staff. In the acute setting the procedure should be carried out in a clinical area which has access to emergency equipment in full working order. In the community setting an individual risk assessment should be made.

Early detection of cyanosis or bradycardia will prevent further deterioration of the patients condition throughout the procedure. Emergency equipment in full working order will enable medical and nursing staff to deal with serious complications should they arise in the acute setting. To ensure that risk versus benefit is assessed.

Mensforth et al (2001)

4 Assist the adult patient to sit in a supported upright position, ensuring the patients head and shoulders are well supported by pillows. If the patient is unconscious or semi-conscious, place into a safe position by laying the patient on their side.

To allow for easy passage of the tube. This position allows easy swallowing and ensures the epiglottis is not obstructing the oesophagus. To ensure correct passage and position of the NG tube.

Miller et al (1985) McConnell (1997) Mallett and Dougherty (2000)

5 Wash hands with soap and water, rinse and dry well. Put on gloves/apron. Assemble the equipment required.

To minimise cross infection.

Anderton (1995)Pratt (2001) NICE (2006)



9

6 Select the appropriate length to be passed by measuring the distance placing the tip of the tube from the nose, extend tube to the patients earlobe and then to the xiphisternum (NEX measurement see diagram below). Mark the length on the tube with a pen.

To ensure the appropriate length of tube is passed into the stomach.

Price (1989) Mallett and Dougherty (2000) NPSA (2011)

7 If the nasogastric tube of choice has a guidewire , pull the wire out 5cms and replace.

To ensure easy withdrawal of the guidewire.

Mensforth and Nightingale (2001)

8 Check that the nostrils are patent. If appropriate, ask the patient to blow nose first. If patients are unable to swallow carry out mouth care prior to inserting the tube.

To identify any obstructions liable to prevent insertion. If the patient has dysphagia (loss of swallow reflex) they will be unable to swallow water safely and should not be asked to drink whilst tube is inserted.

McConnell (1997)

9 Lubricate proximal end of tube with water. (N.B. Do not use aqueous jelly as a lubricant)

To assist passage through the naso-pharynx. Aqueous jelly dries and can block nasal passages irritating the patient.

Mensforth and Nightingale (2001) Mallett and Doughherty (2000)

10 Insert the rounded end of the tube into the clearest nostril and slide it backwards and inwards along the floor of the nose to the nasopharynx. If any obstruction is felt, withdraw the tube and try

To facilitate the passage of the tube by following the natural anatomy of the nose.

Mensforth and Nightingale (2001)

Mallett and Dougherty



10

again in a slightly different direction or use the other nostril.

(2000)

11 As the tube passes down into the nasopharynx ask the patient to swallow water via a straw. (If there is doubt of a patients ability to swallow safely a Speech and Language assessment may be necessary).

A swallowing action closes the glottis enabling the tube to pass into the oesophagus.

Miller et al (1985) McConnell (1997)

12 Advance the tube through the pharynx as the patient swallows until the predetermined mark on the tube has been reached. If the patient shows signs of distress e.g. gasping, coughing or cyanosis, remove the tube immediately. If respiratory distress does not resolve with removal of the tube at this point, abandon the procedure and inform medical staff. If the patient complains of sudden onset ear pain the tube should be removed immediately and inform medical staff.

Distress or ear pain may indicate the incorrect placing of nasogastric tube into the trachea. Signs of respiratory distress may be absent in patients with a poor gag reflex.

Bayes et al (1992) Colagiovanni (1999) Mallett and Dougherty (2000) Miller et al (1985) Gharib (1996) Arslantas et al (2001)

13 pH testing is used as the first line test method, with pH between 0 and 5.5 as the safe range see Section 13a-13d, and that each test and test result is documented on the Nasogastric Tube Position record and care plan (Appendix 5), which is kept at the patients bedside. Nasogastric tubes are NOT flushed, nor any liquid/feed introduced through the tube following initial placement, until the tube tip is confirmed by pH testing or x-ray, to be in the stomach.

To ensure that the tube is in the stomach before any fluid is administered.

Cirgin-Ellett et al (1999) Gharib et al (1996)

13a Aspirate a sample of fluid using a 60ml purple enteral syringe with gentle suction aspirating 2-5mls (5mls Critical Care) of fluid.



11

Place the aspirate onto pH paper (CE marked for human aspirate) and check the reading. N.B. If it is not possible to obtain an aspirate from the nasogastric tube, please see section 13b. A pH of 0- 5.5 indicates a reading deemed to be within a safe range. If pH 0 -5.5 complete Record of Insertion of Nasogastric Tube sticker (Appendix 4) and file in patients medical notes. If the aspirate gives a result of a pH greater than 5.5 note medication (see warning below) and retry after 20-60 minutes. Warning Patients receiving the following drugs may have a high gastric pH:

H2 Antagonists e.g. ranitidine

Proton pump inhibitors e.g. omeprazole

The gastric aspirate obtained from these patients therefore, may be > 6. If patients swallow is intact and not NBM, give acidic drink e.g. Pineapple or Blackcurrant. Retry after 20 minutes. These patients therefore may require repeat aspirate tests observing times of drug administration. If pH still >6 an initial chest x-ray may be appropriate to confirm gastric placement see section 14.

Stomach contents are acidic and have a pH around 3-4. However the National Patient Safety Agency state that a pH reading of 5.5 or below is acceptable Bronchial secretions read greater than pH 6. Prokinetics can affect the ability to gain an aspirate due to their effect of increasing in stomach emptying. PPIs inhibit gastric acid secretion.

NPSA (2011) NPSA (2011)

13b

(i)

If it is not possible to obtain an aspirate try the following: Give mouth care to patients who are nil by mouth.

Stimulates gastric secretion.

Pulling R (1992)



12

(ii)

(iii)

(iv)

If the patient is able to swallow ask them to drink a small amount of water. Flush the tube with 10-20mls of air. Turn the patient on their left side and retry aspiration after 20 60 minutes.

Adds fluid to the stomach. Acts in moving the tube away from the stomach wall to aid aspiration. Improves position of stomach contents.

Colagiovanni L (1999) Mensforth and Dougherty (2001)

13c

Whoosh tests, acid/alkaline tests using litmus paper, or interpretation of the appearance of aspirate ARE NEVER USED to confirm nasogastric tube position.

Use of these methods are unreliable.

NPSA (2011)

13d If still unable to gain aspirate or aspirate is still above 5.5 then DO NOT USE THE TUBE and consult medical staff. Document the medical decision and strategy for that individual patient in the medical notes. Document all techniques that have been used to try to obtain aspirate before a request for chest X-ray is made. Complete Record of Insertion of Nasogastric Tube sticker (Appendix 4) and file in patients medical notes. If the decision is to proceed to a Chest X-ray please see section 14 below.

NPSA (2011)

14

X-ray is used only as a second line test when:

a gastric aspirate is unobtainable after placement following the instructions in section 13b and in Appendix 3 Decision Tree for nasogastric tube placement checks in adults.

Or

Warning: Please note that an X-ray to verify the position of a nasogastric tube is only valid at the time it is taken.

NPSA (2011)



13

(i)

(ii)

a gastric aspirate is obtainable and has a pH of 6 or greater and can not drink an acidic drink.

This should ideally be done in daytime working hours to ensure that sufficient knowledge/expertise is available to interpret chest x-ray and position of the nasogastric tube, unless clinically urgent. The rationale for any decisions made is recorded in the patients medical notes. X-ray request forms clearly state that the purpose of the x-ray is to establish the position of the nasogastric tube, stating the purpose for feeding or drainage. The chest x-ray should be reviewed by a competent practitioner, in most cases this will be a medical practitioner who has been assessed through theoretical and practical learning. Documentation of the tube placement checking process should include:

any x-ray viewed was the most current x-ray for the correct patient.

how placement was

interpreted.

clear instructions as to required actions.

The above should be recorded in the patients medical notes. Any tubes identified to be in the lung are removed immediately,

To prevent potential errors of staff confirming tube position out of hours. To ensure that the radiographer adjusts the exposure of the x-ray. To reduce the risk of misinterpretation of the chest x-ray. To avoid a Serious Untoward Incident

NPSA (2011) NPSA (2011) NPSA (2011)



14

whether in the x-ray department or clinical area.

and patient harm

14 Only when the correct position is confirmed and if a guide-wire is present, the guide-wire will need to be removed. Flush the guidewire port of the tube with 10 mls of freshly drawn tap water and the guide-wire can be gently rotated and withdrawn from the tube.

To be aware that the tube can be misplaced by rapid withdrawal of the guidewire and requires flushing with water to activate water soluble lubricant.

Rollins (1997)

15 Consider cleaning the nose/cheek with an alcohol swab prior to securing the tube. Secure the tube to the nostril and cheek with appropriate tape and/or fixation device. If nasogastric tube for drainage purpose, apply drainage bag or spigot. If nasogastric tube for feeding, follow dietetic instruction/starter regime. Remove gloves/apron and wash hands.

Cleaning with an alcohol swab will remove grease from the skin, increasing the chance of the tube being successfully secured. To maintain the tube in place. To allow drainage of gastric contents. To commence safe enteral feeding. To minimise cross infection risk.

Della Faille al (1996)

17 Document insertion procedure by completing the record of insertion of a nasogastric tube sticker ( Appendix 4) and place in patients medical notes.

To provide a record of care. To identify that safe procedures have been carried out.

NMC 2002a

18 Post insertion and management of a nasogastric tube. See Appendix 6.

19 A full multidisciplinary supported risk assessment is made and documented before a patient with a nasogastric tube is discharged from acute care to the community. (See section 11 of the Adult Enteral tube Feeding Guidelines)

NPSA (2011)



15

To remove the tube Explain the procedure to the patient and obtain their informed verbal consent. Provide tissues for the patient to clean or blow their nose after removal of the tube. Wash hands and put on gloves and apron. Take off the fixation tape and gently withdraw through the nostril. Ensure the tube is intact and document removal.

To reduce anxiety. To ensure that the tube has been removed intact.

MDA (2001)

5. Post insertion care and management of Nasogastric Tubes

once insitu Serious adverse effects on the patients condition may be associated with the incorrect use of the tube once inserted. The patient must be observed for adverse signs and symptoms which may indicate tube misplacement or dislodgement. See Appendix 6 for relevant information: Ongoing Post-Insertion Care and Management of Nasogastric Tubes.

6. Enteral Feeding Please see TRW CLI.NUT.GUI.87 Adult Enteral Tube Feeding Guidelines for further supporting information on:

Indications for enteral tube feeding Choice of feeding route Enteral feeding equipment Infection control and enteral tube feeding Commencing enteral tube feeding Administration of medicines via an enteral feeding tube Trouble shooting guidelines Guidelines for management of enterally fed adult patients with diabetes Home enteral feeding



16

7. Administration of Medicines via a Nasogastric Tube Please refer to TRW CLI.NUT.GUI.87 Adult Enteral Tube Feeding Guidelines, Version 1:6, Section 8.

8. Review and Revision This policy should be reviewed bi-annually or when significant guidance is received from external agencies e.g. MHRA/NPSA.

9. Audit & Monitoring This policy will be monitored through: A timely review of patients with NG tubes by Matron / Ward Manager must be carried out (see Appendix 7) Incidents related to NG tubes will be reviewed via Datix

9.1 Document Control This document is published on the Trust Documents Network Share Folder. The Information Governance Team are responsible for holding and maintaining a master file containing a register and evidence of ratification of the document and corresponding Equality Impact Assessment. The Information Governance Team will ensure that old versions of the document are archived in the archive master file. Access to archived documents will be through the Information Governance Team. The Information Governance Team will issue the document numbers and maintain an index that will include the documents title, number & version, owner, issue date and next review date. The approvals are indicated by the front sheet of the document as is the version (i.e. issue) control.

9.2 Dissemination and Implementation Following approval and ratification, this document is being rolled out across the Trust. Publication of this document has been publicised in Vital Signs, the Trusts weekly staff news briefing. All Directorate Managers will have had the document sent to them and it is available electronically on the Trust Documents Network Share Folder.



17

10. References Adam.S (1994) Aspects of current research in enteral nutrition in the critically ill. Care of the Critically Ill 10(6): 246-51 Nov-Dec.

Anderton, A. (1995) Reducing bacterial contamination of enteral tube feeds. British Journal of Nursing. 4 (7) 368 376.

Arslantas, A., Durmaz, R., Cosan, E., Tel, E. (2001) inadvertent insertion of a nasogastric tube in a patient with head trauma. Childs Nervous System. Jan. 17(1-2): 112 114. Arrowsmith, H. (1993) Nursing management of patients receiving a nasogastric feed. British Journal of Nursing Vol 2, No. 21, p 1053 1058.

Bayes, R.J., Kruse, J.A., (1992) Nasogastric and nasoenteric intubation. Critical Care Clinics. 8(4), 865 867.

Beattie, T.K., Anderton, A., White, S. (1996) Aspiration (of gastric residuals) a cause of bacterial contamination of enteral feeding systems? Journal of Human Nutrition and Dietetics. 9, p 105 115.

Burnham, P. (2000) A guide to nasogastric tube insertion. Nursing Times plus. Vol 96, No.8, P6 7. Centre for Clinical Effectiveness. (2000) What is the optimum method for ensuring correct placement of nasogastric tubes? Southern Health Services/Monash Institute for Public Health Clayton.

Christen, S. & Hess, T. (1996) is clinical positional control for nasogastric tubes good enough? A prospective study of 43 patients. (article in German) Dtsch Med Wochenschr, 121 (37) 1119 1122 sept 13.

Cirgin-Ellett Backstand, J (1999) Examination of gavage tube placement in children. The Journal of Child and Family Nursing 3 (1): 42-4 Jan Feb 2000.

Colagiovanni, L. (1999) Taking the tube. Nursing Times. May 26. 95 (21), 63 68.

Department of Health (2001) Reference Guidelines, 23618, 2p 500k April (col).

Della Faille D, Schmelzer B, Hartoko T, Vandenbroucke M, Brands C, DeDeyn PP. Securing nasogastric tubes in non-cooperative patients. Acta Oto-Rhino Laryngologica Belgica. 1996. 50 (3): 195 197.

Duncan, H.D., Silk, D.B.A. (2001) Insertion and care of enteral feeding tubes, in Nightingale, J.M.D. (ed). Intestinal failure. Pp 281 303. Greenwich Medical Press, London.

Gharib A.M. et al (1996) Nasogastric and Feeding Tubes. Post Graduate Medicine. Vol.99, No. 5, p 165 176.

Harrison, M. (1997) Nursing Standard. 11, 27, 43 45.

Keohane, P.P., Attrill, A., Silk, D.B.A. (1986) Clinical effectiveness of weighted versus unweighted fine-bore nasogastric feeding tubes in enteral nutrition: a controlled clinical trial. J. Clinical Nutrition, Gastroenterology. 1: 189 193.

Mallett, J. and Dougherty (2000) 5th edition The Royal Marsdens Hospital Manual of Clinical Nursing Procedures. Blackwell Science. London.

McConnell, E.A. (1997) Clinical dos and donts: inserting a naso-gastric tube. Nursing. Jan.72. Page 10 of 15

(MDA) Medical Devices Agency. Devices in practice. A guide for health and social care professionals. 2001. MDA. London.



18

Medical Devices Agency (MDA) (1995) The re-use of medical devices supplied for single use only. MDA Bulletin DB 9501. January. MDA, London.

Medical Devices Agency (MDA) (2001) Devices in practice. A guide for health and social care professionals. MDA. London.

Mensforth, A., Nightingale, J.M.D. (2001) Insertion and care of enteral feeding tubes. In Nightingale, J.M.D. (ed) Intestinal Failure. Greenwich Medical Media, London.

Mental Capacity Act (2005) DOH.London

Metheny, N. Williams P et al. (1989) Effectiveness of PH Measurements in Predicting Feed Tube Placement. Nursing Research Vol 38, No.5, p 280 285.

Metheny, N. McSweeney, M., Wehrle, M., Wiersma, L. (1990) Effectiveness of the auscultory method in predicting feeding tube location. Nursing Research. 39 (5), 262 267.

Metheny, N., Dettenmeier, P., Hampton, K., Wiersma, L., William, P. (1990) Detection of _nadvertent respiratory placement of small bore feeding tubes: a report of 10 cases. Heart Lung. 19: 631 638.

Metheny, N., Spiers, M. Eisenberg (1988) Measures to test placement of Nasoenteral FeedingTubes. Western Journal of Nursing Research. 10(4) p 367 383.

Metheny, N. (1993) Minimising respiratory complications of naso-enteric tube feedings: state of the service. Heart Lung. 22: 213 223.

Metheny, N.A., Clouse, R.E., Clarke, J.M., Reed, L., Wehrie, M.A., Wiersma, L. (1994) pH testing of feeding tube aspirates to determine placement. Nutr. Clin. Prac. 9: 185 190.

Miller, K.S., Tomlinson, J.R., Sahn, S.A. (1985) Pleuro-pulmonary Complications of Enteral Tube Feedings; Two reports, reviews of the literature and recommendations. Chest. 88 (2) p230 233.

National Institute for Clinical Excellence (2006) Nutrition Support in Adults. London: NICE

National Patient Safety Agency (2004) Advice to the NHS on reducing harm caused by the misplacement of naso-gastric feeding tubes. www.npsa.nhs.uk

National Patient Safety Agency (2011) Advice to the NHS on reducing harm caused by the misplacement of naso-gastric feeding tubes. www.npsa.nhs.uk

Neumann, M.J., Meyer, C.T., Dutton, J.L., Smith, R. (1995) Hold that X-ray: aspirate pH and auscultation in enteral tube placement. J. Clin. Gastroenterology 20 (4), 293 295.

(NMC) Nursing and Midwifery Council. (2002a) Guidelines for records and record keeping. NMC London.

Payne-James, J.J. (1988) Enteral nutrition: clinical applications. Intensive Therapy and Clinical Monitoring. 7, 239 246.

Pratt, R.J. (2001) The Epic Project. Developing national Evidence based guidelines for preventing health care associated infections. The Journal of Hospital Infection Vol.47. Supplement. Page 23 28.

Price, B. (1989) Nasogastric intubation. Nursing Times. Vol 85, No. 13, p 50-52.

Pulling, R. (1992) The Right Place. The Canadian Nurse 88 (2): 29 30 Feb.

Rollins, H. (1997) A nose for trouble. Nursing Times. Vol 93, No.49, P66 67.

Royal College of Nursing (RCN) (1999) Guidelines for Good Practice. Restraining, holding still and containing children. Royal College of Nursing. London.



19

Storm, H. (2000) Closed System Enteral Feedings; Point-counterpoint. Nutrition in Clinical Practice, 15, p193 200.

Sizer, T., Russell, C.A., Wood, S. et al. (1996) Standards and Guidelines for Nutritional Support Page 11 of 15 of Patients in Hospital. British Association for Parenteral and Enteral Nutrition.



20

11. Appendices Appendix A Checklist for the Review and Approval of Procedural Document To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval.

Title of document being reviewed: Yes/No/Unsure Comments

1. Title Style & Format

Is the title clear and unambiguous? Yes

Does the Style & Format comply with Trust Policy?

Yes

Is it clear whether the document is a guideline, policy, protocol or standard?

Yes

2. Rationale

Are reasons for development of the document stated?

Yes

3. Development Process

Is the method described in brief? Yes

Are people involved in the development identified?

Yes

Do you feel a reasonable attempt has been made to ensure relevant expertise has been used?

Yes

Is there evidence of consultation with stakeholders and users?

Yes

Has an Equality Impact Assessment (EIA) been completed and is it attached to the document?

Yes

4. Content

Is the objective of the document clear? Yes

Is the target population clear and unambiguous?

Yes

Are the intended outcomes described? Yes

Are the statements clear and unambiguous?

Yes



21

5. Evidence Base

Is the type of evidence to support the document identified explicitly?

Yes

Are key references cited? Yes

Are the references cited in full? Yes

Are supporting documents referenced? Yes

6. Approval & Ratification

Does the document identify which committee/group will approve and ratify it?

Yes

If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document?

N/A

7. Dissemination and Implementation

Is there an outline/plan to identify how this will be done?

Yes

Does the plan include the necessary training/support to ensure compliance?

Yes

8. Document Control

Does the document identify where it will be held?

Yes

Have archiving arrangements for superseded documents been addressed?

N/A

9. Process to Monitor Compliance and Effectiveness

Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document?

Yes

Is there a plan to review or audit compliance with the document?

Yes

10. Review Date

Is the review date identified? Yes

Is the frequency of review identified? If so is it acceptable?

Yes



22

11. Overall Responsibility for the

Document

Is it clear who will be responsible for co-ordinating the dissemination, implementation and review of the document?

Yes

Individual Approval If you are happy to approve this document, please sign and date it and forward to the chair of the committee/group where it will receive final approval. Name Date Signature

Committee Approval If the committee is happy to approve this document, please sign and date it and forward copies to the person with responsibility for disseminating and implementing the document and the person who is responsible for maintaining the organisations database of approved documents. Name Date Signature



23

Appendix B Plan for Dissemination of Procedural Documents To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval. Acknowledgement: University Hospitals of Leicester NHS Trust. Title of document:

Adult Nasogastric Tube Insertion Procedure & Management Policy

Date finalised: 23 August 2011 Dissemination lead: Print name and contact details

Kerri West Quality Facilitator 39691

Previous document already being used?

Yes (Please delete as appropriate)

If yes, in what format and where?

Trust Document Network Share Folder

Proposed action to retrieve out-of-date copies of the document:

N/A

To be disseminated to:

How will it be disseminated, who will do it and when?

Paper or

Electronic

Comments

All Clinical Staff Published on Trust Document Network Share Folder by document controller. Advertised in Vital Signs and by email to all managers

Electronically

Dissemination Record - to be used once document is approved.

Date put on register / library of procedural documents

September 2011

Date due to be reviewed

October 2014

Disseminated to: (either directly or via meetings, etc)

Format (i.e. paper

or electronic)

Date Disseminated

No. of Copies

Sent

Contact Details / Comments



Appendix 1 - Competency Assessment Process Insertion and Care of Nasogastric tubes for Adults Supporting Information for Assessors and Managers

Competency Assessment Process

Insertion and Care of Nasogastric

tubes for Adults

Supporting Information

for assessors and managers



Introduction

To avoid catastrophic injury or fatal consequences,the National Patient Safety

Agency ( NPSA 2011) requires Healthcare Professionals to be competent in

the insertion and subsequent management of nasogastric tubes (NGT). Staff

have a responsibility to seek advice and training when necessary. This

document has been developed to provide information for assessors and

managers who have within their scope of practice the potential to manage the

care of patients who require NGTs. It will assist Registered Healthcare

Professionals in the training and recording of competency in the insertion and

subsequent management of fine bore and wide bore NGT .

The aim of the competency assessment process is to ensure the healthcare

practitioner is able to:

Abide by, and fully implement the NPSA directives relating to the

insertion and management of fine and wide bore NGT

Understand of the decision making process for the use of NGTs

Understand the potential risks and contraindications associated with

the use of NGT and how to minimise/respond to these.

Demonstrate competency in the insertion and subsequent care of NGT.

Promote best practice throughout the healthcare environment in the

use and care of NGTs

This competency assessment process consists of 4 parts:

1. Knowledge and Understanding Section:This must be successfully

completed prior to the assessment by clinical observation

2. Practice Assessment for the insertion and confirming position of

nasogastric tubes.

3. Practice Assessment for the Care of the patient with a nasogastric tube

inserted

4. Practice Assessment for the administration of medications via the enteral

route



Who should complete this competency assessment process?

Practitioners who are inexperienced in this skill (such as the newly

qualified, newly appointed to post)

Those staff who have been identified by their manager or clinical

educator as not competent or considered to be at risk of under

performing in their role.

Practitioners who are regularly performing this skill must also be

assessed as competent by a trained assessor using this competency

process.

ALL practitioners who use NGTs within their scope of practice must

sign to declare they have read and are fully understand the current

PHNT policy regarding the insertion and management of NGTs and all

relevant NPSA directives.

Those staff who have fully competed this assessment process, but

have not undertaken this skill for over 6 months should be reassessed

using a simulated assessment technique, if necessary. A manikin for

this purpose is available via the Clinical Education Facilitator.

The Statement of this Competence( example in Appendix 1) at the

end of the learners competency document, must be signed by the

manager and the trained assessor, prior to the practitioner being able

to perform this skill. This record should be entered onto OLM as

training received.

N.B Students undertaking pre-registration programmes should always carry

out the procedure under the supervision of a qualified mentor .



Assessors must be Registered Healthcare Professionals who have:-

Successfully completed the competency assessment process to level 4

Maintained their competency by regularly performing this skill. If an

update is necessary contact the Education Facilitator for a simulated

assessment.

Assessor Responsibilities

Before signing the Statement of Competence assessors should ensure that

on successful completion of this pack, the learner is able to:-

Demonstrate knowledge of PHNT policy and NPSA directives local

related to this skill.

Demonstrate the ability to carry out the procedure competently.

Identify problems and deals with them appropriately.

Demonstrate correct documentation for the procedure.

Assessors must report to manager if any learner fails to achieve

required level of competence

Completed formative statements and action plans must accompany

this report.



Line manager`s responsibilities

Identify those staff who require assessment of competency in the

Insertion and management of nasogastric tubes.

Ensure assessors within their area are fully competent to level 4 of

the assessment criteria

If informed of non achievement of competency, ensure learner is

not given authority to undertake skill until successful.

Record successful completion of clinical competency process and

the Knowledge and Understanding section onto the electronic

training records ( OLM)

Store competency package within staff members` education

records or the employees record file held by the line manager(this

can be electronic)

Store signed Statements of Competency in accessible folder in

order to provide evidence of staff training and record of competency

if requested.

.



Learner Responsibilities

Registered Health Professionals who undertake training to insert and manage

nasogastric tubes must:

Complete the requirements of the NGT Competency Assessment

process within 6 months of commencement

Read the current PHNT policy and all relevant NPSA documents for

insertion and management of NG tubes.

Undertake supervised practice with a competent practitioner who is

skilled in the procedure and has already successfully competed this

competency process.

Take responsibility thereafter for maintaining competence in the skill

and seek supervision from a competent practitioner if for reason of

sickness or absence they have not carried out the procedure in the

previous 6 months.

If due to lack of clinical opportunity a reassessment is necessary

please contact the Clinical Education Facilitator to arrange an update

and reassessment.



Assessment process



Perform a self assessment with a competent practitioner of the

skill and formulate an action plan to address learning needs

Complete Part 1 knowledge and understanding section with their

assessor before attempting Part 2,3 and 4

Undertake a formative assessment using simulation if necessary.

A training manikin is available for this purpose, by contacting the

Clinical Education Facilitator.

Undertake a summative assessment; the learner must reach

level 3 to be signed off as competent this may be achieved at the

formative stage, if all performance criteria are satisfied.

The performance criteria are provided with each competency to help towards

the interpretation of the competency statements and are intended as a guide

but all listed cues should be discussed and demonstrated in practice to

achieve competence.



Assessment scoring system Level 0 Unsafe practice

Has minimum knowledge/skill Unprofessional behaviour

Level 1 Doubt knowledge and ability to meet assessment criteria without direct supervision.

Level 2 Able to perform skill with supervision Has factual knowledge base

Level 3 Has knowledge and skill to perform task safely without supervision Ability to apply problem solving skills Consistently demonstrates clinical competence

Level 4 Has knowledge and skill to perform task unsupervised Ability to apply problem solving skills Can facilitate knowledge and skill to another Consistently demonstrates clinical competence Has attended a specific train the trainer session and is able teach and assess others



Appendix 1

Insertion and Care of Nasogastric tubes for Adults

Statement of competence

PASS / REFER I confirm I have assessed this learners practice and it is at the standard stated within this competency document and is competent in the following: Part 1 Knowledge and understanding section Part 2 Insertion and confirmation of position of nasogastric tubes Part 3 Management of nasogastric tubes Part 4 Administration of medications via the enteral route Assessor Name (please print): ..................................................................................... Assessor Signature: ..................................................................................................... Managers signature providing authority for practitioner to perform task: Date

Learner declaration: I have read and understood the PHNT policy and the the National Patient Safety Alerts related to the insertion and management of nasogastric tubes and enteral administration of medications Learners Name (please print): ..................................................................................... Learners Signature: .....................................................................................................

In the event of a referral or failure to reach required level of competence within 6 months: Date manager informed.

Name of manager (please print).

Manager signature of receipt of report.

Review date for second assessment

This sheet to be printed and stored for evidence of training.



1

Appendix 2 Insertion and Care of Nasogastric Tubes for Adults Competency Assessment Process for Registered Healthcare Professionals

Insertion and Care of Nasogastric

tubes for Adults

Competency Assessment Process for

Registered Healthcare Professionals

Learners Name Mentor/Assessor Name Date Commenced Date Completed Mentor Signature Learner Signature



2

Contents

Aim of the competency process 3

Assessment process 4

Part 1 - Core knowledge and understanding

6

Assessment Record and Feedback sheet

7

Part 2 - Practice Assessment sheet for the insertion and confirming position of fine bore and wide bore nasogastric tubes

9


10

Part 3 - Practice Assessment sheet for the management of fine bore and wide bore nasogastric tubes

11


12

Part 4 Practice Assessment sheet for the administration of medications via the enteral route

13


14


15



3

Introduction

To avoid catastrophic injury or fatal consequences,the National Patient Safety

Agency ( NPSA 2011) requires Healthcare Professionals to be competent in

the insertion and subsequent management of nasogastric tubes(NGT). Staff

have a responsibility to seek advice and training when necessary. This

document has been developed to to assist Registered Healthcare

Professionals in the training and recording of competency in the insertion and

subsequent management of fine bore and wide bore NGTs .

The aim of this competency assessment process is to ensure the healthcare

practitioner is able to:

Abide by, and fully implement the NPSA directives relating to the

insertion and management of fine and wide bore NGT

Understand of the decision making process for the use of NGTs

Understand the potential risks and contraindications associated with

the use of NGT and how to minimise/respond to these.

Demonstrate competency in the insertion and subsequent care of NGT.

Promote best practice throughout the healthcare environment in the

use and care of NGTs

The most important propose of this assessment process is to maintain

patient safety is at all times.

This competency assessment process consists of 4 parts:

1. Core Knowledge and Understanding :This section must be

successfully completed prior to the assessment by clinical observation

2. Practice Assessment for the insertion and confirming position of

nasogastric tubes.

3. Practice Assessment for the Care of the patient with a nasogastric

tube inserted

4. Practice Assessment for the administration of medications via the

enteral route



4

Assessment process



Read the current PHNT policy and all relevant NPSA documents for

insertion and management of NG tubes.

Perform a self assessment with a competent practitioner of the skill

and formulate an action plan to address learning needs

Complete Part 1 Core knowledge and understanding section with their

assessor before attempting Part 2,3 and 4

Undertake a formative assessment using simulation if necessary. A

training manikin is available for this purpose, by contacting the Clinical

Education Facilitator.

Undertake a summative assessment; the learner must reach level 3

to be signed off as competent this may be achieved at the formative

stage, if all performance criteria are satisfied.

In addition:

Complete the requirements of the NGT Competency Assessment

process within 6 months of commencement.

Take responsibility thereafter for maintaining competence in the skill

and seek supervision from a competent practitioner if for reason of

sickness or absence they have not carried out the procedure in the

previous 6 months.

If due to lack of clinical opportunity a reassessment is necessary

please contact the Clinical Education Facilitator to arrange an

assessment using a simulated assessment technique.

NB. The performance criteria are provided with each competency to help towards the

interpretation of the competency statements and are intended as a guide but all listed

cues should be discussed and demonstrated in practice to achieve competence.



5

Assessment scoring system LEVEL 0 Unsafe practice

Has minimum knowledge/skill Unprofessional behaviour

LEVEL 1 Doubt knowledge and ability to meet assessment criteria without direct supervision.

LEVEL 2 Able to perform skill with supervision Has factual knowledge base

LEVEL 3 Has knowledge and skill to perform task safely without supervision Ability to apply problem solving skills Consistently demonstrates clinical competence

Level 4 Has knowledge and skill to perform task unsupervised Ability to apply problem solving skills Consistently demonstrates clinical competence Can facilitate knowledge and skill to another Consistently demonstrates clinical competence Has attended a specific train the trainer session and is able teach and assess others

N. B. For more information regarding the assessment process please read the accompanying Supporting Document



6

Part 1 Knowledge and understanding

Prior to clinical assessment, the learner must demonstrate knowledge

and understanding of the following in relation to the insertion, checking

position and management of all types of nasogastric tubes

Learner to provide a short written answer to the following questions

Question 1

Describe what information should be entered into patients medical notes as a minimum prior to the decision to insert a NGT

Question 2

Describe in detail the actions when aspirate is not obtainable for both feeding and surgical indications

Question 3

Describe when are subsequent position checks are necessary



7

Evidence oral questioning Assessor

to indicate with X if not achieved

Assessor initial if achieved

1 Describe the indications for insertion of fine bore NG tubes and wide bore NG tubes.

2 Describe the basic upper GI anatomy and route of the NGT

3 Describe the actions required to undertake nutritional screening

4 When is it unsafe to pass a NG tube?

5 What is meant by first line check method in relation to the NPSA and why?

6 Describe what information should be documented following the pH test result

7 Describe possible reasons when aspirate is above pH 5.5

8 When is it necessary to confirm position of tube by X-ray ?

9 Describe the potential complications and appropriate remedial action

12 Explains why three way taps should not be used

13 List at least 2 drugs which have significant interactions with enteral feeding formula

14 Describe the legal implications of crushing drugs or opening capsules in relation to the product licence

15 Describe the procedure for a blocked NGT for enteral feeding and for surgical aspiration of stomach contents



8

Knowledge and understanding Assessment Record Assessor to initial and date to indicate level of performance refer to assessment criteria Self Assessment

0 1 2 3 4

Formative Assessment

0 1 2 3

4

Summative Assessment 0 1 2 3

4

Feedback Record

Comments

Action plan

Signature of Learner

Signature of Assessor

Date



9

Part 2 Assessment for the insertion and confirming position of Nasogastric tubes Prior to clinical assessment, the learner must demonstrate knowledge and understanding of the procedure and successfully completed Part 1 Performance criteria - Evidence of Direct Observation and Oral questioning

Can/is/does the learner

Assessor initial and date each section

PRE PROCEDURE:Check identity of patient and explain the procedure to the patient and gain their consent Ensure patient is given an agreed signal to stop procedure if unable to tolerate Position the patient correctly,sitting upright with head and shoulders well supported with pillows. If unconscious or semi-conscious place in a safe position by lying on their side Assemble the correct equipment including emergency equipment ( i.e. suctioning apparatus, oxygen) Select the most appropriate type of NG tube Wash hands with soap and water and dry well. Put on gloves and apron

PROCEDURE:Measure and mark the tube using the NEX method,mark this length with indelible pen If using a fine bore tube with an introducer ,ensure it is moveable by pulling out 5 cms and replacing prior to insertion. Close all portals Ask patient to blow nose if appropriate or clean each nostril Lubricate end of tube with water Insert the rounded end of tube into clearest nostril and slide backwards and inwards along the floor of the nasopharynx. Withdraw tube if obstruction is felt, retry on other side Stop immediately if patient shows signs of respiratory distress such as cyanosis and bradycardia or complains of ear pain Instruct patient to swallow if able as tube passes the naso pharynx (may sip water if not nil by mouth) Advance tube gently but continuously to required position Secure tube to patients nose and cheek/forehead using appropriate fixing tape.

CONFIRMS TUBE IS IN CORRECT POSITION: Withdraw 2 to 5mls of aspirate using a 60ml enteral purple syringe and place fluid onto pH indicator strip A pH of 1 to 5.5 indicates the safe range of acidity to confirm the tube is in the stomach. Undertake all measures to obtain aspirate if not able to withdraw stomach aspirate the first time Check tube by x-ray on first insertion if unable to obtain aspirate after all measures undertaken to do so fail Ensure X-ray request form contains all the required information including the purpose of the tube For Fine bore feeding tubes only Once position confirmed, flush tube with 10mls water and gently remove guide wire

POST PROCEDURE:Record procedure using correct documentation, include type and length of tube and pH of aspirate obtained Complete NGT sticker and adhere to patients notes Dispose of waste and used equipment appropriately



1

0

Assessment Record for the insertion and confirming position of nasogastric tubes Assessor to initial and date to indicate level of performance refer to assessment criteria Indicate level of performance Self Assessment

0 1 2 3 4


0 1 2 3

4


4

Feedback Record

Comments

Action plan



Date



1

1

Part 3 Assessment form for the Care of the patient with a Nasogastric tube Prior to clinical assessment, the learner must demonstrate knowledge and understanding of the procedure and successfully completed Part 1 Performance Criteria Can/is/does the trainee Evidence of Direct Observation and Oral questioning

Assessor to initial and date each section.

Communicate with patient effectively and gains their consent?

Ensure the correct position the patient for enteral feeding

Demonstrate the correct method to aspirate and flush the tube

Describe indications when tube may have moved from correct position and undertakes tube position check after:

Violent coughing or vomiting Before administering medications or start of

feeding regimes After interruption of delivery of feeding regime If it is suspected the tube as moved

Confirm the position of the NG tube correctly using the pH indicator strip

Check length of tube in relation to position of marker at nostril, and ensures tube is fixed securely at all times

For Wide bore (Ryes) tube only set up free drainage system or spigot as appropriate. Checks nature of aspirate and accurately documents amount

Demonstrate ability to attach giving set, run through feed and set enteral feeding pump to correct rate and volume.

Administer medications via NG tube appropriately, using correct mode (syrup, crushed etc) according to PHNT policy and NPSA guidelines .

Take correct action to ensure patency of tube and abides by PHNT policy for dealing with a blocked NG tube

Demonstrate clear and accurate records using correct documentation

Describe action to be taken for vomiting, distension, diarrhoea

Demonstrate awareness of the special needs of the patient with diabetes requiring enteral feeding

Abide by all infection control policies and procedures



1

2

Part 3 Assessment Record for the Care of the patient with a Nasogastric tube Assessor to initial and date to indicate level of performance refer to assessment criteria Self Assessment

0 1 2 3 4


0 1 2 3

4


4

Feedback Record

Comments

Action plan



Date



1

3

Part 4 Practice Assessment for the administration of medications via the enteral route Prior to clinical assessment, the learner must demonstrate knowledge and understanding of the procedure and successfully completed Part 1

Performance Criteria Can/is/does the learner - evidence of Direct Observation and Oral questioning

Assessor initial and date each section

PRE - PROCEDURE

Decontaminates hands and abides by infection control policy Prepares equipment, selects the most appropriate size and type of syringe abiding by NPSA guidelines Explains why a catheter tip syringe should be avoided Ensures all equipment is clean and dry e.g. pestle and mortar Checks medication, frequency and dose using patient drug chart according to PHNT procedure Checks Doctor has reviewed prescription are all medications necessary? Ensure pharmacist has reviewed prescription Checks prescription has considered mode? e.g. Liquid alternative available? Seeks advice for patients on fluid restrictions. Considers if medication requires a break in feeding regime.

PROCEDURE

Checks identity of patient Explains the procedure to the patient and gains consent if appropriate Confirms tube is in correct position and patient is comfortable Demonstrates ability to prepare and administer via enteral route the following

Soluble tablets Liquids Tablets Capsules

Stops feed and gives a minimal flush of 30mls or as directed before and after drug is given If more than one drug, gives separately with 10 ml of water flush in between Restarts feeding regime according to care plan

POST PROCEDURE Abides by control of infection policies and procedures Records procedure using correct documentation Cleans equipment thoroughly after use Disposes of waste and used equipment appropriately.



1

4

Assessment Record for the administration of medications via the enteral route Assessor to initial and date to indicate level of performance refer to assessment criteria ndicate level of performance Self Assessment

0 1 2 3 4


0 1 2 3

4


4

Feedback Record

Comments

Action plan



Date



1

5

Insertion and Care of Nasogastric tubes for Adults


PASS / REFER

1. I confirm I have assessed this learners practice and it is at the standard stated within this competency document in the following

Part 1 Knowledge and understanding section Part 2 Insertion and confirmation of position of nasogastric tubes Part 3 Management of nasogastric tubes Part 4 Administration of medications via the enteral route

Assessor Name (please print): ..................................................................................... Assessor Signature: ..................................................................................................... Managers signature providing authority for practitioner to perform task: Date

Learner declaration: I have read and understood the PHNT policy and the the National Patient Safety Alerts related to the insertion and management of nasogastric tubes and enteral administration of medications Learners Name (please print): ..................................................................................... Learners Signature: .....................................................................................................

In the event of a referral or failure to reach required level of competence

within 6 months:

Date manager informed.

Name of manager (please print).

Manager signature of receipt of report.

Review date for second assessment ..............................

This sheet to be printed and stored in a retrievable place for evidence of training



Appendix 3 Decision Tree for Nasogastric Tube Placement Checks in Adults

Decision Tree for nasogastric tube placement checks in ADULTS

\

NO

If pH above 5.5 on initial and subsequent placement check:

Medication, pt may be on a PPI (Proton Pump Inhibitor) e.g. Omeprazole : try to aspirate as long as possible after giving medication.

Feed, if feed is running continuously: stop feed for up to 60mins and try again

NO NO

Test aspirate on 2-5mls (5mls for Critical Care pts) using CE marked pH indicator paper for use on human aspirate.

DO NOT USE - try each of these techniques to help gain an aspirate: Check length tube inserted to

(NEX measurement) advance /withdraw tube by 5-20cms

If able to drink, give a small drink

Give mouth care to pts who are nil by mouth (stimulates gastric secretion)

Inject 10-20mls air down tube Move patient onto their left

side and retry Wait for 20-60 minutes and

try aspirating again

NO

Is pH aspirate 0 - 5.5?

YES

Use NGT for drainage or administration of feed/medication as per instructions

YES

DO NOT USE THE TUBE If aspirate cannot be obtained or is still above pH 5.5 Consult medical staff. Document the medical decision and strategy for that individual patient in the medical notes. Document all techniques tried to obtain aspirate before request for CXR is made.

Document Complete record of NG sticker accurately and stick on current page of pts medical notes. Complete Innovian NG record page (Critical Care pts). Complete bedside record chart

Subsequent checks pH recordings and length tube inserted at nostril in cms (NEX measurement) MUST be made and recorded on bedside documentation before each use e. g. aspiration feed/medication/flush or if cause for concern.

Is pH aspirate now 0 - 5.5? Is pH aspirate now 0 - 5.5?

On initial placement - A competent practitioner must view the CXR and complete the NGTsticker in the patients medical notes or on the Innovian NG page (Critical Care) and state if the NGT is safe to use. OR On subsequent checks - A competent practitioner must view the CXR and document the findings in the patients medical notes or on the Innovian NG page (Critical Care) and state if the NGT is safe to use.

If the CXR shows the NGT to be in the lungs the tube must be

removed immediately and re-passed

Does the patient need a NGT? Ensure there is enough expertise available to insert and interpret findings of both pH and CXR (if needed) Use a fully radio-opaque tube with visible external markings following the Trust guidelines Estimate NEX measurement (tube tip from Nose - Ear - Xiphisternum) Aspirate using a purple enteral syringe and gentle suction. Confirm and document secured NEX measurement

Aspirate obtained?

File in Medical notes with Nursing Records n

medical notes with F



Appendix 4 Record of Insertion of Nasogastric Tube Sticker

RECORD OF INSERTION OF NASOGASTRIC TUBE This must be completed and stuck to the current continuation sheet in patient

medical notes or complete Innovian NG page prior to use.

Reason for NG placement:-

Feeding Medication

Drainage

NG tube details and size Fine Bore Ryles

8fr 10fr 12fr

14fr 16fr 18fr

Length to which tube inserted (NEX measurement) at nostril in cms

R L Nostril

Inserted by: Print name. Sign.Date: Time:

Ist line test 2-5mls (5mls for critical care pts) of aspirate from NGT pH 5.5 or below, pH result pH 6.0 or above No aspirate Date.Time .. Checked by: Print name..Signature.

If No or pH is above 5.5 refer to NGT policy for aspiration techniques, then retry. If a CXR is required to confirm NGT position it should be requested ideally before 4pm with accurate details on the request.

2nd line test CXR taken: Time..Date....

CXR checked by a competent practitioner :- Time.Date..

Print name:.................................Signature:.. . Bleep

Position confirmed visually on CXR by:-

Follows oesophagus, avoids contours of bronchi

Clearly bisects the carina/bronchi

Crosses the diaphragm in the midline

Tip visable below left hemi-diaphragm

Can the tube be used safely for feeding/meds/drainage? Yes / No

Patient Name: . NHS No. Hospital No.. DOB.. Ward. (Fix Addressograph label)



Appendix 5 Nasogastric Tube Position Record and Care Plan

1

Nasogastric Tube Position Record and Care plan

Initial NGT positon check

External length of NGT in cms at tip of nose

Aspirate obtained

pH value of aspirate

If no aspirate or pH 6.0 or above Do Not use the NGT Follow the Decision Tree for Nasogastric Tube placement checks in adults Document action taken

Y / N

NB. Please ensure the NGT sticker is completed on initial tube placement and placed in the medical notes or Innovian NG page for Critical Care.

If difficulty in obtaining an aspirate refer to NGT policy for aspiration techniques.

Subsequent NGT position checks

Date/time External length of NGT in cms at tip of nose

Aspirate obtained Y / N



Sign and print name

Type and size of tube inserted . Position of the nasogastric tube should be checked:

Following initial insertion When there is suggestion of tube displacement

e.g change in tube length, patient comfort Before administering medications or feed Once daily during continuous feeds Once daily to confirm position when for drainage Any new or unexplained respiratory symptoms Following episodes of vomiting, retching or

coughing spasms

Patient Name: . NHS No. Ward. Hospital No.. DOB..

Date/Time NGT inserted. Inserted by, sign and print name:-

File in Medical notes with Nursing Records n medical notes with F



Date/time External length of NGT in cms at tip of nose

Aspirate obtained Y / N



Sign and print name



Appendix 6 Ongoing Post-Insertion Care and Management of Nasogastric Tubes

Ongoing Post-Insertion Care and Management of Nasogastric Tubes

SUBSEQUENT VERIFICATION OF NASOGASTRIC TUBE POSITION

As the accountable practitioner caring for the patient with a Nasogastric tube, it is your responsibility to ensure that the tube is in the correct position. Tube position should be checked by aspiration :

ACTION

Following each changeover of nursing shifts On each occasion prior to the administration of fluid, nutrition or medications. After vomiting or violent retching. If the patient complains of discomfort or feed reflux into the mouth. After severe bouts of coughing or respiratory distress. After nasopharyngeal, endotracheal or tracheostomy tube suctioning. If the tube is accidently dislodged. If the tube has obviously displaced on checking measurement. If it is suspected that the tube has moved. If there is any doubt that the tube may not be in the stomach. At least once every 24 hours when continuous feeds are used. Drainage tubes where a tube fails to drain or the patient is vomiting. On receipt of patient being transferred prior to using tube.

Use Nasogastric Tube Position Recording Form (Appendix *) to document subsequent checking of tube position

ONGOING MANAGEMENT

Securing a nasogastric tube Daily

Check that tape securing tube is intact and not in need of replacement. Check around nostril for any signs of pressure necrosis. If the nose appears sore or ulcerated, consider re-passing the tube via

the other nostril. Maintaining patency flushing.

Once tube position confirmed, flush tube with 30-50mls of water before and after feed and medications using a 60ml purple enteral syringe.

If the tube is not flushed regularly, occlusion may occur (Colagiovanni 2000)

Where possible medications should be given in liquid/dispersible form with a water flush in between.

If it is not possible to flush a feeding tube, then please refer to Adult Nasogastric Tube Feeding Guidelines, Version 1:6, sections:

9.1 Enteral feeding tube blockage: causes and prevention 9.2 Procedure for irrigating a blocked enteral feeding tube

Administration of medications via a nasogastric tube Please refer to Adult Nasogastric Tube Feeding Guidelines, Version 1:6, section 8.

File in Medical notes

with Nursing Records n

medical notes with

F



Appendix 7 Audit Form

Plymouth Hospitals NHS Trust

Audit Plan Naso-gastric Tube Insertion and Management

To be completed monthly by matron or ward manager for all patients with NG tubes on a pre-selected date. If there are no patients with NG Tubes response to be sent to confirm this. Audit Question Confirmation Comments

1 Is the request for a nasogastric tube documented?

Yes No

2 Has the type of tube required been identified?

Yes No

3 Is there a record of : The time and date the tube was inserted Who inserted it

Yes No Yes No

4 Has the correct sticker been placed in the patients record and completed?

Yes No

5 Is there a record of a ph test being successfully completed?

Yes No

6 If not is there evidence of an Xray to confirm position?

Yes No

7 Is there a record of medical staff having viewed xray and confirming position?

Yes No

8 Is there confirmation that staff administering feed / medication via tube have checked documentation of it being correctly sited?

Yes No

9 Are staff on duty aware of policy & procedure and where this can be found?

Yes No

Date: Time: Ward/Dept: Name of person completing audit ( please print)t: Signature: Designation:



NGT Procedure

Documents

Transcript of NGT Procedure