FNHC Policy and Procedure for passing a Nasogastric Feeding Tube

FNHC Policy and Procedure for passing a Nasogastric Feeding Tube

FAMILY NURSING & HOME CARE RATIFICATION FORM Type i.e. Strategy, Policy, Education Package etc. Name Procedure Procedure for passing a Nasogastric Feeding Tube Category i.e. organisational, clinical, Corporate, Finance etc Clinical Version 1.0 Author Lindy Henesey Approved by i.e. Operational Governance Group Julie Gafoor, CEO Date Approved 15.05.13 Review Date 15.05.16 Person responsible for review Community Paediatric Sister Approved by i.e.sub Committee, H&SS N/A Policy Amendments Version No. Amendments Copy of this form to be given to Information Governance Officer

CONTENTS PAGE NUMBER 1. Aims of the Policy 2. Enteral Feeding 3. Nasogastric Tube Feeding 4. Assessment of Need 5. Training and Competency 6. When to check position of Nasogastric Tube 7. Procedure for passing a Nasogastric Feeding Tube 8. Confirmation of the Nasogastric Feeding Tube position 9. The recommended procedure for checking the position of the Nasogastric Feeding Tubes in infants, children and adults 10. References 11. Appendices

1 Aims of the Policy Enteral feeding is a very useful method of ensuring adequate intake of nutrients in patients who, for a variety of reasons, are unable to use the oral route or are unable to take sufficient nutrients to maintain growth and development. Due to recent reported incidents and subsequent patient safety alerts, there has been a need to adopt a significant change in the practice of nasogastric tube feeding, with particular importance being placed on how positioning of the tube is confirmed. (National Patient Safety Alert 2005). The term child will be used to include young people aged 0 to 19 years of age, the term infant is a child under one year of age, a neonate is a newborn baby under the age of 28 days and the term carer/caregiver will be used to include anyone who has main/parental responsibility for the child. 2 Enteral Feeding Enteral feeding refers to the delivery of a liquid feed through a tube. Children who require enteral feeding often have underlying complex health needs, for example: Gastro-intestinal disorders Neuromuscular disorders Metabolic condition Routes considered for enteral feeding are: Naso-gastric Naso-jejeunal Naso-duodenal Gastrostomy Jejeunostomy Naso-gastric is the most common route of enteral feeding. Benefits include: It is easy to establish and minimally invasive Parents and mature patients can be taught to pass the tube at home Risks/drawbacks associated with naso-gastric tube feeding include: The procedure for inserting a tube is traumatic for the majority of children The tube is very noticeable Babies and young children are likely to pull out the tube making regular pre-insertion necessary Aspiration Damage to the skin on the face This policy is relating to the naso-gastric feeding method

3 Nasogastric Tube Feeding Naso-gastric feeding is when a tube is passed through the nose, down the oesophagus and into the stomach. Tubes are usually made of PVC, polyurethane or silicone. Some tubes have a guide wire to help in passing the tube. Naso-gastric tubes may be inserted by: A registered health care practitioner who has undergone appropriate training and is deemed competent in the skill A health care practitioner in training under supervision by a registered competent health care practitioner A health care assistant who has undergone appropriate training and is deemed competent in the skill under supervision by a registered competent health care professional Mature patients and/or parents and carers who have been trained in the skill and are deemed competent 4 Assessment of Need Feeds may be administered via a feeding pump or by gravity or bolus feeds. Naso-gastric feeding should be considered following full nutritional assessment in negotiation with the child and family. It is usually initiated in hospital but can be commenced at home following assessment of the family s circumstances by the medical nursing and dietetic team and with support from the Children s Community Nursing Team. 5 Training and Competency It is important that parents and carers are given the opportunity to learn and become competent in the care of their child with a naso-gastric tube. This will include confirming the correct position of the tube, passing the tube, knowing how to aspirate tube, knowing how to proceed if no aspirate obtained and their child s usual ph levels. Training should be planned in negotiation with the carers and all sessions and assessments should be documented and kept in the child s records. Training should be given by a qualified nurse who has been appropriately trained. Parents and carers should be given written information on discharge from hospital along with contact telephone numbers for the Community Children s Nurses and the ward in case of difficulties. All children with a naso-gastric tube in place should have individual care plans which states the: The make and type of tube inserted Usual ph levels The external length The date inserted/changed

6 When to Check Position of a Nasogastric Tube The tube position should be checked: Following initial insertion Before administering each feed Before giving medication At least once a day during continuous feeds Following episodes of vomiting, retching or coughing (the absence of coughing does not rule out misplacement or migration) Following evidence of tube displacement e.g. loose tape or visible tube appears longer Procedure to pass a naso-gastric tube

Action 1. Ensure all equipment is available Child s care plan and nursing document Correct size nasogastric tube Non sterile gloves (1 pair) 20ml or 50ml syringe to withdraw aspirate from stomach Ph indicator strips Tape to secure tube Tissues Alcohol gel hand rub Child s dummy or drink if appropriate Water or gel to lubricate the tube Water to flush the tube clear of aspirate once correct placement has been confirmed Procedure 1. Explain and discuss procedure with child and family. 2. Ensure Team contact details available 3. Ensure all equipment is at hand and readily available. 4. Ensure child is comfortable and in the most appropriate position. 5. Infants can be wrapped in a blanket/towel to keep them secure or an adult can hold the infant. 6. An older child may be able to sit upright with support to their back and head Rationale To ensure procedure is carried out safely To ensure all equipment is readily available To aid the tube to move down easier once it has passed through the nose. To ensure child (where appropriate) and family have full understanding of procedure and to aid compliance. To ensure family can contact team for advice and support. To ensure procedure is carried out safely. To ensure child is as comfortable as possible. To ensure tube is fit for purpose 7. Wash hands in accordance with hand hygiene policy. 8. Put on gloves if required. 9. Check the tube is intact. The tube should be stretched to remove any shape retained from being packed. If the tube has a guide wire make sure it is correctly inserted in the tube and is not bent. Flush the tube with 10ml of water 10. Determine length of tube to be inserted: 11. A) for children measure tip of tube from nose to ear and then from ear to stomach, aiming for space in middle below ribs. (appendix 1) 12. B) For neonates and infants measure from mid point between sternum and naval to nose and then to the ear (appendix 1) 13. Note mark on tube or keep fingers on the point measured and document the external length. To reduce risk of infection To reduce risk of tube being inserted too far. To maintain child s safety To reduce risk of tube being inserted too far. To maintain child s safety To have a written record of external length of tube.

14. Lubricate tip of tube using a water based solution (lubricating jelly) according to manufacturer s guidelines. 15. Insert tip of tube into nostril and slide tube backwards along the floor of the nose. 16. If there is an obstruction, pull back tube, turn it slightly and advance again. 17. As the tube passes through the nose encourage the child to drink or swallow (if appropriate) offer an infant a dummy if they usually have one. 18. If child or infant unable to swallow just continue to advance tube until you have reached the point at which the tube was measured. 19. Secure tube with recommended tape or one which will not irritate child s skin. 20. Once correct placement has been confirmed, remove the guide wire, if present, and flush the tube with water. It is now safe to use the tube for administration of feed and medication 21. The guide wire should be cleaned, dried and placed in a sealed container for reuse 22. Wash hands 23. Record in the child s notes the size and type of tube that has been used. Also record the length of tube inserted and record that correct placement has been confirmed. 24. If child starts coughing or their colour changes, stop procedure and remove tube and ensure child is settled then contact qualified nurse or Robin Ward call for advice. 25. If child not breathing commence basic life support as per protocol and dial 999. Dial 999 for an ambulance: To enable tube to be inserted easily. To enable tube to be easily slipped into the nostril. To ensure minimal trauma to nostril. To ensure minimal discomfort to child. To enable tube to move down easily. To reduce risk of tube being inserted too far. To reduce risk of tube becoming dislodged. To maintain child s safety. The nurse will offer advice and support. To maintain child safety and to ensure child goes to hospital. If the child stops breathing If the child s skin colour changes from their usual colour. i.e. becomes blue, pale If the child s usual respiratory rate is increased or decreased If the child becomes agitated and becomes hot and sweaty If you have any concerns or difficulty re-passing the tube

Reducing the harm caused by misplaced naso-gastric feeding tubes Confirming the correct position of nasogastric feeding tubes in infants and children 1. Check for signs of displacement and measure the tube 2. Reposition or repass tube if required 3. Aspirate using 20 or 50ml syringe and gentle suction Aspirate obtained (0.5-1ml) Aspirate not obtained DO NOT FEED 1. If possible turn infant/child onto side 2. Inject 1-5ml air into the tube using 20 or 50ml syringe 3. Wait for 15-30 minutes 4. Try aspirating again Aspirate obtained (0.5-1ml) Aspirate not obtained DO NOT FEED 1. Advance tube by 1-2cm 2. Try aspirating again Aspirate not obtained Aspirate obtained (0.5-1ml ph6 or above Test on ph strip ph 5.5 or below DO NOT FEED 1. Leave for up to 1 hour 2. Try aspirating again ph6 or above ph 5.5 or below DO NOT FEED 1. Call for advice 2. Consider replacement/re-passing of tube and/or checking position by x-ray Proceed to feed CAUTION if there is any query about position and/or the clarity of the colour change on the ph strip, particularly between ages 5 and 6 then feeding should not commence (www.npsa.nhs.uk/advice)

Reducing the harm caused by misplaced naso-gastric feeding tubes The recommended procedure for checking the position of naso-gastric feeding tubes in infants, children and adults Action Check whether the patient is on medication that may increase the ph level of gastric contents Check for signs of tube displacement Sufficient aspirate (0.5 to 1ml) obtained Aspirate is ph 5.5 or below Aspirate if ph 6 or above Wait up to one hour before reaspirating to check ph level Problems obtaining aspirate? Turn patient onto their side Inject air (1-5ml for infants and children, 10-20ml for adults) using a 20ml or 50ml syringe. Wait for 15-30 minutes and try again. This is NOT a testing procedure: DO NOT carry out auscultation of air (whoosh test) to test tube position Advance the tube by 1-2 cm for infants and children or 10-20cm for adults Consider x-ray (all radiographs should be read by appropriately trained staff) Additional tip Rationale Medication that could elevate the ph level of gastric contents are: antacids, H2 antagonists and proton pump inhibitors. For those patients who are regularly on antacids, the initial risk assessment needs to identify actions that staff should take in this scenario and document them in the care plan. The initial ph of the aspirate should also be documented in the case notes Documenting the external length of the tube initially and checking external markings prior to feeding will help to determine if the tube has moved. The documentation will also assist radiographers if an x-ray is needed 0.5 to 1ml of aspirate will cover an adequate area on the single, double or triple reagent panels of ph testing strips/paper. Allow ten seconds for any colour change to occur Commence feed. There are no known reports of pulmonary aspirates at or below this figure. The range of ph 0 to 5.5 balances the risk between increasing the potential problems for clinical staff e.g. removing tubes that are actually in the stomach, increased use of x-ray with the, as yet, unreported possibility of feeding at ph 5.5 when the tube is in the respiratory tract DO NOT FEED. Possible bronchial secretion; leave up to one hour and try again. The initial risk assessment should identify actions for staff to take in this scenario for each patient. The actions should be documented in the care plan and/or in local policies If there is ANY doubt about the position and/or the clarity of the colour change on the ph indicator strip/paper, particularly between the ranges ph 5 and 6 then feeding should NOT commence seek advice The most likely reason for failure to obtain gastric aspirate below ph of 5.5 is the dilution of gastric acid by enteral feed. Waiting up to an hour will allow time for the stomach to empty and the ph to fall The time interval will depend on the clinical need of the patient and whether or not they are on continuous of bolus feeds This will allow the tip of the naso-gastric tube to enter the gastric fluid pool Injecting air through the tube will dispel any residual fluid (feed, water or medicine) and may also dislodge the exit-port of the naso-gastric feeding tube from the gastric mucosa. Using a large syringe allows gentle pressure and suction; smaller syringes may produce too much pressure and split the tube (check manufacturers guidelines). Polyurethane syringes are preferable to other syringes. It is safe practice to use naso-gastric tubes and enteral syringes that have non luer connectors. (Building a Safer NHS for Patients Improving Medication Safety published 22/01/2004 available at www.dh.gov.uk) Advancing the tube may allow it to pass into the stomach if it is in the oesophagus X-ray should not be used routinely. The radiographer will need to know that this advice has been followed, what the problem has been and the reason for the request. The radiographer should document this. Fully radio-opaque tubes with markings to enable measurement, identification and documentation of their external length should be used If the patient is alert, has intact swallow and is perhaps only on supplementary feeding and is thus eating and drinking during the day, ask them to sip a coloured drink and aspirate the tube. If you get the coloured fluid back then you know the tube is in the stomach For more information about the safety issues involved or for details of references used, please see www.npsa.nhs.uk/advice

Appendices 1. How to confirm the correct position of naso-gastric feeding tubes in infants, children and adults 1.1 information leaflet from the NPSA. Measuring length of naso-gastric tube to be passed in neonates, infants and children 2. Check parent care plan to your child s naso-gastric tube position. Parent information leaflet 2.1 Community Children s Nursing Team Care Plan for confirming correct position of naso-gastric tube 3. Parent Care Plan for naso-gastric tube replacement 3.1 Community Children s Nursing Team Care Plan for naso-gastric tube replacement 4. Community Children s Nursing Team Record Sheet for naso-gastric feeding tube change 5. Community Children s Team Competencies for passing a naso-gastric feeding tube for qualified nurses, carers and parents 6. Community Children s Team Competencies for Feeding for qualified nurses, carers and parents

Appendix 1 Measuring the length of a naso-gastric tube to be passed. Measuring the tube for a child. Measure from the child s tip of their nose, to their ear and continue to measure down to the bottom of the sternum (breastbone). Air passage Oesophagus Lungs Stomach Measuring the tube for a baby (neonate and infant). Measure from the baby s ear, to the tip of their nose and continue to measure down to the mid-point between the bottom of the sternum (breastbone) and the navel (belly button). Breastbone Belly-button

Appendix 1a How to confirm the correct position of naso-gastric feeding tubes in infants, children and adults (This information does not apply to neonates (pre-term to 28 days) Naso-gastric tube feeding is common practice and thousands of 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. Studies have shown that conventional methods to check the placement of nasogastric feeding tubes can be inaccurate. The National Patient Safety Agency (NPSA) has put together this information to advise staff which methods should and should not be used to check the position of naso-gastric feeding tubes. Note that this information does not replace clinical judgement. Local written policies may vary slightly as long as they do not fall below the standards set out in this document. Testing the position of the naso-gastric feeding tubes Methods that should be used: Measuring the ph of aspirate using ph indicator strips/paper Radiography Methods that should not be used: Auscultation of air insufflated through the feeding tube (whoosh test( Testing the acidity/alkalinity of aspirate using blue litmus paper Interpreting absence of respiratory distress as an indicator of correct positioning Monitoring bubbling at the end of the tube Observing the appearance of feeding tube aspirate What are the limitations of ph testing and radiography? One of the limitations with the ph testing method is that the stomach ph can be affected by, for example, medication and frequency of feeds. Additionally gaining aspirate from the feeding tube can be difficult particularly when using fine bore tubes. For post-operative patients where the tube has been positioned under direct vision, tube replacement or removal should only be done on the advice of the surgeon. The most accurate method for confirming correct tube placement is radiography. However, there have been multiple reports of x-rays being misinterpreted by physicians who are not trained in radiology. Minimising the number of x-rays is also important in order to avoid increased exposure to radiation, loss of feeding time and increased handling of seriously ill patients. Outside of the acute care setting, access to radiology is difficult, particularly if the patient requires transportation from the community. Radiography should, therefore, not be used routinely and local policies are recommended for particular groups of patients, for example, those on intensive care units and neonates. Fully radio-opaque tubes that have markers to enable accurate measurement, interpretation and documentation of their position should be used. The flowcharts attached to this document set out actions to take to: gain sufficient aspirate; what to do when ph is above 5.5 and when radiography should be considered. The table provides the rationale behind this advice. Prior to feeding each patient, a risk assessment needs to be carried out. This should balance the potential risks with the need to feed. Patients who are comatose or semi-comatose, have swallowing dysfunction or recurrent retching or vomiting, have a higher risk of placement error or migration of the tube, whereas patients on antacid medication are more likely to have ph levels of 6 and above. Actions to reduce risks and the rationale behind the actions should be documented prior to feeding. This information will support staff in making the correct clinical decisions. What ph paper/strips should I use? We recommend that ph indicator strips with 0.5 gradations or paper with a range of 0 to 6 or 1 to 11 should be used. It is important that the resulting colour change on any indicator or paper is easily distinguishable, particularly between the ph 5 and 6 range. When should I check the tube position? The tube position should be checked: Following initial insertion Before administering each feed Before giving medication (see BAPEN guidance at www.bapen.org.uk/drugs-enteral.htm) At least once daily during continuous feeds Following episodes of vomiting, retching or coughing (note that in the absence of coughing does not rule out misplacement or migration) Following evidence of tube displacement (for example, loose tape or visible tube appears longer) Ensure that all staff report misplaced feeding tube incidents through their local risk management systems. The NPSA will automatically receive this information through the National Reporting and Learning System (NRLS). This will enable both local and national monitoring of naso-gastric feeding tube misplacements and inform our understanding of the problem.

Appendix 2 COMMUNITY CHILDREN S NURSING TEAM CARE PLAN Checking Child s Naso-gastric Tube Position To be done by parents/carers who have undergone training by a qualified nurse and successfully completed the competency assessments for the procedure. Name of Child DOB URN Number Named Nurse Date Period of Review: Review Date: Date Aim of identified care need:... has feeds via a naso-gastric tube. To confirm correct position of tube safely in accordance with Family Nursing and Home Care s Policy Date Plan of Care Signature Nasogastric tube Type: Size:... External length of tube:... Child s usual ph levels:. Equipment for checking tube position: 20 or 50 ml syringe ph strip Where do you get Universal ph strips from? Universal ph strips are supplied by Pharmacy Locale, the information to order these will be provided by your child s Community Nurse What are Universal ph Strips? 100 individual strips with 3 coloured squares that change colour when reacting with stomach acid There is a colour code chart indicating the colour of each ph reaction from ph0 (acid) to ph6.0 (alkaline).

Why is it important to check your child s nasogastric tube position? It is important to check the position of your child s tube prior to giving anything via the feeding tube, or after a coughing fit or vomiting episode, to ensure feed goes directly to your child s stomach and not into their lungs. How to check your child s nasogastric tube position: Wash your hands before and after checking your child s nasogastric tube position. Explain to them what you are going to do. Check for signs of displacement and measure tube. Reposition or re-pass tube if required Remove the cap or spigot from the nasogastric tube Attach a 20 or 50 ml syringe to the end of the tube and aspirate (gently pull back plunger of syringe) 0.5ml 1 ml of stomach contents Take a ph strip and place a few drops of stomach content onto it. Match the colour change of the ph strip with the ph colour code to identify the ph of the stomach contents PH 1 ph5.5 indicates an acid reaction, which means the tube is in the stomach. Ensure ph level is within your child s usual levels Proceed to feed Remember to keep ph strips clean and dry in a sealed container. If you are unsure contact the Community Children s Nurse or contact the children s ward for advice. What to do if you a ph of 5.5 or above If your child has just had a feed or is on continuous feeds, the milk in the stomach can increase the ph of stomach contents. If your child is on medicines which reduce the acid in the stomach, such as: Ranitidine, Omeprazole, Gaviscon, Sodium Bicarbonate, you may get a higher ph of 5.5. Discuss this with your doctor/nurse to find out if this is normal for your child. For continuous feeds, stop the feed and test again in 15-30 minutes time. For bolus feeds, wait and test again in 15-30 minutes time. Do not commence feed if ph remains 6 or above. Contact your Community Children s Nurse or the children s ward for advice. If it is not possible to obtain fluid for checking ph: Check external length is correct If possible turn child on to side Try Aspirating again If no aspirate do not feed Advance (gently push) tube by 1-2 cm

Try aspirating again If aspirate obtained an ph is 5.5 or below/is within child s usual levels proceed to feed If no aspirate, do not feed, contact Community Children s Nurse or the children s ward for advice. Signature of Nurse... Date... Signature of Parent... Date... Please note signature of nurse and parent/carer indicated that the care has been negotiated

Appendix 2a COMMUNITY CHILDREN S NURSING TEAM CARE PLAN Name of Child DOB URN Number Named Nurse Date Period of Review: Review Date: Date Aim of identified care need:... has feeds via a naso-gastric tube. To confirm correct position of tube safely in accordance with Family Nursing and Home Care s Policy Date Plan of Care Signature Make of tube: Size: Length: fg cm Date changed (see NGT record chart for tube change) Usual ph levels: Introduce self to child and family Leave appropriate information leaflet Leave team contact details Ensure correct nursing documentation is available Procedure for confirmation of correct position of the tube (see policy) Ensure you have a record of child s usual ph level (to be determined by medical staff of higher than ph 5.5) Document external length of tube Aspirate using 20ml or 50ml syringe If aspirate obtained (0.5 1ml) test on ph strip If ph level is within child s normal limits proceed to feed If no aspirate

If possible turn child onto their side Wait 15 30 minutes Try aspirating again If still no aspirate advance tube by 1-2 cm If still no aspirate DO NOT FEED Call Community Children s Nurse or Robin Ward for advice Consider replacement tube and/or a check x-ray of the chest and abdomen to determine exact position of tube Ensure documentation of procedure is completed Signature of Nurse... Date... Signature of Parent... Date... Please note signature of nurse and parent/carer indicated that the care has been negotiated

Appendix 3 Name of Child DOB URN Number Named Nurse Date COMMUNITY CHILDREN S NURSING TEAM CARE PLAN To pass a naso-gastric tube To be done by parents/carers who have undergone training by a qualified nurse and successfully completed the competency assessment for the procedure Period of Review: Review Date: Date Aim of identified care need:... has feeds via a naso-gastric tube and may need tube replacement. To undertake the procedure safely in accordance with Family Nursing and Home Care s Policy Date Plan of Care Signature Make of tube: Size: Length: fg cm Date changed (see NGT record chart for tube change) Procedure for passing the tube (see the policy) Parents have a copy of the FNHC Procedure to pass a nasogastric tube Ensure all appropriate equipment is readily available Discuss and explain procedure to child Ensure child is in a comfortable position Wash hands Apply alcohol gel hand rub and allow to dry for 30 seconds Put on non-sterile gloves as appropriate Determine length of tube Note mark on tube or keep fingers on the point measured and document external length Ensure guide wire is in place as appropriate Lubricate tip of tube using a water based solution (lubricating jelly) according to manufacturer s guidelines

Insert tip of tube into nostril and slide backwards along the floor of the nose If there is an obstruction pull back tube, turn it slightly and advance again As the tube passes through the nose encourage the child to drink or swallow (if appropriate) Offer an infant a dummy if they usually have one If child/infant is unable to swallow just continue to advance tube until you have reached the point at which the tube was measured Secure tube with recommended tape or one which will not irritate the child s skin Dispose of equipment Remove the guide wire if used and store for re-use Wash hands in accordance with FNHC s hand hygiene policy Document new tube on NGT record chart for tube change If child starts to cough or they have a colour change, remove the tube stop procedure contact Community Children s Nurse or Robin Ward for advice DIAL 999 If child stops breathing If child s usual skin colour changes from their usual colour i.e. becomes blue/pale If the child s usual respiratory rate is increased or decreased If child becomes agitated and becomes hot and sweaty If you have any concerns or difficulty re-passing the tube Signature of Nurse... Date... Signature of Parent... Date... Please note signature of nurse and parent/carer indicated that the care has been negotiated

Appendix 3a Name of Child DOB URN Number Named Nurse Date COMMUNITY CHILDREN S NURSING TEAM CARE PLAN To pass a naso-gastric tube To be done by parents/carers who have undergone training by a qualified nurse and successfully completed the competency assessment for the procedure Period of Review: Review Date: Date Aim of identified care need:... has feeds via a naso-gastric tube and may need tube replacement. To undertake the procedure safely in accordance with Family Nursing and Home Care s Policy Date Plan of Care Signature Make of tube: Size: Length: fg cm Date changed (see NGT record chart for tube change) Usual ph levels: Introduce self to child and family Leave appropriate information leaflet Leave team contact details Ensure correct nursing documentation is available Procedure for passing the tube (see the policy) Ensure all appropriate equipment is readily available Discuss and explain procedure to child and family Ensure child is in a comfortable position Wash hands in accordance with FNHC s Hand Hygiene Policy Apply alcohol gel hand rub and allow to dry for 30 seconds Put on non-sterile gloves as appropriate

Determine length of tube Note mark on tube or keep fingers on the point measured and document external length Ensure guide wire is in place as appropriate Lubricate tip of tube using a water based solution (lubricating jelly) according to manufacturer s guidelines Insert tip of tube into nostril and slide backwards along the floor of the nose If there is an obstruction pull back tube, turn it slightly and advance again As the tube passes through the nose encourage the child to drink or swallow (if appropriate) Offer an infant a dummy if they usually have one If child/infant is unable to swallow just continue to advance tube until you have reached the point at which the tube was measured Secure tube with recommended tape or one which will not irritate the child s skin Dispose of equipment in accordance with FNHC s Waste Policy Wash hands in accordance with FNHC s hand hygiene policy Ensure documentation of the procedure is completed If child starts to cough or they have a colour change, remove the tube stop procedure contact Community Children s Nurse or Robin Ward for advice DIAL 999 If child stops breathing If child s usual skin colour changes from their usual colour i.e. becomes blue/pale If the child s usual respiratory rate is increased or decreased If child becomes agitated and becomes hot and sweaty If you have any concerns or difficulty re-passing the tube Signature of Nurse... Date... Signature of Parent... Date... Please note signature of nurse and parent/carer indicated that the care has been negotiated

Appendix 4 Community Children s Nursing Team RECORD SHEET FOR NASOGASTRIC FEEDING TUBE CHANGES Date Time Size of Tube Type of Tube Passed length (cm) ph Level on passing new tube Signature

Appendix 5 FNHC Competencies for Passing a Nasogastric Feeding Tube (NGT) (For use by Registered Health Care Practitioners, Health Care Practitioners in Training, Assistant Health Care Practitioners, Parents and Carers, Mature Patients) Name: Attend theory session Self Assessment Theory Signed Competent Practical Assessment Date/Signature Practical Assessment Date/Signature Practical Assessment Date/Signature Practical Assessment Date/Signature Practical Assessment Competent Date/Signature Discuss why & when a child may require a NGT Demonstrate knowledge of anatomy & physiology of where NGT should sit Discuss benefits and problems & risks of having a NGT Discuss the equipment needed for the procedure Demonstrate procedure for passing NG tube Demonstrate testing placement of tube Discuss correct procedure if universal ph strips reading is not within recommended limits

Demonstrate knowledge of procedure to follow for blocked tube Discuss how to proceed in an emergency: when to dial 999 when to contact community nurse/robin Ward or when to alert parent/carer Demonstrate knowledge of when & who to contact for advice Discuss safe disposal of equipment, storage of guide wire if appropriate Be aware of Hand Hygiene in line with FNHC s Policy Discuss correct procedure for documenting the procedure. Person responsible for training Registered Nurse who has undergone appropriate training

Appendix 6 Competencies for naso-gastric tube feeding Name:... Attend Theory Session Self Assessment Theory Signed Competent Practical Assessment Date/Signature Practical Assessment Date/Signature Practical Assessment Date/Signature Practical Assessment Date/Signature Practical Assessment Competent Date/Signature Demonstrate awareness of complications of oral, nasogastric feeding as appropriate Demonstrate how to test correct position of naso-gastric feeding tube Demonstrate knowledge of how to proceed if no aspirate obtained Demonstrate how to re-pass/ reinsert: 1. Nasogastric tube if appropriate or who to call for assistance to re-pass tube Demonstrate how to flush naso-gastric tube pre and post feed

Demonstrate how to troubleshoot a blocked nasogastric tube Discuss how to proceed in an emergency: 1. When to dial 999 2. When to contact community nurse/robin Ward 3. When to alert parent/carer Discuss safe disposal of equipment in line with FNHC Waste policy Be aware of hand hygiene in line with FNHC s policy Discuss correct procedure for documenting the procdure as appropriate. Person(s) responsible for training: Registered nurse who has undergone appropriate training