___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Good Practice Guideline
Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults
(Not ongoing care)
March 2012 Review date March 2015
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Description A nasogastric tube is inserted through the nose into the stomach via the oesophagus for the purposes of
a) Gastric aspiration and decompression b) Enteral feeding c) Administration of medication
Many nasogastric feeding tubes are passed each day without incident However there is a small risk of tubes being misplaced during insertion or displaced after a successful insertion Should misplacement occur and not be recognised potentially serious harm could occur to the patient (NPSA 2011) In line with NPSA guidance (2011) fine-bore nasogastric tubes used for enteral feeding should be radio-opaque along their length and have external visual length markings The size of tube used should be 6-12fg There are two common types of naso-gastric feeding tubes
i) A short term nasogastric feeding tube is usually made of PVC and should be used for a maximum of 7-10 days (as per manufacturerrsquos instructions) before replacement is required This is due to the link between the leaching of plasticisers from PVC tubes when in contact with fats in nutrition formulas (MHRA 2007) If a PVC tube is used for feeding it must be NPSA compliant
ii) A long term nasogastric feeding tube is usually made of polyurethane and will often have a guidewire throughout their length to aid the insertion process (Lifespan of this type of tube may vary according to manufacturers Refer to their guidance for product lifespan usually 6-8 weeks)
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Although nasogastric tubes are commonly inserted by a variety of practitioners including nurses doctors and allied health professionals for the purpose of this guideline the term ldquopractitionerrdquo will be used throughout Before undertaking this procedure the practitioner should be assessed as competent (as per local policy) This is a clean procedure therefore non sterile gloves and an apron should be worn throughout In addition adhering to a non-touch technique is recommended Although this procedure can be performed by one practitioner it is advisable to have a second person present to assist with positioning of a patient and to provide reassurance for those patients who require it
No Action Rationale Reference
1 The patient must have an accessible gastro-intestinal tract To be able to safely insert the feeding tube
NICE 2006
2 The patient must have a functioning gastro-intestinal tract To maximise absorption of feeds andor medication
NICE 2006
3 A multi-disciplinary team (MDT) approach to the initiation of feeding should be utilised Before undertaking the procedure
Review the patientrsquos medical notes to assess for any contraindications to tube placement
Ensure all relevant investigations are undertaken (where appropriate) eg blood clotting
Rationale for the decision to place a nasogastric tube should be documented in the notes The responsibility lies with the consultant in charge of the patientrsquos care
Feeding is appropriate and in the best interest of the patient
RCP 2010 NPSA 2011
4 Explain the procedure and where the patient has capacity to consent their agreement should be obtained For this procedure verbal consent is sufficient
To demonstrate understanding and agreement with the procedure
DH 2005 DH 2009a
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
5 Where patients demonstrate a lack of capacity a lsquoBest Interest decisionrsquo should be taken by the practitioner This may necessitate further discussion with the wider MDT and may require an Independent Mental Capacity Assessor(IMCA)
To demonstrate compliance with current legislation and demonstrate wider consultation to ensure appropriate decision
DH 2005 DH 2009a RCP 2010
6 Gather all equipment prior to arriving to the patientrsquos bedside Essential equipment includes
NPSA compliant nasogastric tube appropriate to purpose and in accordance with local policy
Enteral syringe
pH indicator strips (CE marked)
Receiver
Glass of water with drinking straw (if patient has a safe swallow and is not nil by mouth [NBM])
Tissues
Hypoallergenic tape and scissors
Water for flushing once gastric position has been confirmed (freshly run tap water from a drinking sourcecooled boiled water sterile water) as per local policy
Non sterile gloves and apron Prepare equipment at patientrsquos bedside and remind the patient of the procedure and their role within it including
performing a swallow as the tube passes through the pharynx
To ensure timely uninterrupted insertion of the NG tube
NPSA 2005 DH 2009b NPSA 2011
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Agreeing a signal to indicate a problem or stop the procedure Ensure universal precautions are used at all times
To adhere to local infection control policies
7 Estimate the length of the tube required using the NEX measurement (nose ear xiphisternum) Place the exit port of the tube at the tip of the nose Extend the tube across to the earlobe and then down to the xiphisternum Note the predetermined mark (Use this measurement as a guide only ndash it is not prescriptive)
To ascertain an approximate measurement to ensure the tube is sited at the correct length
NPSA 2011
8 Position the patient appropriately ideally sitting upright supported by pillows Where an upright position is not achievable either position the patient as upright as possible or on their side with the head well supported (by pillows)
To increase patient comfort whilst carrying out the procedure and to facilitate easier insertion of the tube and avoid inadvertent tracheal intubation
Grade D evidence Weightman et al 2005
9 Inspect and examine the nose This may include digital examination of the nostrils Clear any nasal debris If the patient can blow their nose advise them to do so Use the sniff test ndash ie using the index finger to occlude one nostril and then asking the patient to sniff and then do the same to the other side ndash there will always be one slightly more clear than the other which alternates throughout the day (nasal cycle) If possible ask the patient if they have any preference for which nostril to use Previous trauma including polyps or sinusitis may mean only one nostril can be used
To ensure nasal passages are clear for smooth passage of the tube To assess for any physiological malformation that may inhibit tube insertion
Eccles 2000 Dougherty amp Lister S 2011
10 Remove the nasogastric tube from its packaging and gently stretch it to loosen the guidewire Lubricate the tube as per local policy manufacturers instructions
To facilitate easier removal of the guidewire following tube placement To facilitate smooth passage of the tube
Grade D evidence Weightman
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
DO NOT lubricate the inner lumen of the tube with water before insertion and checking gastric positioning
and increase patient comfort et al 2005
11 Insert tube into the agreed nostril to the back of nose along the nasopharynx The patients head should not be extended or flexed Where required to assist insertion ask the patient to perform a lsquochin tuckrsquo (tucking the chin down toward the chest) At this point a) Where a patient is safe to swallow fluid and has capacity offer a glass of water with a
straw and ask patient to swallow some water (refer to patientrsquos care plan) b) Where patient is not safe to swallow fluid but has capacity ask patient to perform a
dry swallow (refer to patientrsquos care plan) c) Where a patient is not safe to swallow fluid and lacks capacity wait for the peak of
expiration before advancing the tube
To reduce the risk of a tracheal placed tube Extension of the neck increases the risk of tracheal placement of the tube To aid intubation into the oesophagus and reduce risk of tracheal intubation
Grade D evidence Weightman et al 2005
12 Slowly advance the tube to the predetermined mark (refer to point 7) If any significant resistance is felt during insertion halt the procedure and pull the tube back but do not remove it completely If the patient is coughing stop pull the tube back slightly and wait for coughing to settle Before continuing ask the patient to open their mouth to check nasogastric tube has not coiled up at the back of the oral cavity Never force the tube if resistance continues on subsequent attempts A maximum of 3 attempts should be made at one time and by any one person If the patient becomes distressed during any of these attempts it is advisable to stop and seek senior specialist advice If procedure is unsuccessful after 3 attempts stop and seek senior specialist advice
To achieve gastric placement of the tube
To avoid causing any harm
Grade D evidence Weightman et al (2005)
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
13 When NG tube inserted to predetermined mark aspirate with an enteral syringe as per manufacturerrsquos guidance leaving the guidewire in position Aspiration of gastric contents may be easier if the guidewire is removed but note that should the tube require repositioning or no aspirate is obtained under no circumstances should the guidewire be re-inserted into the tube whilst the tube remains in the patient If unable to obtain aspirate refer to the NPSA decision tree or local policy for assistance This may include chest x-ray (Refer to point 10 regarding tube lubrication)
To obtain gastric aspirate the guidewire is left in to allow for the tube to be repositioned if necessary To adhere to the NPSA guidance for safe measurement administration of medicines NPSA Decision Tree
NPSA 2007 NPSA 2011
14 Test the gastric aspirate with pH indicator paperstrips that comply with NPSA guidance (CE marked) to obtain a pH reading a) pH reading MUST be 55 or below to administer fluid immediately without further
investigation b) The pH lsquocut-offrsquo reading may differ according to local policy but should never exceed
55
To confirm correct gastric position and safe to feed
NPSA 2011
15 Secure the tube at the nose or cheek once gastric position is confirmed Note the external visual length markings at the exit point of the nostril a) If guidewire has not been removed (as per point 13) remove it at this point according
to manufacturersrsquo guidance b) Flush the tube with water as per local policy
To reduce displacement of the tube Securing to the cheek prevents nasal erosion or ulceration To clear tube of gastric contents that have been aspirated up the tube
NPSA 2011
16 Make the patient comfortable before disposing of equipment as per local policy DH 2010
17 Fully document the procedure into the appropriate healthcare records Documentation should include as a minimum
To ensure patient safety To adhere to NPSA guidance
DH 2009 RCP 2010
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
a) The size and type of tube used b) External length markings at the nostril c) The method used to confirm gastric positioning of the tube d) Who placed the tube e) Include how consent was obtainedpatient agreement indicated Fully document Best
Interest decisions Also consider documenting f) Patient tolerability with procedure g) The number of attempts insertion undertaken (ie if very difficult procedure or
multiple attempts made) ndash this is very relevant if there is any trauma from the procedure
h) Which nostril the tube is sited i) Date tube change is due j) Bedside Documentation
To note serial recordings of tube position and pH results
NPSA 2011
The NNNG recognises that practice will vary according to individual risk assessments and local policy However this good practice statement has been
published in accordance with available evidence at the time of publication
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Developed by
Tracy Earley Deputy Secretary Consultant Nurse ndash Nutrition Lancashire Teaching Hospitals NHS Foundation Trust Neil Wilson Senior lecturer Manchester Metropolitan University Liz Evans Chair Nutrition Nurse Specialist Buckinghamshire Healthcare NHS Trust Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust Winnie Magambo Nutrition Nurse Specialist University of Wales Cardiff Anne Myers Lead Nurse Intestinal Failure Unit Salford Royal NHS Foundation Trust Barbara Dovaston Clinical Nurse Specialist Heartlands Hospital Heart of England NHS Foundation Linda Warriner Deputy Communications Officer Home Enteral Feeding Specialist Nurse County Durham and Darlington NHS Foundation
Edited and compiled by
Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust
Peer reviewed by
Andrea Cartwright Senior Nutrition Nurse Specialist Basildon and Thurrock University Hospital NHS Foundation Trust Jane Fletcher Nutrition Nurse Team Leader University Hospitals Birmingham NHS Foundation Trust Zillah Leach Nutrition Support Nurse University Hospital Southampton NHS Foundation Trust
Supported by
The National Patient Safety Agency has reviewed these good practice statements at the time of publication (March 2012) and support their production in improving patient safety in practice - Caroline Lecko - Patient Safety Lead
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
REFERENCES Department of Health (2005) Mental Capacity Act Code of Practice Department of Constitutional affairs Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenSocialCareDeliveringadultsocialcareMentalCapacityMentalCapacityAct2005indexht
m
Department of Health (2009a) Reference guide to consent for examination or treatment 2nd edition Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenPublicationsandstatisticsPublicationsPublicationsPolicyAndGuidanceDH_103643
Department of Health (2009b) Saving Lives High Impact Intervention (HII) Enteral feeding care bundle Department of Health London
httphcaidhgovukfiles2011032011-03-14-HII-Enteral-Feeding-Care-Bundle-FINALpdf
Department of Health (2010) Essence of Care Benchmarks for Respect and Dignity DH London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukprod_consum_dhgroupsdh_digitalassetsdhenpsdocumentsdigitalassetdh_11996
6pdf
Dougherty L Lister S (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (8th edition) Wiley Blackwell
Eccles RB (2000) The nasal cycle in respiratory defence Acta Otorhinolaryngologica Belgica 54(3)281-6
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Medicines and Healthcare Products Regulatory Agency (2007) PhthalatesDEHP in PVC medical devices MHRA London
httpwwwmhragovukSafetyinformationGeneralsafetyinformationandadviceTechnicalinformationPhthalatesinPVCmedicaldevicesindexhtm
National Institute of Clinical Excellence (2006) Nutrition Support for Adults Oral nutrition support enteral tube feeding and parenteral nutrition Clinical
Guideline 32 NICE London httpwwwniceorgukCG32
National Patient Safety Agency (2005) Patient safety alert 05 Reducing the harm caused by misplaced nasogastric tubes National Patient Safety Agency
February 21 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59794
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes National
Patient Safety Agency Ref NPSA200719 March 2007 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59808
National Patient Safety Agency (2011) Patient Safety Alert 2011PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults
children and infants NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=129640
Royal College of Physicians and British Society of Gastroenterology (2010) Oral feeding difficulties and dilemmas A guide to practical care particularly
towards the end of life Royal College of Physicians London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Weightman A Ellis S Cullum A et al (2005) Grading evidence and recommendations for public health interventions developing and piloting a framework
Health Development Agency London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Description A nasogastric tube is inserted through the nose into the stomach via the oesophagus for the purposes of
a) Gastric aspiration and decompression b) Enteral feeding c) Administration of medication
Many nasogastric feeding tubes are passed each day without incident However there is a small risk of tubes being misplaced during insertion or displaced after a successful insertion Should misplacement occur and not be recognised potentially serious harm could occur to the patient (NPSA 2011) In line with NPSA guidance (2011) fine-bore nasogastric tubes used for enteral feeding should be radio-opaque along their length and have external visual length markings The size of tube used should be 6-12fg There are two common types of naso-gastric feeding tubes
i) A short term nasogastric feeding tube is usually made of PVC and should be used for a maximum of 7-10 days (as per manufacturerrsquos instructions) before replacement is required This is due to the link between the leaching of plasticisers from PVC tubes when in contact with fats in nutrition formulas (MHRA 2007) If a PVC tube is used for feeding it must be NPSA compliant
ii) A long term nasogastric feeding tube is usually made of polyurethane and will often have a guidewire throughout their length to aid the insertion process (Lifespan of this type of tube may vary according to manufacturers Refer to their guidance for product lifespan usually 6-8 weeks)
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Although nasogastric tubes are commonly inserted by a variety of practitioners including nurses doctors and allied health professionals for the purpose of this guideline the term ldquopractitionerrdquo will be used throughout Before undertaking this procedure the practitioner should be assessed as competent (as per local policy) This is a clean procedure therefore non sterile gloves and an apron should be worn throughout In addition adhering to a non-touch technique is recommended Although this procedure can be performed by one practitioner it is advisable to have a second person present to assist with positioning of a patient and to provide reassurance for those patients who require it
No Action Rationale Reference
1 The patient must have an accessible gastro-intestinal tract To be able to safely insert the feeding tube
NICE 2006
2 The patient must have a functioning gastro-intestinal tract To maximise absorption of feeds andor medication
NICE 2006
3 A multi-disciplinary team (MDT) approach to the initiation of feeding should be utilised Before undertaking the procedure
Review the patientrsquos medical notes to assess for any contraindications to tube placement
Ensure all relevant investigations are undertaken (where appropriate) eg blood clotting
Rationale for the decision to place a nasogastric tube should be documented in the notes The responsibility lies with the consultant in charge of the patientrsquos care
Feeding is appropriate and in the best interest of the patient
RCP 2010 NPSA 2011
4 Explain the procedure and where the patient has capacity to consent their agreement should be obtained For this procedure verbal consent is sufficient
To demonstrate understanding and agreement with the procedure
DH 2005 DH 2009a
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
5 Where patients demonstrate a lack of capacity a lsquoBest Interest decisionrsquo should be taken by the practitioner This may necessitate further discussion with the wider MDT and may require an Independent Mental Capacity Assessor(IMCA)
To demonstrate compliance with current legislation and demonstrate wider consultation to ensure appropriate decision
DH 2005 DH 2009a RCP 2010
6 Gather all equipment prior to arriving to the patientrsquos bedside Essential equipment includes
NPSA compliant nasogastric tube appropriate to purpose and in accordance with local policy
Enteral syringe
pH indicator strips (CE marked)
Receiver
Glass of water with drinking straw (if patient has a safe swallow and is not nil by mouth [NBM])
Tissues
Hypoallergenic tape and scissors
Water for flushing once gastric position has been confirmed (freshly run tap water from a drinking sourcecooled boiled water sterile water) as per local policy
Non sterile gloves and apron Prepare equipment at patientrsquos bedside and remind the patient of the procedure and their role within it including
performing a swallow as the tube passes through the pharynx
To ensure timely uninterrupted insertion of the NG tube
NPSA 2005 DH 2009b NPSA 2011
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Agreeing a signal to indicate a problem or stop the procedure Ensure universal precautions are used at all times
To adhere to local infection control policies
7 Estimate the length of the tube required using the NEX measurement (nose ear xiphisternum) Place the exit port of the tube at the tip of the nose Extend the tube across to the earlobe and then down to the xiphisternum Note the predetermined mark (Use this measurement as a guide only ndash it is not prescriptive)
To ascertain an approximate measurement to ensure the tube is sited at the correct length
NPSA 2011
8 Position the patient appropriately ideally sitting upright supported by pillows Where an upright position is not achievable either position the patient as upright as possible or on their side with the head well supported (by pillows)
To increase patient comfort whilst carrying out the procedure and to facilitate easier insertion of the tube and avoid inadvertent tracheal intubation
Grade D evidence Weightman et al 2005
9 Inspect and examine the nose This may include digital examination of the nostrils Clear any nasal debris If the patient can blow their nose advise them to do so Use the sniff test ndash ie using the index finger to occlude one nostril and then asking the patient to sniff and then do the same to the other side ndash there will always be one slightly more clear than the other which alternates throughout the day (nasal cycle) If possible ask the patient if they have any preference for which nostril to use Previous trauma including polyps or sinusitis may mean only one nostril can be used
To ensure nasal passages are clear for smooth passage of the tube To assess for any physiological malformation that may inhibit tube insertion
Eccles 2000 Dougherty amp Lister S 2011
10 Remove the nasogastric tube from its packaging and gently stretch it to loosen the guidewire Lubricate the tube as per local policy manufacturers instructions
To facilitate easier removal of the guidewire following tube placement To facilitate smooth passage of the tube
Grade D evidence Weightman
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
DO NOT lubricate the inner lumen of the tube with water before insertion and checking gastric positioning
and increase patient comfort et al 2005
11 Insert tube into the agreed nostril to the back of nose along the nasopharynx The patients head should not be extended or flexed Where required to assist insertion ask the patient to perform a lsquochin tuckrsquo (tucking the chin down toward the chest) At this point a) Where a patient is safe to swallow fluid and has capacity offer a glass of water with a
straw and ask patient to swallow some water (refer to patientrsquos care plan) b) Where patient is not safe to swallow fluid but has capacity ask patient to perform a
dry swallow (refer to patientrsquos care plan) c) Where a patient is not safe to swallow fluid and lacks capacity wait for the peak of
expiration before advancing the tube
To reduce the risk of a tracheal placed tube Extension of the neck increases the risk of tracheal placement of the tube To aid intubation into the oesophagus and reduce risk of tracheal intubation
Grade D evidence Weightman et al 2005
12 Slowly advance the tube to the predetermined mark (refer to point 7) If any significant resistance is felt during insertion halt the procedure and pull the tube back but do not remove it completely If the patient is coughing stop pull the tube back slightly and wait for coughing to settle Before continuing ask the patient to open their mouth to check nasogastric tube has not coiled up at the back of the oral cavity Never force the tube if resistance continues on subsequent attempts A maximum of 3 attempts should be made at one time and by any one person If the patient becomes distressed during any of these attempts it is advisable to stop and seek senior specialist advice If procedure is unsuccessful after 3 attempts stop and seek senior specialist advice
To achieve gastric placement of the tube
To avoid causing any harm
Grade D evidence Weightman et al (2005)
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
13 When NG tube inserted to predetermined mark aspirate with an enteral syringe as per manufacturerrsquos guidance leaving the guidewire in position Aspiration of gastric contents may be easier if the guidewire is removed but note that should the tube require repositioning or no aspirate is obtained under no circumstances should the guidewire be re-inserted into the tube whilst the tube remains in the patient If unable to obtain aspirate refer to the NPSA decision tree or local policy for assistance This may include chest x-ray (Refer to point 10 regarding tube lubrication)
To obtain gastric aspirate the guidewire is left in to allow for the tube to be repositioned if necessary To adhere to the NPSA guidance for safe measurement administration of medicines NPSA Decision Tree
NPSA 2007 NPSA 2011
14 Test the gastric aspirate with pH indicator paperstrips that comply with NPSA guidance (CE marked) to obtain a pH reading a) pH reading MUST be 55 or below to administer fluid immediately without further
investigation b) The pH lsquocut-offrsquo reading may differ according to local policy but should never exceed
55
To confirm correct gastric position and safe to feed
NPSA 2011
15 Secure the tube at the nose or cheek once gastric position is confirmed Note the external visual length markings at the exit point of the nostril a) If guidewire has not been removed (as per point 13) remove it at this point according
to manufacturersrsquo guidance b) Flush the tube with water as per local policy
To reduce displacement of the tube Securing to the cheek prevents nasal erosion or ulceration To clear tube of gastric contents that have been aspirated up the tube
NPSA 2011
16 Make the patient comfortable before disposing of equipment as per local policy DH 2010
17 Fully document the procedure into the appropriate healthcare records Documentation should include as a minimum
To ensure patient safety To adhere to NPSA guidance
DH 2009 RCP 2010
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
a) The size and type of tube used b) External length markings at the nostril c) The method used to confirm gastric positioning of the tube d) Who placed the tube e) Include how consent was obtainedpatient agreement indicated Fully document Best
Interest decisions Also consider documenting f) Patient tolerability with procedure g) The number of attempts insertion undertaken (ie if very difficult procedure or
multiple attempts made) ndash this is very relevant if there is any trauma from the procedure
h) Which nostril the tube is sited i) Date tube change is due j) Bedside Documentation
To note serial recordings of tube position and pH results
NPSA 2011
The NNNG recognises that practice will vary according to individual risk assessments and local policy However this good practice statement has been
published in accordance with available evidence at the time of publication
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Developed by
Tracy Earley Deputy Secretary Consultant Nurse ndash Nutrition Lancashire Teaching Hospitals NHS Foundation Trust Neil Wilson Senior lecturer Manchester Metropolitan University Liz Evans Chair Nutrition Nurse Specialist Buckinghamshire Healthcare NHS Trust Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust Winnie Magambo Nutrition Nurse Specialist University of Wales Cardiff Anne Myers Lead Nurse Intestinal Failure Unit Salford Royal NHS Foundation Trust Barbara Dovaston Clinical Nurse Specialist Heartlands Hospital Heart of England NHS Foundation Linda Warriner Deputy Communications Officer Home Enteral Feeding Specialist Nurse County Durham and Darlington NHS Foundation
Edited and compiled by
Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust
Peer reviewed by
Andrea Cartwright Senior Nutrition Nurse Specialist Basildon and Thurrock University Hospital NHS Foundation Trust Jane Fletcher Nutrition Nurse Team Leader University Hospitals Birmingham NHS Foundation Trust Zillah Leach Nutrition Support Nurse University Hospital Southampton NHS Foundation Trust
Supported by
The National Patient Safety Agency has reviewed these good practice statements at the time of publication (March 2012) and support their production in improving patient safety in practice - Caroline Lecko - Patient Safety Lead
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
REFERENCES Department of Health (2005) Mental Capacity Act Code of Practice Department of Constitutional affairs Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenSocialCareDeliveringadultsocialcareMentalCapacityMentalCapacityAct2005indexht
m
Department of Health (2009a) Reference guide to consent for examination or treatment 2nd edition Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenPublicationsandstatisticsPublicationsPublicationsPolicyAndGuidanceDH_103643
Department of Health (2009b) Saving Lives High Impact Intervention (HII) Enteral feeding care bundle Department of Health London
httphcaidhgovukfiles2011032011-03-14-HII-Enteral-Feeding-Care-Bundle-FINALpdf
Department of Health (2010) Essence of Care Benchmarks for Respect and Dignity DH London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukprod_consum_dhgroupsdh_digitalassetsdhenpsdocumentsdigitalassetdh_11996
6pdf
Dougherty L Lister S (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (8th edition) Wiley Blackwell
Eccles RB (2000) The nasal cycle in respiratory defence Acta Otorhinolaryngologica Belgica 54(3)281-6
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Medicines and Healthcare Products Regulatory Agency (2007) PhthalatesDEHP in PVC medical devices MHRA London
httpwwwmhragovukSafetyinformationGeneralsafetyinformationandadviceTechnicalinformationPhthalatesinPVCmedicaldevicesindexhtm
National Institute of Clinical Excellence (2006) Nutrition Support for Adults Oral nutrition support enteral tube feeding and parenteral nutrition Clinical
Guideline 32 NICE London httpwwwniceorgukCG32
National Patient Safety Agency (2005) Patient safety alert 05 Reducing the harm caused by misplaced nasogastric tubes National Patient Safety Agency
February 21 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59794
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes National
Patient Safety Agency Ref NPSA200719 March 2007 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59808
National Patient Safety Agency (2011) Patient Safety Alert 2011PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults
children and infants NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=129640
Royal College of Physicians and British Society of Gastroenterology (2010) Oral feeding difficulties and dilemmas A guide to practical care particularly
towards the end of life Royal College of Physicians London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Weightman A Ellis S Cullum A et al (2005) Grading evidence and recommendations for public health interventions developing and piloting a framework
Health Development Agency London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Although nasogastric tubes are commonly inserted by a variety of practitioners including nurses doctors and allied health professionals for the purpose of this guideline the term ldquopractitionerrdquo will be used throughout Before undertaking this procedure the practitioner should be assessed as competent (as per local policy) This is a clean procedure therefore non sterile gloves and an apron should be worn throughout In addition adhering to a non-touch technique is recommended Although this procedure can be performed by one practitioner it is advisable to have a second person present to assist with positioning of a patient and to provide reassurance for those patients who require it
No Action Rationale Reference
1 The patient must have an accessible gastro-intestinal tract To be able to safely insert the feeding tube
NICE 2006
2 The patient must have a functioning gastro-intestinal tract To maximise absorption of feeds andor medication
NICE 2006
3 A multi-disciplinary team (MDT) approach to the initiation of feeding should be utilised Before undertaking the procedure
Review the patientrsquos medical notes to assess for any contraindications to tube placement
Ensure all relevant investigations are undertaken (where appropriate) eg blood clotting
Rationale for the decision to place a nasogastric tube should be documented in the notes The responsibility lies with the consultant in charge of the patientrsquos care
Feeding is appropriate and in the best interest of the patient
RCP 2010 NPSA 2011
4 Explain the procedure and where the patient has capacity to consent their agreement should be obtained For this procedure verbal consent is sufficient
To demonstrate understanding and agreement with the procedure
DH 2005 DH 2009a
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
5 Where patients demonstrate a lack of capacity a lsquoBest Interest decisionrsquo should be taken by the practitioner This may necessitate further discussion with the wider MDT and may require an Independent Mental Capacity Assessor(IMCA)
To demonstrate compliance with current legislation and demonstrate wider consultation to ensure appropriate decision
DH 2005 DH 2009a RCP 2010
6 Gather all equipment prior to arriving to the patientrsquos bedside Essential equipment includes
NPSA compliant nasogastric tube appropriate to purpose and in accordance with local policy
Enteral syringe
pH indicator strips (CE marked)
Receiver
Glass of water with drinking straw (if patient has a safe swallow and is not nil by mouth [NBM])
Tissues
Hypoallergenic tape and scissors
Water for flushing once gastric position has been confirmed (freshly run tap water from a drinking sourcecooled boiled water sterile water) as per local policy
Non sterile gloves and apron Prepare equipment at patientrsquos bedside and remind the patient of the procedure and their role within it including
performing a swallow as the tube passes through the pharynx
To ensure timely uninterrupted insertion of the NG tube
NPSA 2005 DH 2009b NPSA 2011
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Agreeing a signal to indicate a problem or stop the procedure Ensure universal precautions are used at all times
To adhere to local infection control policies
7 Estimate the length of the tube required using the NEX measurement (nose ear xiphisternum) Place the exit port of the tube at the tip of the nose Extend the tube across to the earlobe and then down to the xiphisternum Note the predetermined mark (Use this measurement as a guide only ndash it is not prescriptive)
To ascertain an approximate measurement to ensure the tube is sited at the correct length
NPSA 2011
8 Position the patient appropriately ideally sitting upright supported by pillows Where an upright position is not achievable either position the patient as upright as possible or on their side with the head well supported (by pillows)
To increase patient comfort whilst carrying out the procedure and to facilitate easier insertion of the tube and avoid inadvertent tracheal intubation
Grade D evidence Weightman et al 2005
9 Inspect and examine the nose This may include digital examination of the nostrils Clear any nasal debris If the patient can blow their nose advise them to do so Use the sniff test ndash ie using the index finger to occlude one nostril and then asking the patient to sniff and then do the same to the other side ndash there will always be one slightly more clear than the other which alternates throughout the day (nasal cycle) If possible ask the patient if they have any preference for which nostril to use Previous trauma including polyps or sinusitis may mean only one nostril can be used
To ensure nasal passages are clear for smooth passage of the tube To assess for any physiological malformation that may inhibit tube insertion
Eccles 2000 Dougherty amp Lister S 2011
10 Remove the nasogastric tube from its packaging and gently stretch it to loosen the guidewire Lubricate the tube as per local policy manufacturers instructions
To facilitate easier removal of the guidewire following tube placement To facilitate smooth passage of the tube
Grade D evidence Weightman
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
DO NOT lubricate the inner lumen of the tube with water before insertion and checking gastric positioning
and increase patient comfort et al 2005
11 Insert tube into the agreed nostril to the back of nose along the nasopharynx The patients head should not be extended or flexed Where required to assist insertion ask the patient to perform a lsquochin tuckrsquo (tucking the chin down toward the chest) At this point a) Where a patient is safe to swallow fluid and has capacity offer a glass of water with a
straw and ask patient to swallow some water (refer to patientrsquos care plan) b) Where patient is not safe to swallow fluid but has capacity ask patient to perform a
dry swallow (refer to patientrsquos care plan) c) Where a patient is not safe to swallow fluid and lacks capacity wait for the peak of
expiration before advancing the tube
To reduce the risk of a tracheal placed tube Extension of the neck increases the risk of tracheal placement of the tube To aid intubation into the oesophagus and reduce risk of tracheal intubation
Grade D evidence Weightman et al 2005
12 Slowly advance the tube to the predetermined mark (refer to point 7) If any significant resistance is felt during insertion halt the procedure and pull the tube back but do not remove it completely If the patient is coughing stop pull the tube back slightly and wait for coughing to settle Before continuing ask the patient to open their mouth to check nasogastric tube has not coiled up at the back of the oral cavity Never force the tube if resistance continues on subsequent attempts A maximum of 3 attempts should be made at one time and by any one person If the patient becomes distressed during any of these attempts it is advisable to stop and seek senior specialist advice If procedure is unsuccessful after 3 attempts stop and seek senior specialist advice
To achieve gastric placement of the tube
To avoid causing any harm
Grade D evidence Weightman et al (2005)
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
13 When NG tube inserted to predetermined mark aspirate with an enteral syringe as per manufacturerrsquos guidance leaving the guidewire in position Aspiration of gastric contents may be easier if the guidewire is removed but note that should the tube require repositioning or no aspirate is obtained under no circumstances should the guidewire be re-inserted into the tube whilst the tube remains in the patient If unable to obtain aspirate refer to the NPSA decision tree or local policy for assistance This may include chest x-ray (Refer to point 10 regarding tube lubrication)
To obtain gastric aspirate the guidewire is left in to allow for the tube to be repositioned if necessary To adhere to the NPSA guidance for safe measurement administration of medicines NPSA Decision Tree
NPSA 2007 NPSA 2011
14 Test the gastric aspirate with pH indicator paperstrips that comply with NPSA guidance (CE marked) to obtain a pH reading a) pH reading MUST be 55 or below to administer fluid immediately without further
investigation b) The pH lsquocut-offrsquo reading may differ according to local policy but should never exceed
55
To confirm correct gastric position and safe to feed
NPSA 2011
15 Secure the tube at the nose or cheek once gastric position is confirmed Note the external visual length markings at the exit point of the nostril a) If guidewire has not been removed (as per point 13) remove it at this point according
to manufacturersrsquo guidance b) Flush the tube with water as per local policy
To reduce displacement of the tube Securing to the cheek prevents nasal erosion or ulceration To clear tube of gastric contents that have been aspirated up the tube
NPSA 2011
16 Make the patient comfortable before disposing of equipment as per local policy DH 2010
17 Fully document the procedure into the appropriate healthcare records Documentation should include as a minimum
To ensure patient safety To adhere to NPSA guidance
DH 2009 RCP 2010
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
a) The size and type of tube used b) External length markings at the nostril c) The method used to confirm gastric positioning of the tube d) Who placed the tube e) Include how consent was obtainedpatient agreement indicated Fully document Best
Interest decisions Also consider documenting f) Patient tolerability with procedure g) The number of attempts insertion undertaken (ie if very difficult procedure or
multiple attempts made) ndash this is very relevant if there is any trauma from the procedure
h) Which nostril the tube is sited i) Date tube change is due j) Bedside Documentation
To note serial recordings of tube position and pH results
NPSA 2011
The NNNG recognises that practice will vary according to individual risk assessments and local policy However this good practice statement has been
published in accordance with available evidence at the time of publication
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Developed by
Tracy Earley Deputy Secretary Consultant Nurse ndash Nutrition Lancashire Teaching Hospitals NHS Foundation Trust Neil Wilson Senior lecturer Manchester Metropolitan University Liz Evans Chair Nutrition Nurse Specialist Buckinghamshire Healthcare NHS Trust Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust Winnie Magambo Nutrition Nurse Specialist University of Wales Cardiff Anne Myers Lead Nurse Intestinal Failure Unit Salford Royal NHS Foundation Trust Barbara Dovaston Clinical Nurse Specialist Heartlands Hospital Heart of England NHS Foundation Linda Warriner Deputy Communications Officer Home Enteral Feeding Specialist Nurse County Durham and Darlington NHS Foundation
Edited and compiled by
Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust
Peer reviewed by
Andrea Cartwright Senior Nutrition Nurse Specialist Basildon and Thurrock University Hospital NHS Foundation Trust Jane Fletcher Nutrition Nurse Team Leader University Hospitals Birmingham NHS Foundation Trust Zillah Leach Nutrition Support Nurse University Hospital Southampton NHS Foundation Trust
Supported by
The National Patient Safety Agency has reviewed these good practice statements at the time of publication (March 2012) and support their production in improving patient safety in practice - Caroline Lecko - Patient Safety Lead
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
REFERENCES Department of Health (2005) Mental Capacity Act Code of Practice Department of Constitutional affairs Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenSocialCareDeliveringadultsocialcareMentalCapacityMentalCapacityAct2005indexht
m
Department of Health (2009a) Reference guide to consent for examination or treatment 2nd edition Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenPublicationsandstatisticsPublicationsPublicationsPolicyAndGuidanceDH_103643
Department of Health (2009b) Saving Lives High Impact Intervention (HII) Enteral feeding care bundle Department of Health London
httphcaidhgovukfiles2011032011-03-14-HII-Enteral-Feeding-Care-Bundle-FINALpdf
Department of Health (2010) Essence of Care Benchmarks for Respect and Dignity DH London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukprod_consum_dhgroupsdh_digitalassetsdhenpsdocumentsdigitalassetdh_11996
6pdf
Dougherty L Lister S (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (8th edition) Wiley Blackwell
Eccles RB (2000) The nasal cycle in respiratory defence Acta Otorhinolaryngologica Belgica 54(3)281-6
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Medicines and Healthcare Products Regulatory Agency (2007) PhthalatesDEHP in PVC medical devices MHRA London
httpwwwmhragovukSafetyinformationGeneralsafetyinformationandadviceTechnicalinformationPhthalatesinPVCmedicaldevicesindexhtm
National Institute of Clinical Excellence (2006) Nutrition Support for Adults Oral nutrition support enteral tube feeding and parenteral nutrition Clinical
Guideline 32 NICE London httpwwwniceorgukCG32
National Patient Safety Agency (2005) Patient safety alert 05 Reducing the harm caused by misplaced nasogastric tubes National Patient Safety Agency
February 21 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59794
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes National
Patient Safety Agency Ref NPSA200719 March 2007 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59808
National Patient Safety Agency (2011) Patient Safety Alert 2011PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults
children and infants NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=129640
Royal College of Physicians and British Society of Gastroenterology (2010) Oral feeding difficulties and dilemmas A guide to practical care particularly
towards the end of life Royal College of Physicians London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Weightman A Ellis S Cullum A et al (2005) Grading evidence and recommendations for public health interventions developing and piloting a framework
Health Development Agency London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
5 Where patients demonstrate a lack of capacity a lsquoBest Interest decisionrsquo should be taken by the practitioner This may necessitate further discussion with the wider MDT and may require an Independent Mental Capacity Assessor(IMCA)
To demonstrate compliance with current legislation and demonstrate wider consultation to ensure appropriate decision
DH 2005 DH 2009a RCP 2010
6 Gather all equipment prior to arriving to the patientrsquos bedside Essential equipment includes
NPSA compliant nasogastric tube appropriate to purpose and in accordance with local policy
Enteral syringe
pH indicator strips (CE marked)
Receiver
Glass of water with drinking straw (if patient has a safe swallow and is not nil by mouth [NBM])
Tissues
Hypoallergenic tape and scissors
Water for flushing once gastric position has been confirmed (freshly run tap water from a drinking sourcecooled boiled water sterile water) as per local policy
Non sterile gloves and apron Prepare equipment at patientrsquos bedside and remind the patient of the procedure and their role within it including
performing a swallow as the tube passes through the pharynx
To ensure timely uninterrupted insertion of the NG tube
NPSA 2005 DH 2009b NPSA 2011
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Agreeing a signal to indicate a problem or stop the procedure Ensure universal precautions are used at all times
To adhere to local infection control policies
7 Estimate the length of the tube required using the NEX measurement (nose ear xiphisternum) Place the exit port of the tube at the tip of the nose Extend the tube across to the earlobe and then down to the xiphisternum Note the predetermined mark (Use this measurement as a guide only ndash it is not prescriptive)
To ascertain an approximate measurement to ensure the tube is sited at the correct length
NPSA 2011
8 Position the patient appropriately ideally sitting upright supported by pillows Where an upright position is not achievable either position the patient as upright as possible or on their side with the head well supported (by pillows)
To increase patient comfort whilst carrying out the procedure and to facilitate easier insertion of the tube and avoid inadvertent tracheal intubation
Grade D evidence Weightman et al 2005
9 Inspect and examine the nose This may include digital examination of the nostrils Clear any nasal debris If the patient can blow their nose advise them to do so Use the sniff test ndash ie using the index finger to occlude one nostril and then asking the patient to sniff and then do the same to the other side ndash there will always be one slightly more clear than the other which alternates throughout the day (nasal cycle) If possible ask the patient if they have any preference for which nostril to use Previous trauma including polyps or sinusitis may mean only one nostril can be used
To ensure nasal passages are clear for smooth passage of the tube To assess for any physiological malformation that may inhibit tube insertion
Eccles 2000 Dougherty amp Lister S 2011
10 Remove the nasogastric tube from its packaging and gently stretch it to loosen the guidewire Lubricate the tube as per local policy manufacturers instructions
To facilitate easier removal of the guidewire following tube placement To facilitate smooth passage of the tube
Grade D evidence Weightman
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
DO NOT lubricate the inner lumen of the tube with water before insertion and checking gastric positioning
and increase patient comfort et al 2005
11 Insert tube into the agreed nostril to the back of nose along the nasopharynx The patients head should not be extended or flexed Where required to assist insertion ask the patient to perform a lsquochin tuckrsquo (tucking the chin down toward the chest) At this point a) Where a patient is safe to swallow fluid and has capacity offer a glass of water with a
straw and ask patient to swallow some water (refer to patientrsquos care plan) b) Where patient is not safe to swallow fluid but has capacity ask patient to perform a
dry swallow (refer to patientrsquos care plan) c) Where a patient is not safe to swallow fluid and lacks capacity wait for the peak of
expiration before advancing the tube
To reduce the risk of a tracheal placed tube Extension of the neck increases the risk of tracheal placement of the tube To aid intubation into the oesophagus and reduce risk of tracheal intubation
Grade D evidence Weightman et al 2005
12 Slowly advance the tube to the predetermined mark (refer to point 7) If any significant resistance is felt during insertion halt the procedure and pull the tube back but do not remove it completely If the patient is coughing stop pull the tube back slightly and wait for coughing to settle Before continuing ask the patient to open their mouth to check nasogastric tube has not coiled up at the back of the oral cavity Never force the tube if resistance continues on subsequent attempts A maximum of 3 attempts should be made at one time and by any one person If the patient becomes distressed during any of these attempts it is advisable to stop and seek senior specialist advice If procedure is unsuccessful after 3 attempts stop and seek senior specialist advice
To achieve gastric placement of the tube
To avoid causing any harm
Grade D evidence Weightman et al (2005)
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
13 When NG tube inserted to predetermined mark aspirate with an enteral syringe as per manufacturerrsquos guidance leaving the guidewire in position Aspiration of gastric contents may be easier if the guidewire is removed but note that should the tube require repositioning or no aspirate is obtained under no circumstances should the guidewire be re-inserted into the tube whilst the tube remains in the patient If unable to obtain aspirate refer to the NPSA decision tree or local policy for assistance This may include chest x-ray (Refer to point 10 regarding tube lubrication)
To obtain gastric aspirate the guidewire is left in to allow for the tube to be repositioned if necessary To adhere to the NPSA guidance for safe measurement administration of medicines NPSA Decision Tree
NPSA 2007 NPSA 2011
14 Test the gastric aspirate with pH indicator paperstrips that comply with NPSA guidance (CE marked) to obtain a pH reading a) pH reading MUST be 55 or below to administer fluid immediately without further
investigation b) The pH lsquocut-offrsquo reading may differ according to local policy but should never exceed
55
To confirm correct gastric position and safe to feed
NPSA 2011
15 Secure the tube at the nose or cheek once gastric position is confirmed Note the external visual length markings at the exit point of the nostril a) If guidewire has not been removed (as per point 13) remove it at this point according
to manufacturersrsquo guidance b) Flush the tube with water as per local policy
To reduce displacement of the tube Securing to the cheek prevents nasal erosion or ulceration To clear tube of gastric contents that have been aspirated up the tube
NPSA 2011
16 Make the patient comfortable before disposing of equipment as per local policy DH 2010
17 Fully document the procedure into the appropriate healthcare records Documentation should include as a minimum
To ensure patient safety To adhere to NPSA guidance
DH 2009 RCP 2010
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
a) The size and type of tube used b) External length markings at the nostril c) The method used to confirm gastric positioning of the tube d) Who placed the tube e) Include how consent was obtainedpatient agreement indicated Fully document Best
Interest decisions Also consider documenting f) Patient tolerability with procedure g) The number of attempts insertion undertaken (ie if very difficult procedure or
multiple attempts made) ndash this is very relevant if there is any trauma from the procedure
h) Which nostril the tube is sited i) Date tube change is due j) Bedside Documentation
To note serial recordings of tube position and pH results
NPSA 2011
The NNNG recognises that practice will vary according to individual risk assessments and local policy However this good practice statement has been
published in accordance with available evidence at the time of publication
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Developed by
Tracy Earley Deputy Secretary Consultant Nurse ndash Nutrition Lancashire Teaching Hospitals NHS Foundation Trust Neil Wilson Senior lecturer Manchester Metropolitan University Liz Evans Chair Nutrition Nurse Specialist Buckinghamshire Healthcare NHS Trust Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust Winnie Magambo Nutrition Nurse Specialist University of Wales Cardiff Anne Myers Lead Nurse Intestinal Failure Unit Salford Royal NHS Foundation Trust Barbara Dovaston Clinical Nurse Specialist Heartlands Hospital Heart of England NHS Foundation Linda Warriner Deputy Communications Officer Home Enteral Feeding Specialist Nurse County Durham and Darlington NHS Foundation
Edited and compiled by
Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust
Peer reviewed by
Andrea Cartwright Senior Nutrition Nurse Specialist Basildon and Thurrock University Hospital NHS Foundation Trust Jane Fletcher Nutrition Nurse Team Leader University Hospitals Birmingham NHS Foundation Trust Zillah Leach Nutrition Support Nurse University Hospital Southampton NHS Foundation Trust
Supported by
The National Patient Safety Agency has reviewed these good practice statements at the time of publication (March 2012) and support their production in improving patient safety in practice - Caroline Lecko - Patient Safety Lead
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
REFERENCES Department of Health (2005) Mental Capacity Act Code of Practice Department of Constitutional affairs Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenSocialCareDeliveringadultsocialcareMentalCapacityMentalCapacityAct2005indexht
m
Department of Health (2009a) Reference guide to consent for examination or treatment 2nd edition Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenPublicationsandstatisticsPublicationsPublicationsPolicyAndGuidanceDH_103643
Department of Health (2009b) Saving Lives High Impact Intervention (HII) Enteral feeding care bundle Department of Health London
httphcaidhgovukfiles2011032011-03-14-HII-Enteral-Feeding-Care-Bundle-FINALpdf
Department of Health (2010) Essence of Care Benchmarks for Respect and Dignity DH London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukprod_consum_dhgroupsdh_digitalassetsdhenpsdocumentsdigitalassetdh_11996
6pdf
Dougherty L Lister S (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (8th edition) Wiley Blackwell
Eccles RB (2000) The nasal cycle in respiratory defence Acta Otorhinolaryngologica Belgica 54(3)281-6
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Medicines and Healthcare Products Regulatory Agency (2007) PhthalatesDEHP in PVC medical devices MHRA London
httpwwwmhragovukSafetyinformationGeneralsafetyinformationandadviceTechnicalinformationPhthalatesinPVCmedicaldevicesindexhtm
National Institute of Clinical Excellence (2006) Nutrition Support for Adults Oral nutrition support enteral tube feeding and parenteral nutrition Clinical
Guideline 32 NICE London httpwwwniceorgukCG32
National Patient Safety Agency (2005) Patient safety alert 05 Reducing the harm caused by misplaced nasogastric tubes National Patient Safety Agency
February 21 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59794
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes National
Patient Safety Agency Ref NPSA200719 March 2007 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59808
National Patient Safety Agency (2011) Patient Safety Alert 2011PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults
children and infants NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=129640
Royal College of Physicians and British Society of Gastroenterology (2010) Oral feeding difficulties and dilemmas A guide to practical care particularly
towards the end of life Royal College of Physicians London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Weightman A Ellis S Cullum A et al (2005) Grading evidence and recommendations for public health interventions developing and piloting a framework
Health Development Agency London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Agreeing a signal to indicate a problem or stop the procedure Ensure universal precautions are used at all times
To adhere to local infection control policies
7 Estimate the length of the tube required using the NEX measurement (nose ear xiphisternum) Place the exit port of the tube at the tip of the nose Extend the tube across to the earlobe and then down to the xiphisternum Note the predetermined mark (Use this measurement as a guide only ndash it is not prescriptive)
To ascertain an approximate measurement to ensure the tube is sited at the correct length
NPSA 2011
8 Position the patient appropriately ideally sitting upright supported by pillows Where an upright position is not achievable either position the patient as upright as possible or on their side with the head well supported (by pillows)
To increase patient comfort whilst carrying out the procedure and to facilitate easier insertion of the tube and avoid inadvertent tracheal intubation
Grade D evidence Weightman et al 2005
9 Inspect and examine the nose This may include digital examination of the nostrils Clear any nasal debris If the patient can blow their nose advise them to do so Use the sniff test ndash ie using the index finger to occlude one nostril and then asking the patient to sniff and then do the same to the other side ndash there will always be one slightly more clear than the other which alternates throughout the day (nasal cycle) If possible ask the patient if they have any preference for which nostril to use Previous trauma including polyps or sinusitis may mean only one nostril can be used
To ensure nasal passages are clear for smooth passage of the tube To assess for any physiological malformation that may inhibit tube insertion
Eccles 2000 Dougherty amp Lister S 2011
10 Remove the nasogastric tube from its packaging and gently stretch it to loosen the guidewire Lubricate the tube as per local policy manufacturers instructions
To facilitate easier removal of the guidewire following tube placement To facilitate smooth passage of the tube
Grade D evidence Weightman
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
DO NOT lubricate the inner lumen of the tube with water before insertion and checking gastric positioning
and increase patient comfort et al 2005
11 Insert tube into the agreed nostril to the back of nose along the nasopharynx The patients head should not be extended or flexed Where required to assist insertion ask the patient to perform a lsquochin tuckrsquo (tucking the chin down toward the chest) At this point a) Where a patient is safe to swallow fluid and has capacity offer a glass of water with a
straw and ask patient to swallow some water (refer to patientrsquos care plan) b) Where patient is not safe to swallow fluid but has capacity ask patient to perform a
dry swallow (refer to patientrsquos care plan) c) Where a patient is not safe to swallow fluid and lacks capacity wait for the peak of
expiration before advancing the tube
To reduce the risk of a tracheal placed tube Extension of the neck increases the risk of tracheal placement of the tube To aid intubation into the oesophagus and reduce risk of tracheal intubation
Grade D evidence Weightman et al 2005
12 Slowly advance the tube to the predetermined mark (refer to point 7) If any significant resistance is felt during insertion halt the procedure and pull the tube back but do not remove it completely If the patient is coughing stop pull the tube back slightly and wait for coughing to settle Before continuing ask the patient to open their mouth to check nasogastric tube has not coiled up at the back of the oral cavity Never force the tube if resistance continues on subsequent attempts A maximum of 3 attempts should be made at one time and by any one person If the patient becomes distressed during any of these attempts it is advisable to stop and seek senior specialist advice If procedure is unsuccessful after 3 attempts stop and seek senior specialist advice
To achieve gastric placement of the tube
To avoid causing any harm
Grade D evidence Weightman et al (2005)
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
13 When NG tube inserted to predetermined mark aspirate with an enteral syringe as per manufacturerrsquos guidance leaving the guidewire in position Aspiration of gastric contents may be easier if the guidewire is removed but note that should the tube require repositioning or no aspirate is obtained under no circumstances should the guidewire be re-inserted into the tube whilst the tube remains in the patient If unable to obtain aspirate refer to the NPSA decision tree or local policy for assistance This may include chest x-ray (Refer to point 10 regarding tube lubrication)
To obtain gastric aspirate the guidewire is left in to allow for the tube to be repositioned if necessary To adhere to the NPSA guidance for safe measurement administration of medicines NPSA Decision Tree
NPSA 2007 NPSA 2011
14 Test the gastric aspirate with pH indicator paperstrips that comply with NPSA guidance (CE marked) to obtain a pH reading a) pH reading MUST be 55 or below to administer fluid immediately without further
investigation b) The pH lsquocut-offrsquo reading may differ according to local policy but should never exceed
55
To confirm correct gastric position and safe to feed
NPSA 2011
15 Secure the tube at the nose or cheek once gastric position is confirmed Note the external visual length markings at the exit point of the nostril a) If guidewire has not been removed (as per point 13) remove it at this point according
to manufacturersrsquo guidance b) Flush the tube with water as per local policy
To reduce displacement of the tube Securing to the cheek prevents nasal erosion or ulceration To clear tube of gastric contents that have been aspirated up the tube
NPSA 2011
16 Make the patient comfortable before disposing of equipment as per local policy DH 2010
17 Fully document the procedure into the appropriate healthcare records Documentation should include as a minimum
To ensure patient safety To adhere to NPSA guidance
DH 2009 RCP 2010
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
a) The size and type of tube used b) External length markings at the nostril c) The method used to confirm gastric positioning of the tube d) Who placed the tube e) Include how consent was obtainedpatient agreement indicated Fully document Best
Interest decisions Also consider documenting f) Patient tolerability with procedure g) The number of attempts insertion undertaken (ie if very difficult procedure or
multiple attempts made) ndash this is very relevant if there is any trauma from the procedure
h) Which nostril the tube is sited i) Date tube change is due j) Bedside Documentation
To note serial recordings of tube position and pH results
NPSA 2011
The NNNG recognises that practice will vary according to individual risk assessments and local policy However this good practice statement has been
published in accordance with available evidence at the time of publication
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Developed by
Tracy Earley Deputy Secretary Consultant Nurse ndash Nutrition Lancashire Teaching Hospitals NHS Foundation Trust Neil Wilson Senior lecturer Manchester Metropolitan University Liz Evans Chair Nutrition Nurse Specialist Buckinghamshire Healthcare NHS Trust Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust Winnie Magambo Nutrition Nurse Specialist University of Wales Cardiff Anne Myers Lead Nurse Intestinal Failure Unit Salford Royal NHS Foundation Trust Barbara Dovaston Clinical Nurse Specialist Heartlands Hospital Heart of England NHS Foundation Linda Warriner Deputy Communications Officer Home Enteral Feeding Specialist Nurse County Durham and Darlington NHS Foundation
Edited and compiled by
Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust
Peer reviewed by
Andrea Cartwright Senior Nutrition Nurse Specialist Basildon and Thurrock University Hospital NHS Foundation Trust Jane Fletcher Nutrition Nurse Team Leader University Hospitals Birmingham NHS Foundation Trust Zillah Leach Nutrition Support Nurse University Hospital Southampton NHS Foundation Trust
Supported by
The National Patient Safety Agency has reviewed these good practice statements at the time of publication (March 2012) and support their production in improving patient safety in practice - Caroline Lecko - Patient Safety Lead
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
REFERENCES Department of Health (2005) Mental Capacity Act Code of Practice Department of Constitutional affairs Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenSocialCareDeliveringadultsocialcareMentalCapacityMentalCapacityAct2005indexht
m
Department of Health (2009a) Reference guide to consent for examination or treatment 2nd edition Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenPublicationsandstatisticsPublicationsPublicationsPolicyAndGuidanceDH_103643
Department of Health (2009b) Saving Lives High Impact Intervention (HII) Enteral feeding care bundle Department of Health London
httphcaidhgovukfiles2011032011-03-14-HII-Enteral-Feeding-Care-Bundle-FINALpdf
Department of Health (2010) Essence of Care Benchmarks for Respect and Dignity DH London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukprod_consum_dhgroupsdh_digitalassetsdhenpsdocumentsdigitalassetdh_11996
6pdf
Dougherty L Lister S (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (8th edition) Wiley Blackwell
Eccles RB (2000) The nasal cycle in respiratory defence Acta Otorhinolaryngologica Belgica 54(3)281-6
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Medicines and Healthcare Products Regulatory Agency (2007) PhthalatesDEHP in PVC medical devices MHRA London
httpwwwmhragovukSafetyinformationGeneralsafetyinformationandadviceTechnicalinformationPhthalatesinPVCmedicaldevicesindexhtm
National Institute of Clinical Excellence (2006) Nutrition Support for Adults Oral nutrition support enteral tube feeding and parenteral nutrition Clinical
Guideline 32 NICE London httpwwwniceorgukCG32
National Patient Safety Agency (2005) Patient safety alert 05 Reducing the harm caused by misplaced nasogastric tubes National Patient Safety Agency
February 21 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59794
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes National
Patient Safety Agency Ref NPSA200719 March 2007 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59808
National Patient Safety Agency (2011) Patient Safety Alert 2011PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults
children and infants NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=129640
Royal College of Physicians and British Society of Gastroenterology (2010) Oral feeding difficulties and dilemmas A guide to practical care particularly
towards the end of life Royal College of Physicians London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Weightman A Ellis S Cullum A et al (2005) Grading evidence and recommendations for public health interventions developing and piloting a framework
Health Development Agency London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
DO NOT lubricate the inner lumen of the tube with water before insertion and checking gastric positioning
and increase patient comfort et al 2005
11 Insert tube into the agreed nostril to the back of nose along the nasopharynx The patients head should not be extended or flexed Where required to assist insertion ask the patient to perform a lsquochin tuckrsquo (tucking the chin down toward the chest) At this point a) Where a patient is safe to swallow fluid and has capacity offer a glass of water with a
straw and ask patient to swallow some water (refer to patientrsquos care plan) b) Where patient is not safe to swallow fluid but has capacity ask patient to perform a
dry swallow (refer to patientrsquos care plan) c) Where a patient is not safe to swallow fluid and lacks capacity wait for the peak of
expiration before advancing the tube
To reduce the risk of a tracheal placed tube Extension of the neck increases the risk of tracheal placement of the tube To aid intubation into the oesophagus and reduce risk of tracheal intubation
Grade D evidence Weightman et al 2005
12 Slowly advance the tube to the predetermined mark (refer to point 7) If any significant resistance is felt during insertion halt the procedure and pull the tube back but do not remove it completely If the patient is coughing stop pull the tube back slightly and wait for coughing to settle Before continuing ask the patient to open their mouth to check nasogastric tube has not coiled up at the back of the oral cavity Never force the tube if resistance continues on subsequent attempts A maximum of 3 attempts should be made at one time and by any one person If the patient becomes distressed during any of these attempts it is advisable to stop and seek senior specialist advice If procedure is unsuccessful after 3 attempts stop and seek senior specialist advice
To achieve gastric placement of the tube
To avoid causing any harm
Grade D evidence Weightman et al (2005)
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
13 When NG tube inserted to predetermined mark aspirate with an enteral syringe as per manufacturerrsquos guidance leaving the guidewire in position Aspiration of gastric contents may be easier if the guidewire is removed but note that should the tube require repositioning or no aspirate is obtained under no circumstances should the guidewire be re-inserted into the tube whilst the tube remains in the patient If unable to obtain aspirate refer to the NPSA decision tree or local policy for assistance This may include chest x-ray (Refer to point 10 regarding tube lubrication)
To obtain gastric aspirate the guidewire is left in to allow for the tube to be repositioned if necessary To adhere to the NPSA guidance for safe measurement administration of medicines NPSA Decision Tree
NPSA 2007 NPSA 2011
14 Test the gastric aspirate with pH indicator paperstrips that comply with NPSA guidance (CE marked) to obtain a pH reading a) pH reading MUST be 55 or below to administer fluid immediately without further
investigation b) The pH lsquocut-offrsquo reading may differ according to local policy but should never exceed
55
To confirm correct gastric position and safe to feed
NPSA 2011
15 Secure the tube at the nose or cheek once gastric position is confirmed Note the external visual length markings at the exit point of the nostril a) If guidewire has not been removed (as per point 13) remove it at this point according
to manufacturersrsquo guidance b) Flush the tube with water as per local policy
To reduce displacement of the tube Securing to the cheek prevents nasal erosion or ulceration To clear tube of gastric contents that have been aspirated up the tube
NPSA 2011
16 Make the patient comfortable before disposing of equipment as per local policy DH 2010
17 Fully document the procedure into the appropriate healthcare records Documentation should include as a minimum
To ensure patient safety To adhere to NPSA guidance
DH 2009 RCP 2010
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
a) The size and type of tube used b) External length markings at the nostril c) The method used to confirm gastric positioning of the tube d) Who placed the tube e) Include how consent was obtainedpatient agreement indicated Fully document Best
Interest decisions Also consider documenting f) Patient tolerability with procedure g) The number of attempts insertion undertaken (ie if very difficult procedure or
multiple attempts made) ndash this is very relevant if there is any trauma from the procedure
h) Which nostril the tube is sited i) Date tube change is due j) Bedside Documentation
To note serial recordings of tube position and pH results
NPSA 2011
The NNNG recognises that practice will vary according to individual risk assessments and local policy However this good practice statement has been
published in accordance with available evidence at the time of publication
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Developed by
Tracy Earley Deputy Secretary Consultant Nurse ndash Nutrition Lancashire Teaching Hospitals NHS Foundation Trust Neil Wilson Senior lecturer Manchester Metropolitan University Liz Evans Chair Nutrition Nurse Specialist Buckinghamshire Healthcare NHS Trust Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust Winnie Magambo Nutrition Nurse Specialist University of Wales Cardiff Anne Myers Lead Nurse Intestinal Failure Unit Salford Royal NHS Foundation Trust Barbara Dovaston Clinical Nurse Specialist Heartlands Hospital Heart of England NHS Foundation Linda Warriner Deputy Communications Officer Home Enteral Feeding Specialist Nurse County Durham and Darlington NHS Foundation
Edited and compiled by
Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust
Peer reviewed by
Andrea Cartwright Senior Nutrition Nurse Specialist Basildon and Thurrock University Hospital NHS Foundation Trust Jane Fletcher Nutrition Nurse Team Leader University Hospitals Birmingham NHS Foundation Trust Zillah Leach Nutrition Support Nurse University Hospital Southampton NHS Foundation Trust
Supported by
The National Patient Safety Agency has reviewed these good practice statements at the time of publication (March 2012) and support their production in improving patient safety in practice - Caroline Lecko - Patient Safety Lead
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
REFERENCES Department of Health (2005) Mental Capacity Act Code of Practice Department of Constitutional affairs Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenSocialCareDeliveringadultsocialcareMentalCapacityMentalCapacityAct2005indexht
m
Department of Health (2009a) Reference guide to consent for examination or treatment 2nd edition Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenPublicationsandstatisticsPublicationsPublicationsPolicyAndGuidanceDH_103643
Department of Health (2009b) Saving Lives High Impact Intervention (HII) Enteral feeding care bundle Department of Health London
httphcaidhgovukfiles2011032011-03-14-HII-Enteral-Feeding-Care-Bundle-FINALpdf
Department of Health (2010) Essence of Care Benchmarks for Respect and Dignity DH London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukprod_consum_dhgroupsdh_digitalassetsdhenpsdocumentsdigitalassetdh_11996
6pdf
Dougherty L Lister S (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (8th edition) Wiley Blackwell
Eccles RB (2000) The nasal cycle in respiratory defence Acta Otorhinolaryngologica Belgica 54(3)281-6
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Medicines and Healthcare Products Regulatory Agency (2007) PhthalatesDEHP in PVC medical devices MHRA London
httpwwwmhragovukSafetyinformationGeneralsafetyinformationandadviceTechnicalinformationPhthalatesinPVCmedicaldevicesindexhtm
National Institute of Clinical Excellence (2006) Nutrition Support for Adults Oral nutrition support enteral tube feeding and parenteral nutrition Clinical
Guideline 32 NICE London httpwwwniceorgukCG32
National Patient Safety Agency (2005) Patient safety alert 05 Reducing the harm caused by misplaced nasogastric tubes National Patient Safety Agency
February 21 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59794
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes National
Patient Safety Agency Ref NPSA200719 March 2007 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59808
National Patient Safety Agency (2011) Patient Safety Alert 2011PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults
children and infants NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=129640
Royal College of Physicians and British Society of Gastroenterology (2010) Oral feeding difficulties and dilemmas A guide to practical care particularly
towards the end of life Royal College of Physicians London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Weightman A Ellis S Cullum A et al (2005) Grading evidence and recommendations for public health interventions developing and piloting a framework
Health Development Agency London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
13 When NG tube inserted to predetermined mark aspirate with an enteral syringe as per manufacturerrsquos guidance leaving the guidewire in position Aspiration of gastric contents may be easier if the guidewire is removed but note that should the tube require repositioning or no aspirate is obtained under no circumstances should the guidewire be re-inserted into the tube whilst the tube remains in the patient If unable to obtain aspirate refer to the NPSA decision tree or local policy for assistance This may include chest x-ray (Refer to point 10 regarding tube lubrication)
To obtain gastric aspirate the guidewire is left in to allow for the tube to be repositioned if necessary To adhere to the NPSA guidance for safe measurement administration of medicines NPSA Decision Tree
NPSA 2007 NPSA 2011
14 Test the gastric aspirate with pH indicator paperstrips that comply with NPSA guidance (CE marked) to obtain a pH reading a) pH reading MUST be 55 or below to administer fluid immediately without further
investigation b) The pH lsquocut-offrsquo reading may differ according to local policy but should never exceed
55
To confirm correct gastric position and safe to feed
NPSA 2011
15 Secure the tube at the nose or cheek once gastric position is confirmed Note the external visual length markings at the exit point of the nostril a) If guidewire has not been removed (as per point 13) remove it at this point according
to manufacturersrsquo guidance b) Flush the tube with water as per local policy
To reduce displacement of the tube Securing to the cheek prevents nasal erosion or ulceration To clear tube of gastric contents that have been aspirated up the tube
NPSA 2011
16 Make the patient comfortable before disposing of equipment as per local policy DH 2010
17 Fully document the procedure into the appropriate healthcare records Documentation should include as a minimum
To ensure patient safety To adhere to NPSA guidance
DH 2009 RCP 2010
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
a) The size and type of tube used b) External length markings at the nostril c) The method used to confirm gastric positioning of the tube d) Who placed the tube e) Include how consent was obtainedpatient agreement indicated Fully document Best
Interest decisions Also consider documenting f) Patient tolerability with procedure g) The number of attempts insertion undertaken (ie if very difficult procedure or
multiple attempts made) ndash this is very relevant if there is any trauma from the procedure
h) Which nostril the tube is sited i) Date tube change is due j) Bedside Documentation
To note serial recordings of tube position and pH results
NPSA 2011
The NNNG recognises that practice will vary according to individual risk assessments and local policy However this good practice statement has been
published in accordance with available evidence at the time of publication
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Developed by
Tracy Earley Deputy Secretary Consultant Nurse ndash Nutrition Lancashire Teaching Hospitals NHS Foundation Trust Neil Wilson Senior lecturer Manchester Metropolitan University Liz Evans Chair Nutrition Nurse Specialist Buckinghamshire Healthcare NHS Trust Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust Winnie Magambo Nutrition Nurse Specialist University of Wales Cardiff Anne Myers Lead Nurse Intestinal Failure Unit Salford Royal NHS Foundation Trust Barbara Dovaston Clinical Nurse Specialist Heartlands Hospital Heart of England NHS Foundation Linda Warriner Deputy Communications Officer Home Enteral Feeding Specialist Nurse County Durham and Darlington NHS Foundation
Edited and compiled by
Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust
Peer reviewed by
Andrea Cartwright Senior Nutrition Nurse Specialist Basildon and Thurrock University Hospital NHS Foundation Trust Jane Fletcher Nutrition Nurse Team Leader University Hospitals Birmingham NHS Foundation Trust Zillah Leach Nutrition Support Nurse University Hospital Southampton NHS Foundation Trust
Supported by
The National Patient Safety Agency has reviewed these good practice statements at the time of publication (March 2012) and support their production in improving patient safety in practice - Caroline Lecko - Patient Safety Lead
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
REFERENCES Department of Health (2005) Mental Capacity Act Code of Practice Department of Constitutional affairs Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenSocialCareDeliveringadultsocialcareMentalCapacityMentalCapacityAct2005indexht
m
Department of Health (2009a) Reference guide to consent for examination or treatment 2nd edition Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenPublicationsandstatisticsPublicationsPublicationsPolicyAndGuidanceDH_103643
Department of Health (2009b) Saving Lives High Impact Intervention (HII) Enteral feeding care bundle Department of Health London
httphcaidhgovukfiles2011032011-03-14-HII-Enteral-Feeding-Care-Bundle-FINALpdf
Department of Health (2010) Essence of Care Benchmarks for Respect and Dignity DH London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukprod_consum_dhgroupsdh_digitalassetsdhenpsdocumentsdigitalassetdh_11996
6pdf
Dougherty L Lister S (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (8th edition) Wiley Blackwell
Eccles RB (2000) The nasal cycle in respiratory defence Acta Otorhinolaryngologica Belgica 54(3)281-6
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Medicines and Healthcare Products Regulatory Agency (2007) PhthalatesDEHP in PVC medical devices MHRA London
httpwwwmhragovukSafetyinformationGeneralsafetyinformationandadviceTechnicalinformationPhthalatesinPVCmedicaldevicesindexhtm
National Institute of Clinical Excellence (2006) Nutrition Support for Adults Oral nutrition support enteral tube feeding and parenteral nutrition Clinical
Guideline 32 NICE London httpwwwniceorgukCG32
National Patient Safety Agency (2005) Patient safety alert 05 Reducing the harm caused by misplaced nasogastric tubes National Patient Safety Agency
February 21 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59794
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes National
Patient Safety Agency Ref NPSA200719 March 2007 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59808
National Patient Safety Agency (2011) Patient Safety Alert 2011PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults
children and infants NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=129640
Royal College of Physicians and British Society of Gastroenterology (2010) Oral feeding difficulties and dilemmas A guide to practical care particularly
towards the end of life Royal College of Physicians London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Weightman A Ellis S Cullum A et al (2005) Grading evidence and recommendations for public health interventions developing and piloting a framework
Health Development Agency London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
a) The size and type of tube used b) External length markings at the nostril c) The method used to confirm gastric positioning of the tube d) Who placed the tube e) Include how consent was obtainedpatient agreement indicated Fully document Best
Interest decisions Also consider documenting f) Patient tolerability with procedure g) The number of attempts insertion undertaken (ie if very difficult procedure or
multiple attempts made) ndash this is very relevant if there is any trauma from the procedure
h) Which nostril the tube is sited i) Date tube change is due j) Bedside Documentation
To note serial recordings of tube position and pH results
NPSA 2011
The NNNG recognises that practice will vary according to individual risk assessments and local policy However this good practice statement has been
published in accordance with available evidence at the time of publication
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Developed by
Tracy Earley Deputy Secretary Consultant Nurse ndash Nutrition Lancashire Teaching Hospitals NHS Foundation Trust Neil Wilson Senior lecturer Manchester Metropolitan University Liz Evans Chair Nutrition Nurse Specialist Buckinghamshire Healthcare NHS Trust Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust Winnie Magambo Nutrition Nurse Specialist University of Wales Cardiff Anne Myers Lead Nurse Intestinal Failure Unit Salford Royal NHS Foundation Trust Barbara Dovaston Clinical Nurse Specialist Heartlands Hospital Heart of England NHS Foundation Linda Warriner Deputy Communications Officer Home Enteral Feeding Specialist Nurse County Durham and Darlington NHS Foundation
Edited and compiled by
Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust
Peer reviewed by
Andrea Cartwright Senior Nutrition Nurse Specialist Basildon and Thurrock University Hospital NHS Foundation Trust Jane Fletcher Nutrition Nurse Team Leader University Hospitals Birmingham NHS Foundation Trust Zillah Leach Nutrition Support Nurse University Hospital Southampton NHS Foundation Trust
Supported by
The National Patient Safety Agency has reviewed these good practice statements at the time of publication (March 2012) and support their production in improving patient safety in practice - Caroline Lecko - Patient Safety Lead
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
REFERENCES Department of Health (2005) Mental Capacity Act Code of Practice Department of Constitutional affairs Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenSocialCareDeliveringadultsocialcareMentalCapacityMentalCapacityAct2005indexht
m
Department of Health (2009a) Reference guide to consent for examination or treatment 2nd edition Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenPublicationsandstatisticsPublicationsPublicationsPolicyAndGuidanceDH_103643
Department of Health (2009b) Saving Lives High Impact Intervention (HII) Enteral feeding care bundle Department of Health London
httphcaidhgovukfiles2011032011-03-14-HII-Enteral-Feeding-Care-Bundle-FINALpdf
Department of Health (2010) Essence of Care Benchmarks for Respect and Dignity DH London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukprod_consum_dhgroupsdh_digitalassetsdhenpsdocumentsdigitalassetdh_11996
6pdf
Dougherty L Lister S (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (8th edition) Wiley Blackwell
Eccles RB (2000) The nasal cycle in respiratory defence Acta Otorhinolaryngologica Belgica 54(3)281-6
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Medicines and Healthcare Products Regulatory Agency (2007) PhthalatesDEHP in PVC medical devices MHRA London
httpwwwmhragovukSafetyinformationGeneralsafetyinformationandadviceTechnicalinformationPhthalatesinPVCmedicaldevicesindexhtm
National Institute of Clinical Excellence (2006) Nutrition Support for Adults Oral nutrition support enteral tube feeding and parenteral nutrition Clinical
Guideline 32 NICE London httpwwwniceorgukCG32
National Patient Safety Agency (2005) Patient safety alert 05 Reducing the harm caused by misplaced nasogastric tubes National Patient Safety Agency
February 21 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59794
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes National
Patient Safety Agency Ref NPSA200719 March 2007 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59808
National Patient Safety Agency (2011) Patient Safety Alert 2011PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults
children and infants NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=129640
Royal College of Physicians and British Society of Gastroenterology (2010) Oral feeding difficulties and dilemmas A guide to practical care particularly
towards the end of life Royal College of Physicians London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Weightman A Ellis S Cullum A et al (2005) Grading evidence and recommendations for public health interventions developing and piloting a framework
Health Development Agency London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Developed by
Tracy Earley Deputy Secretary Consultant Nurse ndash Nutrition Lancashire Teaching Hospitals NHS Foundation Trust Neil Wilson Senior lecturer Manchester Metropolitan University Liz Evans Chair Nutrition Nurse Specialist Buckinghamshire Healthcare NHS Trust Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust Winnie Magambo Nutrition Nurse Specialist University of Wales Cardiff Anne Myers Lead Nurse Intestinal Failure Unit Salford Royal NHS Foundation Trust Barbara Dovaston Clinical Nurse Specialist Heartlands Hospital Heart of England NHS Foundation Linda Warriner Deputy Communications Officer Home Enteral Feeding Specialist Nurse County Durham and Darlington NHS Foundation
Edited and compiled by
Carolyn Best Nutrition Nurse Specialist Hampshire Hospitals NHS Foundation Trust
Peer reviewed by
Andrea Cartwright Senior Nutrition Nurse Specialist Basildon and Thurrock University Hospital NHS Foundation Trust Jane Fletcher Nutrition Nurse Team Leader University Hospitals Birmingham NHS Foundation Trust Zillah Leach Nutrition Support Nurse University Hospital Southampton NHS Foundation Trust
Supported by
The National Patient Safety Agency has reviewed these good practice statements at the time of publication (March 2012) and support their production in improving patient safety in practice - Caroline Lecko - Patient Safety Lead
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
REFERENCES Department of Health (2005) Mental Capacity Act Code of Practice Department of Constitutional affairs Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenSocialCareDeliveringadultsocialcareMentalCapacityMentalCapacityAct2005indexht
m
Department of Health (2009a) Reference guide to consent for examination or treatment 2nd edition Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenPublicationsandstatisticsPublicationsPublicationsPolicyAndGuidanceDH_103643
Department of Health (2009b) Saving Lives High Impact Intervention (HII) Enteral feeding care bundle Department of Health London
httphcaidhgovukfiles2011032011-03-14-HII-Enteral-Feeding-Care-Bundle-FINALpdf
Department of Health (2010) Essence of Care Benchmarks for Respect and Dignity DH London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukprod_consum_dhgroupsdh_digitalassetsdhenpsdocumentsdigitalassetdh_11996
6pdf
Dougherty L Lister S (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (8th edition) Wiley Blackwell
Eccles RB (2000) The nasal cycle in respiratory defence Acta Otorhinolaryngologica Belgica 54(3)281-6
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Medicines and Healthcare Products Regulatory Agency (2007) PhthalatesDEHP in PVC medical devices MHRA London
httpwwwmhragovukSafetyinformationGeneralsafetyinformationandadviceTechnicalinformationPhthalatesinPVCmedicaldevicesindexhtm
National Institute of Clinical Excellence (2006) Nutrition Support for Adults Oral nutrition support enteral tube feeding and parenteral nutrition Clinical
Guideline 32 NICE London httpwwwniceorgukCG32
National Patient Safety Agency (2005) Patient safety alert 05 Reducing the harm caused by misplaced nasogastric tubes National Patient Safety Agency
February 21 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59794
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes National
Patient Safety Agency Ref NPSA200719 March 2007 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59808
National Patient Safety Agency (2011) Patient Safety Alert 2011PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults
children and infants NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=129640
Royal College of Physicians and British Society of Gastroenterology (2010) Oral feeding difficulties and dilemmas A guide to practical care particularly
towards the end of life Royal College of Physicians London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Weightman A Ellis S Cullum A et al (2005) Grading evidence and recommendations for public health interventions developing and piloting a framework
Health Development Agency London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
REFERENCES Department of Health (2005) Mental Capacity Act Code of Practice Department of Constitutional affairs Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenSocialCareDeliveringadultsocialcareMentalCapacityMentalCapacityAct2005indexht
m
Department of Health (2009a) Reference guide to consent for examination or treatment 2nd edition Department of Health London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukenPublicationsandstatisticsPublicationsPublicationsPolicyAndGuidanceDH_103643
Department of Health (2009b) Saving Lives High Impact Intervention (HII) Enteral feeding care bundle Department of Health London
httphcaidhgovukfiles2011032011-03-14-HII-Enteral-Feeding-Care-Bundle-FINALpdf
Department of Health (2010) Essence of Care Benchmarks for Respect and Dignity DH London
httpwebarchivenationalarchivesgovuk+httpwwwdhgovukprod_consum_dhgroupsdh_digitalassetsdhenpsdocumentsdigitalassetdh_11996
6pdf
Dougherty L Lister S (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (8th edition) Wiley Blackwell
Eccles RB (2000) The nasal cycle in respiratory defence Acta Otorhinolaryngologica Belgica 54(3)281-6
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Medicines and Healthcare Products Regulatory Agency (2007) PhthalatesDEHP in PVC medical devices MHRA London
httpwwwmhragovukSafetyinformationGeneralsafetyinformationandadviceTechnicalinformationPhthalatesinPVCmedicaldevicesindexhtm
National Institute of Clinical Excellence (2006) Nutrition Support for Adults Oral nutrition support enteral tube feeding and parenteral nutrition Clinical
Guideline 32 NICE London httpwwwniceorgukCG32
National Patient Safety Agency (2005) Patient safety alert 05 Reducing the harm caused by misplaced nasogastric tubes National Patient Safety Agency
February 21 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59794
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes National
Patient Safety Agency Ref NPSA200719 March 2007 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59808
National Patient Safety Agency (2011) Patient Safety Alert 2011PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults
children and infants NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=129640
Royal College of Physicians and British Society of Gastroenterology (2010) Oral feeding difficulties and dilemmas A guide to practical care particularly
towards the end of life Royal College of Physicians London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Weightman A Ellis S Cullum A et al (2005) Grading evidence and recommendations for public health interventions developing and piloting a framework
Health Development Agency London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Medicines and Healthcare Products Regulatory Agency (2007) PhthalatesDEHP in PVC medical devices MHRA London
httpwwwmhragovukSafetyinformationGeneralsafetyinformationandadviceTechnicalinformationPhthalatesinPVCmedicaldevicesindexhtm
National Institute of Clinical Excellence (2006) Nutrition Support for Adults Oral nutrition support enteral tube feeding and parenteral nutrition Clinical
Guideline 32 NICE London httpwwwniceorgukCG32
National Patient Safety Agency (2005) Patient safety alert 05 Reducing the harm caused by misplaced nasogastric tubes National Patient Safety Agency
February 21 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59794
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes National
Patient Safety Agency Ref NPSA200719 March 2007 NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=59808
National Patient Safety Agency (2011) Patient Safety Alert 2011PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults
children and infants NPSA London httpwwwnrlsnpsanhsukresourcesEntryId45=129640
Royal College of Physicians and British Society of Gastroenterology (2010) Oral feeding difficulties and dilemmas A guide to practical care particularly
towards the end of life Royal College of Physicians London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Weightman A Ellis S Cullum A et al (2005) Grading evidence and recommendations for public health interventions developing and piloting a framework
Health Development Agency London
___________________Good Practice Guideline ndash Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (not ongoing care) ____________________
______________________________ Good Nutrition Needs Nurses____________________________
wwwnnngorguk
Weightman A Ellis S Cullum A et al (2005) Grading evidence and recommendations for public health interventions developing and piloting a framework
Health Development Agency London