nasogastric feeding tube insertion and ongoing …

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Nasogastric Feeding Tube Insertion and Ongoing Care Bundle Sept 2021

Consultant:

Ward:

Date admitted:

Patient Name: Trust ID Number: Date of birth:

Or attach PAS label

STAFF SIGNATURES

Please fill in this section prior to making an entry in this document, you only need do it once.

Print Name Signature Initials Designation

NASOGASTRIC FEEDING

TUBE INSERTION AND

ONGOING CARE BUNDLE

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Nasogastric tubes:

First line method for confirming position is pH testing:

pH 4.5 or below: PROCEED WITH FEED. Monitor for signs of intolerance of feed/respiratory deterioration

pH 5-5.5: DO NOT FEED. Request 2nd checker to confirm pH. If confirmed as 5.0-5.5,

PROCEED TO FEED. Monitor for signs of intolerance of feed/respiratory

deterioration

pH 6.0 or above: DO NOT FEED. Wait 15-30 minutes & recheck. If remains elevated request

CXR or consider replacing the tube.

If repeated CXRs have been required to confirm position, please refer to medical team for advice.

Second line method for confirming position is CXR and review of this must be documented in the medical notes, use sticker ‘Radiological confirmation of NGT placement’. Verbal confirmation is

only accepted with 2 nurses’ signatures stating the verbal confirmation of the NGT position. CXR should not be taken and reviewed overnight unless overnight feeding regime is prescribed. Consider if patient will require IV hydration until position can be confirmed.

Nasojejunal tubes:

Do not require pH check. However, the measurement of tube to the nose must be documented.

CXR will be required to confirm position. If they are experiencing vomiting episodes, or are

becoming chesty, coughing, the feed should be stopped as it may have become dislodged.

Troubleshooting Gastric Aspirate

• Not enough aspirate – check tube length.

• Lie patient on their left side & retry.

• No aspirate – Check tube length & consider advancing tube 5-10 cm & retry.

• No air/aspirate – Check tube length.

• Inject 10ml air to free tube tip from gastric mucosa and retry aspirating. This is not the same as the Whoosh test which must NOT be used to confirm position.

• Consider withdrawing tube 5cm & retry.

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Ensure your patient is upright at 30-45 ° angle during feeding and for at least an hour afterward to minimise aspiration risk

Placement checklist for new feeding tubes (NG / NJ) Complete all sections of this form EXCEPT the pH for NJ tubes

* If patient has removed 2 or more tubes in a 24hr period consider using mitts or a nasal bridle – refer to Mental Capacity Act and DoLs policies; refer to

nasal bridle policy.

** pH testing for NGT position must take place:

• Following initial insertion.

• Before the administration of each bolus of feed or fluid.

• Before medication, if feed not in progress.

• Following episodes of vomiting, retching or persistent and strong coughing. • When there is evidence of tube displacement, e.g. length of tube at nostril is less than previously documented or securement device has loosened. • If there are any new or unexplained respiratory symptoms or reduction in oxygen saturation.

NG / NJ

Tube No:

(Circle if NG

or NJ)

Consent

obtained DOCUMENT

IN NOTES

Date/ time

insertion

No. of

attempts

Make &

FR

gauge

Measurem

ent to

nostril

(internal

length, cm)

pH result

on insertion

(NOT for NJ

tubes)

CXR – if required

must document

in medical notes

& 4 criteria

confirmation of

position

Guidewire

removed

Patient on Insulin -

Diabetic Team informed & insulin

adjusted to support feeding

Dietitian referral

Enteral Feeding Regime

Prescribed

Initials of person

inserting NG/NJ tube

1.

NG / NJ

Verbal

Non-verbal

Best interest

decision

Y / N Y / N Y / N / NA Y / N Y / N / NA

2.

NG / NJ

Verbal

Non-verbal

Best interest

decision

Y / N Y / N Y / N / NA Y / N Y / N / NA

3.

NG / NJ

Verbal

Non-verbal

Best interest

decision

Y / N Y / N Y / N / NA Y / N Y / N / NA

4.

NG / NJ

Verbal

Non-verbal

Best interest

decision

Y / N Y / N Y / N / NA Y / N Y / N / NA

5.

NG / NJ

Verbal

Non-verbal

Best interest

decision

Y / N Y / N Y / N / NA Y / N Y / N / NA

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Monitoring of feeding tube – pH, internal tube length, nasal pressure damage, fluid chart

Date

EXAMPLE IN RED

Time Internal tube measurement at nostril

1st pH check or document unable

(NOT applicable

for NJ tubes)

2nd pH check if required

(NOT applicable

for NJ tubes)

Unable to gain aspirate – Action taken:

1. Check position of tube

2. Lie flat & turn to left side

3. Wait for 30 minutes & retry

4. CXR

Tape securement or Nasal Bridle checked to avoid pressure damage

Fluid chart completed

Initial

10.06.14 08.00 57cm 4.0 - - Y / N Y / N AB

11.06.14 08.00 57cm Unable - 1.2.3. Y / N Y / N AB

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

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Date

Time Internal tube measurement at nostril

1st pH check or document unable

(NOT applicable

for NJ tubes)

2nd pH check if required (NOT applicable

for NJ tubes)

Unable to gain aspirate – Action taken:

1. Check position of tube

2. Lie flat & turn to left side

3. Wait for 30 minutes & retry

4. CXR

Tape securement or Nasal Bridle checked to avoid pressure damage

Fluid chart completed

Initial

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

Y / N Y / N

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NASOGASTRIC FEEDING REGIMEN

Date/Day Feed Volume of feed (ml)

Rate (ml/hr)

No. of Hours

Rest Period

Comments (additional fluid/flushes)

Flush with __50___mls of sterile water pre & post feed

Flush with _____mls of sterile water pre & post feed



Many Nutrison feeds contain Fish Oils. If this patient is a vegetarian or vegan please use Nutrison Soya unless contraindicated and inform the ward dietitian

If a patient does not tolerate the feed please decrease the feed to the rate previously tolerated and contact your ward dietitian

Raise the head of the bed to 30-45º degrees during feeding and for 1 hour afterwards

Use a new giving set, bag of feed or water container every 24 hours

Use a 60 ml enteral syringe and sterile water for all water flushes

Flush with a minimum of 30 mls sterile water both pre and post all medications

Dietitian: _________________________ Ext / Bleep: _____________ Date: ___________ Updated July 2021

Once tip of nasogastric tube has been confirmed to be in stomach by either a pH aspirate (pH must be 1-5.5) or a chest X-ray, repeated checks must be made to confirm correct position:

Before administering each feed

Before giving medication

At least once daily

If you suspect tube displacement arrange

for chest X-ray and replace if appropriate

Fluid Requirements ____________mls/day

Ward: ___________________________________

Patient’s name: ___________________________

Hospital Number: _________________________

Weight:___________________kg

Nasogastric Feeding Tube Insertion and Ongoing Care Bundle Sept 2021 of 12

NASOGASTRIC FEEDING TUBE: ONGOING CARE

PRE-PROCEDURE: Check bedside oxygen and suction available and working

PROCEDURE: (full procedure in Policy for safe insertion and care of nasogastric feeding tubes in adults)

1. Medical team documented in notes that nasogastric feeding is the right decision for patient.

2. Sufficient knowledge / expertise & resources available to safely check placement of nasogastric tube and interpret XR

3. Other medical contraindications have been excluded (basal skull fracture)

4. Ensure patient privacy. Reassure patient.

5. Procedure explained to patient, carers and/or family and their understanding of the procedure established. Consent Agreed.

6. Collect equipment and use clean blue tray.

7. Position patient, sitting upright, neck in neutral position. If patient is unconscious – lateral position.

8. Select nostril – if necessary ask patient to blow nose, check for obstruction.

9. Estimate NEX (Tip of Nose to Earlobe to Xiphisternum) measurement

10. Only 60ml purple oral/enteral syringes to be used to access device

11. Prior to insertion lubricate outside of fully radio-opaque nasogastric feeding tube with water only.

12. Insert nasogastric feeding tube, if obstruction felt you may need to try slightly different angle, gentle rotation of tube or the other nostril. Never force tube when passing.

13. To facilitate tube insertion, ask patient to swallow as you pass the tube through the Oropharynx. Unless strictly Nil By Mouth/unsafe swallow, give sips of water.

14. Unless contraindicated – Tilt chin downwards and continue to advance tube to NEX measurement. Check tube is not coiled in throat or mouth.

15. If at any time during the procedure the patient experiences respiratory distress, withdraw tube immediately.

16. Secure tube to face/nose with fixation device.

17. Aspirate gently to obtain aspirate with 60ml purple oral/enteral syringe.

18. Only commence feeding if aspirate of 1- 5.5 pH obtained.

19. Follow the NPSA decision tree for confirming placement of nasogastric feeding tube in adults if aspirate is not obtained.

20. Once correct placement confirmed, remove guidewire.

21. Complete documentation.

NASOGASTRIC FEEDING TUBE INSERTION

Equipment required:

Nasogastric feeding tube fully

radio-opaque with 1cm

markings (smallest Fr gauge

suitable)

pH indicator paper CE

marked for human aspirate

Fixation device

60 ml purple oral/enteral

syringes


Date/Time Document reason for variance here

e.g. Nasogastric feeding tube inserted in theatre.

Initials and

staff no.


RISK ASSESSMENT – MUST BE COMPLETED FOR EVERY NASOGASTRIC FEEDING TUBE INSERTION

Proceed to insert a Nasogastric feeding tube (NGT) if the answer is YES to ALL of these questions

1. Have the medical team documented in the patient’s notes that nasogastric tube feeding is the right decision for the patient?

YES / NO

2. Confirm that patient has no medical contra indicators to tube being placed, i.e. basal

skull fracture, Spinal CSF leak, Trans sphenoidal (removal of pituitary tumour)?

YES / NO

3. Is there sufficient knowledge/expertise and resources available at this time to safely

check placement of the nasogastric feeding tube and interpret chest XR if required

(is this the right time?)

YES / NO

4. Consent gained from the patient, clear understanding of the reasons for placement and

nutrition or best interest and UHS Mental Capacity Act Policy referred to?

YES / NO

5. I have had the relevant training and have been assessed as competent to insert a

nasogastric feeding tube.

YES / NO

Date: ………………………… Print Name: …………………………………………………

Signature…………………………………………………………..….

Examples of anatomical changes (not an exhaustive list) that increases risks or may be a contra indicator to placement of nasogastric feeding tube:

maxilla facial disorders, nasal/pharyngeal/oesophageal obstruction or ulceration, choanal atresia, tracheo-oesophageal fistula, oesophageal/pharyngeal pouch, oesophageal stricture/tumours/surgery, oropharyngeal tumours or surgery, post laryngectomy, varices,

gastric outflow or intestinal obstruction.

Proceed to insert a Nasogastric feeding tube (NGT) if the answer is YES to ALL

of these questions



Care Plan: Procedure explained to patient

1. ANTT used throughout procedure. 2. Use clean tray. Feeding pump functional and decontaminated 3. Tube secured to nose/face with fixation device. 4. Check for signs of nasal erosion.

5. Check Length of tube inserted unchanged from previous observations. 6. Only purple oral/enteral syringes used to access device. 7. Gently Aspirate with 60ml purple/oral syringe. 8. Aspirate of 1 - 5.5 pH obtained, gastric placement confirmed. 9. Medications screened and signed by the pharmacist for administration via enteral device. 10. Patients on insulin must be referred to the diabetic nurse specialist and Insulin regime must be

appropriately adjusted to coincide with the feed. 11. Patient positioned with head elevated minimum 30-45 degrees throughout feeding to reduce risk of

aspiration. 12. Infusion stopped if patient is required to lie flat for nursing care. 13. Nasogastric tube is flushed with at least 30 - 50mls of sterile water before & after feed or administration

of any drugs using a push/pause motion. 14. Enteral administration set and sterile water dated, timed and changed every 24 hours. 15. Fluid balance/feed chart accurately maintained. 16. Only increase the infusion rate prescribed if tolerated. If the patient is suffering from abdominal

discomfort, diarrhoea, constipation, nausea or vomiting, then inform the dietitian. 17. Regular mouth care has been given & oral assessment completed to ensure mouth is clean and

moist.

Date:

A (Achieved) or V (Variance)

Am Pm N Am Pm N Am Pm N Am Pm N Am Pm N Am Pm N Am Pm N

Nasogastric feeding tube still required? Y / N

Care plan adhered to? A / V

Nasogastric tube secured A / V

Length inserted remains unchanged Y / N

NGT aspirate obtained and within range, every time

prior to accessing. pH documented each time A / V

If Chest X-ray indicated, X-ray interpretation

documented in medical notes? A / V

Pump and patient check each time NGT has been

accessed, documented on pump chart A / V

Daily blood glucose for all pts until stable on enteral

feeding regimen. A / V

If patient is diabetic blood glucose monitored according to stability A / V

There are no feed related complications? (If Yes, document variance on next page) A / V

Staff signature: (Initials & Staff no.)



Date/Time Document reason for variance here Initials & staff no.

nasogastric feeding tube insertion and ongoing …

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