Enteral Tubes Enteral Feeding Management Best Practice Enteral Tubes Enteral Feeding Management Best Practice Metropolitan Working Party

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					Enteral Tubes: Enteral Feeding
  Management Best Practice

Metropolitan Working Party: 2007
Endorsed by Chief Nursing Officer of
Western Australia
Power point options

• Section 1- Essential changes to enteral tube
  management
• Section 2 – Overview of Enteral Tubes: Enteral Feeding
  Nursing Practice Standard (NPS)
Section 1:

    Essential changes to enteral tube
               management
Critical incident reports

• 2005 a sentinel event in a WA tertiary hospital
• UK findings- 11 deaths over a two year period, due to
  misplaced nasogastric tubes (NGT) 1
• Areas of concern

       • Reliability of methods to assess tube placement
       • Validity of litmus paper test
       • Reliability of ‘whoosh test’
Challenge to nursing care

• Practice to reflect current best practice
  recommendations


• To standardise nursing practice and documentation


• To optimise patient outcomes through risk reduction
WA response

• Metropolitan collaboration (FH, PMH, RPH, SCGH, SGOJ)
• Investigation of existing practices
• Literature review and recommendations
• Confirmation of key areas of change
• Development of nursing practice standard metropolitan
  wide
• Education and audit
Key areas of change

• Do NOT carry out auscultation or ‘whoosh’ test to
  assess NGT position as unreliable
• Do NOT use litmus paper as false results (the lungs can
  have an acidic content to give positive litmus reading 1)
• Criteria for NGT selection
Key areas of change

Auscultation and ‘Whoosh’ test replaced by:


• Confirmation of NGT placement by X-ray1 (radiation
  exposure)
  OR
• An aspirate result of pH <5.5 with introduction of pH
  specific indicator strips (will exclude pulmonary
  placement 1,2)
 Criteria for NGT selection

Tubes recommended to include the following features:
• Be radiopaque (X-ray detection)
• Have multiple ports (air port - to aid aspiration)
• Display clear centimetre line markers present (tube placement)
• Have caps attached (Close ports when they are not in use)
• Be available in a variety of materials which cater for different
  clinical situations – medications, allergies
• Be available in a number of lengths and sizes   3
Best practice


       NEVER place anything into a NGT
                    unless
  the tip is confirmed as being in the stomach
Caution

• Nurses are not permitted to insert a NGT into patients
  with possible or confirmed facial/skull fractures (risk of
  insertion into cranium via fracture sites 4,5)


• No more than 3 attempts at NGT insertion are to be
  made by one Nurse 6

   – Liaise with Medical staff
Conclusion

• Never place anything into the NGT unless placement is
  confirmed
• Confirm NGT placement by X-ray OR an aspirate result
  of pH <5.5 using pH specific indicator strips
• Recommended criteria for NGT selection
• Refer to Enteral Tubes: Enteral Feeding Nursing
  Practice Standard for detailed information
Section 2 :

Overview of Enteral Tubes: Enteral Feeding
     Nursing Practice Standard (NPS)
Nasogastric tube (NGT) measurement
Measure the selected tube from:
• Nose tip to ear lobe
• Ear lobe to xiphoid process of
  sternum
• Note the required length by
  attaching a piece of tape to
  the tube


NB: Silastic tubes must be
  measured from the weight and
  not the tube tip.
NGT insertion documentation to
include:
• Date & time             • Additional comments
• Reason for insertion    • Any complications
• Type of tube            • Method of placement
                            confirmation
• Size of tube
                          • Signature: name &
• Length of tube
                            designate of Nurse
• Nostril tube inserted     inserting tube
• Number of attempts
  required
Assessing NGT Placement

1. Aspirate NGT using pH indicator strips- non bleeding:
   blue litmus paper is not sensitive enough to distinguish
   between bronchial and gastric secretions 1 (pH of 5.5
   or below will exclude pulmonary placement 1,2)
2. Assess tube length- compare to documented tube
   length to determine migration
3. X-ray: shows radio opaque placement of NGT
   (Limitations: exposure to radiation)
Frequency of checking placement

• Following insertion    • Alteration of external
                           length of tube
• Prior to each bolus
  feeding                • Post vomiting
• Following a break in   • Complaining of discomfort
  continuous feeding       or feed reflux in
                           throat/mouth
• Prior to medication
  administration         • Sudden signs of respiratory
                           distress
• After oropharyngeal
  suction                • Interdepartmental transfer
• Coughing fit
 Aspirate pH above 5.5

• Check external tube length
• Instigate Multidisciplinary Management Team Risk
  Assessment
• Wait 1 hour post last feed (dilution of gastric acid by the
  enteral feed causes higher pH1)
• Check medications (some can increase level of gastric
  contents – H2 antagonists, proton pump inhibitors &
  antacids 7)
  No gastric aspirate obtained
• If appropriate, X-ray to confirm placement
• Clear NGT: insufflate 10-20mL air into NGT; aspirate; test
  pH
• Reposition pt onto side  wait 15-30 mins (allows tip to
  enter gastric pool), repeat aspiration & test pH
• Reposition NGT: advance NGT 10-20cm (inserted too far
  it may be in duodenum7); aspirate & test pH.
   - Remember to document new external length
Gastric residual volume
                Volume >300mL
• Return 300mL of aspirate
• Continue feeding
• At next aspirate; repeat above 2 steps if volume
  is >300mL & notify RMO
• Review hypoglycaemic medications (insulin) if
  appropriate
• Position head up 30-45 degrees
  (unless contraindicated)
Gastric residual volume (cont’d)

                Volume <300mL
• Return aspirate
• Continue feeding
• Position patient head up 30-45 degrees
  (unless contraindicated)
Medication administration

Consult with Pharmacist to determine:
• If liquid preparation available
• Drug compatibilities if administering multiple
  medications at the same prescribed time
• Timing of medication administration as some interact
  with enteral formula (phenytoin, warfarin, ciprofloxin 8)
Medication administration

• All medications must be administered via gravity flow –
  do not use the plunger to force medication down the
  NGT
• Do NOT add medications to feeding formula
  (Exception: certain electrolyte solutions &
  multivitamins)
• Flush NGT with 20 -30mL room temperature tap water
  pre and post medication administration (unless immuno-
  compromised use sterile water and syringe)
Known drug incompatibility


• Liaise with Pharmacist
• Administer separately using dedicated syringe for each
  specific medication
• Flush between each medication administered
Removal of NGT

• Liaise with Medical staff to confirm removal
• Disconnect drainage bag or feeding device
• Insufflate 10-20mL (adult), 1-5mL (child) of air into NGT
• Ask pt to take a deep breath (where appropriate)
• Coil the tube around gloved hand while pulling slowly
  and evenly over 3-6 seconds
• Document as per NPS
Conclusion

• Never place anything into the NGT unless placement is
  confirmed
• Confirm NGT placement by X-ray OR an aspirate result
  of pH <5.5 using pH specific indicator strips
• Recommended criteria for NGT selection
• Refer to Enteral Tubes: Enteral Feeding Nursing
  Practice Standard for detailed information
 References
1.   National Patient Safety Agency Alert. Reducing the harm caused by misplaced
     nasogastric feeding tubes. NHS 21 February, 2005.
2.   Khair J. Guidelines for testing the placing of nasogastric tubes. Nursing Time 2005;
     101(20): 26-27.
3.   Metcalf S. Nasogastric Tube Clinical Audit. 12th July 2006. Cross Hospital Review of
     Practice. Royal Perth Hospital Report unpublished.
4.   Methany NA, Meert KL. Monitoring feeding tube placement Nutrition in Clinical
     Practice 2004; 19: 487- 595.
5.   Genu PR et al. Inadvertent intracranial placement of a nasogastric tube in a patient
     with severe craniofacial trauma: A case report. Journal of Oral Maxillofacial Surgery
     2004; 62:1435-1438.
6.   Best C. Caring for the patient with a nasogastric tube. Nursing Standard 2005;
     2(3):59-65.
7.   Holmes J et al: Guidelines for the management of enteral feeding in adults, Clinical
     Resource Efficiency Team (CREST); April 2004
8.   Joanna Briggs Acute Care Manual. Administration of enteral medications. May 2005.