insertion and maintenance of fine bore nasogastric feeding tubes in adults

7/28/2019 Insertion and Maintenance of Fine Bore Nasogastric Feeding Tubes in Adults

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PORTSMOUTH HOSPITALS NHS TRUST Section 3.11CLINICAL POLICIES

Insertion and maintenance of fine bore naso-gastric feeding tubes in adults policy. Issue 4. 04.03.2008 Page 1 of 22

Control Date: 09/10/2008

TITLEPHT POLICY FOR THE INSERTION AND MAINTENANCE OF FINEBORE NASO-GASTRIC FEEDING TUBES IN ADULTS

REFERENCE

NUMBER3.11

MANAGER /

COMMITTEERESPONSIBLE

CLINICAL NUTRITION NURSE SPECIALISTS

DATE ISSUED 04.03.2008

VERSION 4

REVIEW DATE December 2009

Equality Impact

Assessment has been

applied to this policyJoanne Pratt - Lead Clinical Nutrition Nurse Specialist

AUTHOR Jo Pratt and Gillian Fraser - Clinical Nutrition Nurse Specialists

RATIFIED BY PROFESSIONAL ADVISORY COMMITTEE 06.02.2008

Amendments record:

Date Page Comments Approved By:

15th Dec 2007 throughoutSyringe changed toenteral syringe

CNNS, NST, MATRONS,Debbie Knight

24 Nov 2007 5 Updated referencesCNNS,NST, MATRONS,Debbie Knight

15 Dec 2007 7,12, 13 Use of blackcurrant drinkCNNS, NST MATRONS,Debbie Knight

19TH Dec 2007

6th Jan 200814th Jan 2008

16

17 1920 -22

NG tube position chart

Updated competencyUpdated starter regimen CNNS, NST, MATRONS,Debbie Knight


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CONTENTS:1. INTRODUCTION / BACKGROUND2. STATUS3. PURPOSE

4. SCOPE/AUDIENCE5. DEFINITIONS6. PROCESS7. DUTIES AND RESPONSIBILITIES8. TRAINING9. ASSOCIATED DOCUMENTATION

APPENDICES:1. PROTOCOLS FOR PRACTICE2. PRODUCT INFORMATION / TUBE SELECTION3. ANATOMY + PHYSIOLOGY OF SWALLOWING

4. CONFIRMING THE CORRECT POSITION OF NASOGASTRIC FEEDING TUBES IN ADULTS(FLOWCHART)

5. NG TUBE POSITION CHART6. NG COMPETENCY7. STARTER REGIMEN FOR ADULTS

1. INTRODUCTION / BACKGROUNDNasogastric tube feeding is common practice and many tubes are inserted daily without incident. However,there is a small risk that the tube can become misplaced into the lungs during insertion, or move out of the

stomach at a later stage. Auscultation must not be used as the sole method for checking correct nasogastrictube (NGT) placement as studies have shown this method to be inaccurate. NG tubes should be aspiratedand tube position confirmed using ph indicator strips BDH (0-6) (See Appendix 1 & 2) X-rays should not

routinely be used. (9).

2. STATUSThis is a clinical policy.

3. PURPOSEThis policy is designed to guide all Healthcare Professionals in the safe insertion and maintenance of fine

bore naso-gastric feeding tubes in adults.

4. SCOPE/AUDIENCEThese guidelines apply to all competent healthcare professionals inserting and/or maintaining fine bore

naso-gastric feeding tubes in Portsmouth Hospitals NHS Trust.They are applicable to adult patients who require short term (4-6weeks) feeding via a fine bore naso-gastricfeeding tube.

For administration of medication via a fine bore nasogastric feeding tube please refer to Administration ofDrugs to Adult Patients with Feeding Tubes guideline (11).

For fine/wide bore naso-gastric feeding tubes or orogastric feeding tubes inserted other than at the bedside(ie endoscopy, imaging, theatres) this policy should be adhered to for verification of tube position.Patients in the Department of Critical Care are excluded from this Policy. The Department of Critical Care is

responsible for producing its own speciality specific guidelines to Trust Standards.


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A. INDICATIONS

Indication for feeding Example Evidence

Unconscious patientSwallowing disorder

Physiological anorexia

Upper GI obstructionPartial intestinal failure

Increased nutritional requirements

Psychological problems

GI, gastrointestinal:

Head injury, ventilated patientPost-CVA, multiple sclerosis, motor neurone

disease.

Liver disease (particularly with ascities)

Oesophageal stricturePostoperative ileus inflammatory bowel disease,short bowel syndrome.

Cystic fibrosis, renal disease, critical illness

Severe depression or anorexia nervosa

Cerebrovascular accident.

1.

B CONTRADINDICATIONS Fractured Base of skull Bleeding Oesophageal Varices Perforated oesophagus Perforated pharyngeal pouchC CONSIDERATIONS NGT insertion may be problematic if the patient is known to have: - Head & Neck malignancy/obstruction Upper Gastrointestinal Malignancy/obstruction/surgery i.e. Gastrectomy Pharyngeal pouch Hiatus Hernia Fractured cervical spine

COMPLICATIONS

Type Complication EvidenceInsertion

Post insertion trauma

Displacement

Reflux

GI intolerance

Metabolic

Nasal damage, intracranial insertion,

pharyngeal/oesophageal pouch perforation,

bronchial placement, variceal bleeding.

Discomfort, erosions, fistulae, and strictures.

Tube falls out, bronchial administration of

feed. *See below.Potential aspiration pneumonia.

Oesophagitis, aspiration

Nausea, bloating, pain, diarrhoea.

Refeeding syndrome, hyperglycaaemia, fluid

overload, electrolyte disturbance.

1

*In a patient with a functioning Gastro-Intestinal Tract, who repeatedly displaces NGTs it may be possible to

insert a nasal bridle, which will prevent displacement. Please contact the Clinical Nutrition Nurse Specialistsfor assessment.


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5. DEFINITIONSFine bore naso-gastric feeding tube: -Defined as between a 6fg - 8fg. The length of the tube is measured in cms starting at the distal tip (stomachend = 0cms). Measurements are seen along the length of the tube, the tube length will vary depending on

manufacturer. The tube is made of silicone or polyurethane which is passed through the nostril via the naso-pharynx into the oesophagus, then stomach. (Appendix 2)Nasogastric tube feeding: -

The administration of artificial nutrition via a fine bore nasogastric tube. Feeding via a naso-gastric tube isusually a short- term intervention (4-6 weeks). A route for permanent enteral access should be considered ifenteral support is required for longer than this. (Appendix No 8)

Healthcare Professionals: -A registered or trained competent member of staff including doctors, nurses and midwives. Competencylevel 2 and above (Appendix 6).

Maintenance of a Nasogastric tube: -

Includes correctly checking tube position, and maintaining the patency of that tube. Ongoing managementincludes skin care, checking tube position.

Enteral Syringe:-Purple single use non I.V. compatible syringe for enteral use only.

6. SEE APPENDIX 1 FOR PROTOCOLS FOR PRACTICE

Critical reporting within Clinical Nutrition and completion of Trust risk forms will be the systems used tomanage risk.

7. DUTIES AND RESPONSIBILITIES

DoctorsThe decision to commence artificial nutrition via a nasogastric tube is a medical decision to be made in

conjunction with the patient, the patients family and the MDT members. If the Healthcare Professional isunable to confirm tube position at the bedside it is the Doctors responsibility to request and review a chest x-ray to establish gastric placement. It should be noted that nasogastric tubes as stated in Appendix 2 are

radio opaque.

Healthcare Professionals -

a) Healthcare Professionals are responsible for establishing the gastric placement of NGTs prior to their use.

b) It is the responsibility of the Healthcare Professional to develop and maintain their own level ofcompetency (Appendix 6).

Clinical Nutrition Nurse Specialists are responsible for the development and review of the policy.Clinical Nutrition Nurse Specialists in conjunction with Modern Matrons, Ward Managers, Practice Development Nurses and Clinical

Educators are responsible for the management and implementation of this policy.

It is expected that fine bore nasogastric tubes will be inserted and maintained by a level 2 and abovepractitioner in a safe and competent manner (see Appendix 6: NG Competency).


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Aspect of Care/OutcomesExpected Standard

TargetSource of Data Collection

1. NGTs are inserted by a competent level 2

and above practitioner.

NGTs are safely maintained by level2 and above practitioners 100%

Review of medical notes.

Staff Interviews.

2. All ward areas use pH indicator strips BDH0 - 6 to test aspirate when confirming NGposition.

100% Audits

3. NG Tube is not used if inadvertently placedin the lungs 100% Risk Incident Forms

4. CxR requested on placement only when

aspirate is unobtainable. 100% Audit x-rayReview of medical notes

5. The position of NG tube is checked as perPolicy and documented on NG Tube Position

Chart (see appendix 5).

100%Review of patient notes.

Audit of use of NG Tube Position

Chart

8. TRAINING

Liaison with Ward Managers, Practice Development Nurses, Clinical Educators and Modern Matronsto ensure policy is adhered to at ward level.

Clinical Nutrition Nurse Specialists to maintain a high profile in clinical areas to support

implementation of this policy. Dissemination via Clinical Nutrition Nurse Specialists in ongoing training programmes.

9. ASSOCIATED DOCUMENTATION

Note all documents that support the policy and include further reading if required.

1. Stroud, M., Duncan, H., & Nightingale, J. (2003). Guidelines for Enteral Feeding in Adult HospitalPatients. Gut, 52 (suppl. Vii), vii-vii 12.

2. Burnham, P. (2000). A Guide to Nasogastric Tube Insertion. Nursing Times Plus 96 (8), 6-7.3. Reid, W. (2002). Clinical Governance: Implementing a Change in Workplace Practice. Nasogastric Tube

Placement. Professional Nurse, 17(12), 734-737.4. Cannaby, A., Evans, L. & Freeman, A. (2002). Nursing Care of Patients with Nasogastric Feeding

Tubes. British Journal of Nursing, 11(6), 366-372

5. Christensen, M. (2001). Bedside Methods of Determining Nasogastric Tube Placement: A literatureReview. Nursing in Critical Care 6 (4), 192-199.

6. Colagiovanni, L. (1999). Taking the Tube. Nursing Times 95 (21), 63 - 71.7. Colagiovanni, L. (2000). Preventing and Clearing Blocked Feeding Tubes. Nursing Times Plus, 96 (17),

3 - 4.8. Metheny, N. & Titler, M.G. (2001). Assessing Placement of Feeding Tubes. American Journal of

Nursing, 101(5), 36 - 45.9. Great Britain National Patient Safety Agency (2005). Reducing the harm caused by misplaced

Nasogastric Feeding Tubes.


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10.Great Britain National Patient Safety Agency (2007). Promoting safer measurement and administrationof liquid medicines via oral and other enteral routes.

11.Portsmouth NHS Trust (2005). Administration of Drugs to Adult Patients with feeding tubes. DrugTherapy Guideline No 52.01, p1-25.

12.Metheny, N., et.al. (2005). Indicators of Tubesite during Feedings. Journal of Neuroscience Nursing37(b), 320-325.13.Taylor, S. & Clemente, R. (2005). Confirmation of Nasogastric tube position by pH testing. Journal of

Human Nutrition and Dietetics 18 371-375.14.Great Britain. National Institute for Health and Clinical Excellence (2006). Nutrition Support in Adults

(Clinical Guideline 32) London : NICE


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APPENDIX 1: PROTOCOLS FOR PRACTICE

List of Equipment for Procedure: -Clean tray or trolley1 x fine bore feeding tube 6 - 8fg

1 x glass of water and straw1x 10ml enteral syringe filled with tap water1 x 50ml enteral syringe

Bioclusive/HypafixpH Indicator strips

ACTION RATIONALE EVIDENCE

1. Explain procedure to patient. To obtain patients consent and co-operation. 1

2a. Where possible the patient should be sitting in

a semi-upright position supported with pillows.

2b. For the semi-conscious patient it is often

easier to be in a lying position.

This position allows easy swallowing and

ensures that the epiglottis is not obstructing

the oesophagus.

Appendix 3.

3. Wash hands and apply gloves. Assemble

required equipment, select appropriate tube.To ensure a clean procedure is maintained

throughout.

Consider gauge required dependent on

diagnosis.

Appendix 2.

Infection Control

Policy

2

1

4. Check nose and mouth for any signs of

Obstruction and ensure both are clean.

Check nasal patency by sniff with each nostriloccluded in turn.

Patient may have one nostril which is

clearer than the other e.g. deviated nasalseptum

1

2

5. Estimate the length of NG tube by measuring

from the xiphisternum to the tip of the nose, and

from the tip of the nose to the ear lobe.

(Measurement approx 50-60cm).

To gain an approximate length for that

patient.

1 12

2

4

6. Flush the tube with 1-2mls of water

Ensure guidewire moves freely.This will ensure that the guide wire can be

easily removed once placed.

Manufacturers

guidelines

7. Lubricate the NG tube by immersing end of

tube in water.This will facilitate easy passage when

inserting the tube.2

8. Insert the tube into the clearest nostril and slidebackwards and inwards along the floor of the

nose to the nasopharynx approx 10cm and STOP

If any obstruction is felt withdraw tube slightly

and try again at a slightly different angle.

There are two distinct stages when passingthe tube.

a. nose pharynx stop and swallowb. pharynx stomach.

Appendix 3

9a. If the patient can swallow coincide

passing NGT with swallowing a sip of

water.

9b. If the patient is dysphagic but can

swallow own secretions - trickle 1-2mls

of water into the mouth using a syringe

to elicit a swallow.

Repeat the water/swallow and advance until

estimated length is reached.If swallowing reflex is not initiated DO NOT

continue with this method.

The passing of the NGT can be co-

ordinated with observing for laryngeal

movement. During this phase the epiglottis

covers the airway and NGT can pass into

oesophagus.

Risk of aspiration.

Appendix 3.

14


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ACTION RATIONALE EVIDENCE

9c. If the patient is dysphagic and unable to

swallow secretions or the above fails attempt to

pass the tube unaided to the estimated

measurement.

NB Advancing chin forwards and/or turning head

to one side may facilitate tube advancement.

This reduces the risk of aspirating fluids.1

14

10. If you are unsuccessful repeat above

procedure in other nostril. Consider smaller bore

and/or weighted tube. Do not repeat procedure

more than 3 times.

One nostril may be clearer than the other.

Smaller gauge or weighted tube may be

easier to pass on specific patients.

Appendix 2

1

2

8

11. Remove guide wire and secure naso-gastric

tube in place using hypafix/bioclusive across side

of face. Do not apply tape to nose.

Mark NGT with pen at point of entry into nostril.

Most fine bore NGTs are radio- opaque

and do not require the guide wire to be in

situ for x-ray (see manufacturers

guidelines).

This will provide an easily identifiable

mark as a baseline.

2

8

12. Follow steps A-Cto obtain aspirate andverify

correct NGT position.

.

A. Using a 50ml enteral syringe insufflate up to

30mls of air via NGT.

B. Attempt to gain aspirate from NGT.

If aspirate obtained check using ph indicator

strips. (See appendix 2)

C. If pH is less than 5, use tube - x-ray is not

required.

Gastric secretions have a pH of less than 5.

This confirms that tube is in the stomach.

This clears tube of debris and forces end of

the tube away from the stomach mucosa.

The pH of aspirate should be measured

using pH indicator strips in the range 0-6

with 1/2 point gradations.

Litmus paper must not be used as it does

not indicate the degree of acidity.

3, 13

4

5

10

3, 9, 12, 13

9, 13

13. If unable to obtain aspirate or pH of aspirate

is 5 or above follow flowchart See Appendix 4.Appendix 4.

14. If the patients swallow is intact and aspirate

cannot be obtained, ask patient to drink 200mls of

blackcurrant, then aspirate this via NGT

If tip of NGT is in gastric fluid pool

blackcurrant will be aspirated USE

TUBE X-RAY IS NOT REQUIRED.

DO NOT USE THIS METHOD UNLESS

PATIENTS SWALLOW IS INTACT.

13

15. In the absence of a positive aspirate test a

chest x-ray will be required to confirm tube

position.

NB Confirmation of tube position by x-ray is only

correct at the time of x- ray. Subsequent

checking of position by aspirate test must be

carried out at the bedside. See below.

X-ray request forms need to document that

CXR is to verify NG tube position, as a

specific density is required.

4

5

13

16. Following insertion and confirmation of

correct position document procedure - including

pH of aspirate obtained +/or confirmed by x-ray,

and measurement of tube at nose.

Position of tube on x-ray must be confirmed by a

level 4 competent practitioner or medic and

documented in medical notes.

Accountability for checking the tube

position before use lies with the competent

Healthcare Professional.

Recording the procedure is a requirement

in law and provides a baseline for future

measurement.

This is a legal requirement.

Trust Policy and

Protocol for the

Management of

Records (2005)

Care of a Patient with a

Fine Bore Nasogastric

Feeding Tube (2005)

Competency Appendix

6.17. Implement NG tube position chart

(Appendix 5) at bedside

To ensure documentation of NG position

check.


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SUBSEQUENT VERIFICATION OF NGT POSITIONAs the accountable practitioner caring for the patient with an NGT it is your responsibility to ensure the tube is in the

correct position.

Tube position should be checked by aspiration before: -

ACTION RATIONALE EVIDENCE1. Each bolus feed or drug administration. To confirm correct position prior to use. 4, 6, 8, 14

2. At least once every 24hrs whencontinuous feeds are used.

To ensure tube has not displaced. 4, 6, 8

3. If the patient complains of discomfort orfeed reflux into the mouth.

To ensure tube has not displaced. Tube

may be coiled in back of throat.4, 6, 8

4. After vomiting or violent retching. To ensure tube has not displaced. 4, 6, 8

5. After severe coughing bouts/respiratorydistress.

To ensure tube has not displaced. Check

back of throat to ensure that tube is not

coiled.

4, 6, 8

6. After endotracheal or tracheostomy tubesuctioning.

To ensure tube has not displaced. 4, 6, 8

7. If tube has obviously displaced onchecking measurement.

4, 6, 8

8. On receipt of patient being transferredprior to using tube.

4, 6, 8

Use NG Tube Position Chart (Appendix 5) to document subsequent checking of tube position.

It is recognised that obtaining aspirate for subsequent checking may at times be difficult.

In the absence of aspirate of a pH below 5 it is the responsibility of the most senior Health Care Professional to use

their clinical judgement to determine if the tube is safe to use.

The following is provided to assist in your decision making.

ACTION RATIONALE EVIDENCE1. Check that level 2 Practitioner has

followed guidance on flowchart

(appendix 4).

To ensure correct procedure has been

followed.14

2. Obtain patient history:Check measurement at nose

Has patient vomited, coughed, or

complained of feed reflux?

To check if tube has moved.

To ensure tube has not displaced. 4

3. If tube position has not moved, inject

5/10mls of water into NG tube. Attemptto re-aspirate using a 10ml enteral

syringe.

This has been shown to ease the process for

obtaining aspirate3

4. Aspirate visualisation: - Altered feed may indicate gastric digestion.Bile may indicate stomach or small bowel

position.12

5. Consider auscultation to give furthersupportive information.

Auscultation has some benefit as an ancillary

method for checking tube placement. It must

not be used as the sole method of determining

tube location.

8, 9, 13


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ONGOING MANAGEMENT

ACTION RATIONALE EVIDENCESkin Care

Daily:

* Check that tape securing tube is

intact and not in need of replacement

* Check around nostril for any signs

of pressure necrosis.

If patient is NBM ensure mouth care

is maintained 2 hourly.

To ensure tube is safely secured in position.

Tape may need to be changed to secure tube in a

different position.

To ensure oral hygiene is maintained reducing risk of

opportunistic infections.

2, 14

Maintaining Patency

Flush tube with 30-50mls water

before and after feed using a 50ml

enteral syringe.

If fluid restricted may need to reduce

these amounts.

If continuous feeding flush every 4-

6hrs as above.

Administration of medications

Where possible medications should

be given in liquid/dispersible form

with a water flush in between.

To ensure tube does not become blocked.

Use 50ml enteral syringe to prevent tube rupture or

collapse

To ensure fluid balance in 24hr period does not exceed

restriction.

To avoid blockage of tube.

3, 6, 7

4, 6, 11


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APPENDIX 2: PRODUCT INFORMATION / TUBE SELECTION / ENTERAL SYRINGES

PRODUCT ORDER NO. COST HOW TO ORDER

Flocare 8fg (non weighted) 35243 5.35 each UK Procure FWM 040

Merck 6fg (weighted) 090120004 10.03 each UK Procure FWM 243Merck 8fg (weighted) 090120012 10.03 each UK Procure FWM 301

BDH 0-6 Indicator Strips 315052J 3.19 pack UK Procure HHD 046

PRODUCT CONCENTRATED FEED THICK MEDICATION DIFFICULT INSERTION

Flocare 8fg (non weighted)

Merck 8fg (weighted)

Merck 6fg (weighted)

Catheter tip 60ml enteralsyringe PE60B 39p each (box of 55) FTA 048

60ml enteral syringe

(female luer lock)PE60 39p each (box of 60) FTA 047

20ml enteral syringe

(female luer lock)PE20 23p each (box of 80) FTA 046

10ml enteral syringe(female luer lock)

PE10 18p each (box of 100) FTA 044


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APPENDIX 3: ANATOMY + PHYSIOLOGY OF SWALLOWING

Upper Oesophageal sphincter contractedPass NG tube into Pharynx

Upper Oesophageal sphincter When patient swallows upper Oecloses over trachea sealing off ai

ass into Oeso ha us.


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


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IF YOU ARE UNABLE TO OBTAIN ASPIRATE

A. Turn patient onto their side Aspirate tube

This will allow the tip of the tube to enter the gastric

fluid pool.

B. If tube measurement is less than 60cm

advance tube 5 10cm Aspirate tube

Tube may be in oesophagus advancing tube may

allow it to pass into the stomach.C. If tube measurement is more than 70cm

withdraw tube 5 10cm Aspirate tubeTube may be inserted past the stomach into small

bowel. Withdrawing tube may bring tube back into

the stomach.

D. Is patient on any medication that increasesstomach emptying: i.e. metoclopramide

May result in little or no fluid within the stomach.

Seek senior advice.

E. If swallow is intact ask patient to drink 200mls

blackcurrant and attempt to aspirate via NGT.

On initial NGT placement if aspirate is

unobtainable and/or blackcurrant test is notappropriate an x-ray must be requested.

Aspiration of blackcurrant via NG indicates that

NGT is in stomach.

To confirm gastric placement. To give baseline

information for subsequent checking.Seek senior advice prior to requesting x-ray.

F. For subsequent checking of tubeposition

x-ray should not be routinely used.

It is inappropriate/unsafe to repeatedly send patients

for x-ray to verify tube position.

Seek senior advice.

IF ASPIRATE HAS A pH of 5 or above (if swallow intact refer to E above)

1. On initial NGT placement an x-ray must be

requested.

To confirm gastric placement

2. On subsequent check of tube positionif pH 5 5.5

a) Is patient on medication that could elevatepH of gastric contents?

b) Was an x-ray taken on placement thatconfirmed stomach position?

If yes to a and b and there is no indication that tubehas moved it is likely to be in stomach

Use Tube (see Appendix 1)

3. Aspirate appears to contain feed.

Wait 60 minutes Aspirate tube

Feed in stomach will elevate pH. If pH remains

elevated.

Seek senior advice.

4. If tube measurement is more than 70cm withdrawtube 5 10cm

Aspirate tube

Possible small bowel position of tube tip.Withdrawing tube will bring it back into stomach.

5. Bile Aspirated (green/yellow colour) Bile can indicate either small bowel or gastricplacement.

Seek senior advice.

6. No reason for pH.a. On initial placement of NGT an x-ray must

be obtained.

b. For subsequent checking of tube position it

is inappropriate to x-ray

a. To confirm gastric placement.

b. Seek senior advice.


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APPENDIX 5. NG TUBE POSITION CHART

NG TUBE POSITION CHART

Name: Date of birth: Hospital Number:

On initial NGT placement size/type of NGT . If pH less than 5 use Tube

Date Time Length of NGT in

cms at tip of nose

If Aspirate

obtainedpH value

If No Aspirate

Action Taken

If pH not less than

Action Taken

*If unsure seek senior guidance and refer to policy for The Insertion and Maintenance of Fine Bore Naso-Gastric Feeding T* Use BDH 0 6 Indicator strips Order No: HHD 046 - 315052J CLIN

023


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Competency Indicators1st Level

Achieved

Assessor

Signature

CompetencyIndicators2nd Level

Achieved

Assessor

Signature

CompetencyIndicators3rd level

Achie

Asses

Signat

f) Utilising an holisticapproach, understandthe implications for apatient having a NG eg

altered body image.g) Assist Health Care

Professional with theinsertion of the Naso-Gastric Tube

h) Maintain patient comfortand safety.

i) Maintain correct infectioncontrol procedures

j) Inform Health CareProfessional of anychange in patientscondition/status

Can access and maintainrelevant supplies at wardlevel

f) Subsequently check theposition of the Naso-gastricTube before administeringfeed and medication.

g) Demonstrate ability tomaintain patency andensure correct feedingregime is maintained.

h) Correctly administer

medication via Naso-gastrictube (if already competent at

administering medication)i) Initiate discharge planning,

involving relevant HealthCare Professionals.

e) Utilising experience and

knowledge, manage anycomplications, referringto Specialist Practitioneras required.

f) Co-ordinate dischargeplan, supporting thepatient in selfmanagement or involvecarers as required

g) Document allinterventions in the

patients recordsh) Facilitate learning andpractice developmentwithin clinical area.

i) Initiate a feeding regimenat weekends and over

Bank Holidays usingStarter regimen,provided in NGT Policy


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Education resources to support your development

- Policy & Guidelines for gainingConsent

- Policy & Guidelines for TheInsertion and Maintenance of Fine

bore Naso-gastric Feeding Tubesin Adults.

- Nutrition Benchmark (Essence ofCare)

- Policy and guidelines for infectioncontrol

Access Clinical Nutrition Nurse SpecialistsContact No 023 9228 6000 ext 5918

- Guidelines for enteral feeding inAdult Hospital Patients by Stroud,Duncan & Nightingale 2003 in GUT52 (suppl. V111) V11-1 V11-12

Opportunity for bi-annual education vianutrition link study days

- Web Site:British Association of Enteral & Pa

Contact Practice Development Nursavailable relevant courses.

Author: Gillian Fraser/Chris Caws Department: Nutrition/Gen. Surgery Review Date: Sept 2009

Record of Achievement.

To verify competence please ensure that you have the appropriate level signed as a record of yLevel 1 Level 2 Level 3 Level 4

Date

Signature of Educator/ Trainer

Date


Date


Date:

Signature of Assessor

Date:

Signature of Assessor

Date:

Signature of Assessor Signatu


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References to Support Competency

1. Cannaby, A et al. (2002) Nursing Care of Patients with Nasogastric Tubes British Journal of Nursing

11 (6) 366-3722. Christensen, M. (2001) Bedside Methods of Determining Nasogastric Tube Placement: A literature

review. Nursing in Critical Care 6 (4) 192-1993. Colagiovanni, l. (1999). Taking the Tube Nursing Times 95 (21) 63-714. Great Britain National Patient Safety Agency (2007). Promoting safer measurement and

administration of liquid medicines via oral and other enteral routes.5. Portsmouth NHS Trust (2005). Administration of Drugs to Adult Patients with feeding tubes. Drug

Therapy Guideline No 52.01, p1-25.6. Metheny, N., et.al. (2005). Indicators of Tubesite during Feedings. Journal of Neuroscience Nursing

37 (b), 320-325.

7. Taylor, S. & Clemente, R. (2005). Confirmation of Nasogastric tube position by pH testing. Journal ofHuman Nutrition and Dietetics 18 371-375.8. Great Britain. National Institute for Health and Clinical Excellence (2006). Nutrition Support in adults

(Clinical Guideline 32) London : NICE


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APPENDIX 7: STARTER REGIMEN FOR ADULTS

DEPARTMENTS OF NUTRITION AND DIETETICS AND CLINICAL NUTRITION

STARTER REGIMENFOR NASO-GASTRIC TUBE FEEDING IN ADULTS

The following instructions have been devised to enable competent Healthcare Professionals

(level 3) to commence artificial feeding via a naso-gastric tube.

Refer patient as soon as possible to the Dietitians for assessment and anindividualised Feeding Regimen see telephone extensions on page 2 or useOrderComms if you have access.

The decision to commence artificial feed is a medical decision and if a naso-gastric tube has been inserted for feeding it is not

acceptable to withhold feed because a Dietitian is not available to provide a feeding regimen.

The aim of the starter regimen is not to meet the patients total nutritional requirements but to avoid starvation and to introduce feed

slowly and safely so as not to cause harm to the patient.

Prior to commencement of feed you must request review by medical team to ensure there are no contraindications or special

measures that may need to be applied (for example: renal failure/congestive cardiac failure/fluid restricted patients/gastro-intestinal

obstruction).

You will need to assess if the patient is at risk of Refeeding Syndrome. If the patient is at risk you must use the feeding regimen on

page 3. Please see PHT Guidelines for the Prevention and Treatment of Adult Patients at Risk of Developing Refeeding Syndrome

for further details.

If the patient is not at risk proceed to use the regimen on page 2.

If the patient is very underweight i.e. less than 40kg you must follow the Refeeding regimen as the patient will need to be fed very

small amounts to start with.

The following starter regimens have been designed to be used at the end of the patients bed as a stand-alone document outside of

this policy.

PRODUCED BY Registered Dietitians and Clinical Nutrition Nurse SpecialistsDATE: June 2006REVIEWED: Reviewed and Updated July 2007 and December 2007REVIEW DATE: December 2009Portsmouth Hospitals NHS Trust

1


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Portsmouth Hospitals NHS Trust Departments of Nutrition and Dietetics AND Clinical Nutrition

NASOGASTRIC TUBEFEEDING STARTER REGIMEN FOR ADULTS

Ward:... Name:.. DOB:. DATE:.. Sheet No:..

Fluid Balance should be closely monitored. Feed should be delivered within the context of careful fluid balance with

intravenous fluids being reduced or discontinued as required*. Biochemistry (within last 48 hours) should be checked before starting and regularly monitored during feeding

Recommended rates are for guidance and not to contravene medical opinion.

REFER PATIENT TO DIETITIAN AS SOON AS POSSIBLE

For patients 40kg weight and over

(if patient less than 40kg use regimen for Refeeding Syndrome see over)Date/Day number Feed Type Rate

(ml/hour)Duration(hours)

Volume(ml)

DAY 1 Water 30 4 120

Fresubin Original 20 20 400





Patient may require additional intravenous fluids* - please assess fluid balance

Dietitians x 7700 6150 QAH x 7701 3720 SMH Nutrition Nurses x 7700 5918

2

2

Continue as Day 3 until Dietetic Review

Ensure the patients head is elevated to at least 30 degrees during feeding, and for one hour after feedinghas stopped

Feeding tubes should be flushed before and after medication and whenever the feed is started/stoppedwith 30ml water

Giving sets should be changed daily

If symptoms of intolerance occur (vomiting, abdominal distension, diarrhoea etc) consult medical staff.

If problems with tube management occur eg tube choice, insertion techniques, position check andongoing care, please contact the Nutrition Nurses.

Further information:

- Policy on Insertion and Maintenance of Fine Bore Naso-gastric feeding Tubes in Adults, ClinicalGuidelines, PHT Intranet. This Starter Regimen is Appendix 6 of this Clinical Policy.

- Marsden Manual Chapter 27 pp385-401 Nutrition Support- located on ward and PHT Intranet- NICE Clinical Guideline 32 Nutrition Support in Adults - (URI on PHT Intranet)- 2Drug Therapy Guideline No: 52.01 Administration of Drugs to Adult Patients with Feeding Tubes- 3Drug Therapy Guideline No: 46.00 Guidelines for the Prevention and treatment of Adult Patients At

Risk of Developing Refeeding Syndrome.


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Insertion and maintenance of fine bore naso gastric feeding tubes in adults policy Issue 4 04 03 2008 Page 22 of 22

FOR ADULT PATIENTS AT RISK OF REFEEDING SYNDROME

Ward:... Name:.. DOB:. DATE:.. Sheet No:..

Fl

u

i

d

B

a

l

a

n

c

e

s

hould be closely monitored. Feed should be delivered within the context of careful fluid balance with intravenous fluids

being reduced or discontinued as required. * Thiamine -100 mg three times daily (the first dose 30 minutes prior to starting feeding3) either orally OR crushed via

feeding tube2

AND Vigranon B 5ml three times daily via feeding tube.2 3 OR Vitamin B compound strong - 1 tablet three times dailyorally

AND Sanatogen Gold 1 tablet daily either crushed via feeding tube.2 3 or orally.

Biochemistry should be closely monitored BEFORE STARTING (within last 24 hours) and DAILY during feeding,especially Potassium, Magnesium, Phosphate, and Corrected Calcium. If any of these are low do not increase feed rate

do inform medical staff and dietitian when available.

Recommended rates are to guide but not contravene medical opinion. Recommend not to start nutritional supplement drinks (eg Fresubin Energy, Provide Xtra etc) at same time as

starter regimen if patient at risk of Refeeding syndrome

REFER PATIENT TO DIETITIAN AS SOON AS POSSIBLE

Feeding must be increased slowly in accordance with the regimen below following thiamine administration, see above.

For patients At Risk of Refeeding Syndrome or below 40 kg in weight

Date/Daynumber

Feed Type Rate(ml/hour)

Duration(hours)

Volume(ml)

Day 1 Water 30 4 120


Day 2 Water 30 4 120Fresubin Original 20 20 400

Day 3 Water 30 4 120


Patient will require additional intravenous fluids*

SEE INFORMATION REGARDING DAILY PATIENT MANAGEMENT WHILST FEEDINGON PAGE 2 of this appendix

Occasionally patients will be at risk of Refeeding Syndrome. They can be identified from the following list.Patients with:

ONE OR MORE OF THE FOLLOWING:

Little or no nutritional intake for more than 10 days

Unintentional weight loss greater than 15% within the last 3-6 months

Body Mass Index less than 16

Low levels of potassium, phosphate or magnesium prior to feeding

TWO OR MORE OF THE FOLLOWING:

Little or no nutritional intake for more than 5 days

Unintentional weight loss greater than 10% within last 3-6 months

Body Mass Index less than 18.5

insertion and maintenance of fine bore nasogastric feeding tubes in adults

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