Good Practice Guideline Safe Insertion of Nasogastric (NG) Feeding Tubes in Adults (Not ongoing care) March 2012 Review date: March 2015
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 (). 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 manufacturer s 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)
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 practitioner 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 NICE 2006 tube 2. The patient must have a functioning gastro-intestinal tract To maximise absorption of feeds and/or NICE 2006 medication 3. A multi-disciplinary team (MDT) approach to the initiation of feeding should be utilised. Before undertaking the procedure: Feeding is appropriate and in the best interest of the patient RCP 2010 Review the patient s medical notes to assess for any contraindications to tube placement Ensure all relevant investigations are undertaken (where appropriate) e.g. 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 patient s care 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
5. Where patients demonstrate a lack of capacity a Best Interest decision should be taken by the practitioner. This may necessitate further discussion with the wider MDT and may require an Independent Mental Capacity Assessor(IMCA) 6. Gather all equipment prior to arriving to the patient s 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 source/cooled boiled water / sterile water) as per local policy Non sterile gloves and apron Prepare equipment at patient s 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 demonstrate compliance with current legislation and demonstrate wider consultation to ensure appropriate decision. To ensure timely uninterrupted insertion of the NG tube DH 2005 DH 2009a RCP 2010 NPSA 2005 DH 2009b
Agreeing a signal to indicate a problem or stop the procedure Ensure universal precautions are used at all times 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 it is not prescriptive). 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). 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 i.e. using the index finger to occlude one nostril and then asking the patient to sniff and then do the same to the other side 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 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 adhere to local infection control policies To ascertain an approximate measurement to ensure the tube is sited at the correct length To increase patient comfort whilst carrying out the procedure and to facilitate easier insertion of the tube and avoid inadvertent tracheal intubation To ensure nasal passages are clear for smooth passage of the tube. To assess for any physiological malformation that may inhibit tube insertion. To facilitate easier removal of the guidewire following tube placement To facilitate smooth passage of the tube Grade D evidence Weightman et al 2005 Eccles 2000 Dougherty & Lister S 2011 Grade D evidence Weightman
DO NOT lubricate the inner lumen of the tube with water before insertion and checking gastric positioning 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 chin tuck (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 patient s care plan) b) Where patient is not safe to swallow fluid but has capacity, ask patient to perform a dry swallow (refer to patient s 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 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 and increase patient comfort et al 2005 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 To achieve gastric placement of the tube To avoid causing any harm Grade D evidence Weightman et al 2005 Grade D evidence Weightman et al (2005)
13. When NG tube inserted to predetermined mark aspirate with an enteral syringe as per manufacturer s 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) 14. Test the gastric aspirate, with ph indicator paper/strips that comply with NPSA guidance (CE marked), to obtain a ph reading. a) ph reading MUST be 5.5 or below to administer fluid immediately without further investigation b) The ph cut-off reading may differ according to local policy but should never exceed 5.5 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 manufacturers guidance. b) Flush the tube with water as per local policy 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 To confirm correct gastric position and safe to feed. 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 2007 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 To ensure patient safety DH 2009 should include as a minimum: To adhere to NPSA guidance RCP 2010
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 obtained/patient agreement indicated. Fully document Best Interest decisions Also consider documenting: f) Patient tolerability with procedure g) The number of attempts insertion undertaken (i.e. if very difficult procedure or multiple attempts made) 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 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
Developed by: Tracy Earley, Deputy Secretary Consultant Nurse 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
REFERENCES: Department of Health (2005) Mental Capacity Act, Code of Practice, Department of Constitutional affairs, Department of Health, London http://webarchive.nationalarchives.gov.uk/+/http://www.dh.gov.uk/en/socialcare/deliveringadultsocialcare/mentalcapacity/mentalcapacityact2005/index.ht m Department of Health (2009a) Reference guide to consent for examination or treatment, 2 nd edition, Department of Health, London http://webarchive.nationalarchives.gov.uk/+/http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_103643 Department of Health (2009b) Saving Lives High Impact Intervention (HII) Enteral feeding care bundle, Department of Health, London http://hcai.dh.gov.uk/files/2011/03/2011-03-14-hii-enteral-feeding-care-bundle-final.pdf Department of Health (2010) Essence of Care Benchmarks for Respect and Dignity, DH, London http://webarchive.nationalarchives.gov.uk/+/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_11996 6.pdf Dougherty L, Lister S (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (8 th edition) Wiley Blackwell Eccles RB (2000) The nasal cycle in respiratory defence Acta Otorhinolaryngologica Belgica 54(3):281-6
Medicines and Healthcare Products Regulatory Agency (2007) Phthalates/DEHP in PVC medical devices, MHRA, London http://www.mhra.gov.uk/safetyinformation/generalsafetyinformationandadvice/technicalinformation/phthalatesinpvcmedicaldevices/index.htm National Institute of Clinical Excellence (2006) Nutrition Support for Adults. Oral nutrition support, enteral tube feeding and parenteral nutrition Clinical Guideline 32, NICE, London http://www.nice.org.uk/cg32 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 http://www.nrls.npsa.nhs.uk/resources/?entryid45=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: NPSA/2007/19 March 2007 NPSA, London http://www.nrls.npsa.nhs.uk/resources/?entryid45=59808 National Patient Safety Agency (2011) Patient Safety Alert 2011/PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants, NPSA London http://www.nrls.npsa.nhs.uk/resources/?entryid45=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
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