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Nasogastric Tube and Medicine Administration for Paediatrics

Community Children’s Nurses Team of 13

Document Control

Title

Nasogastric Tube and Medicine Administration for Paediatrics Standard Operating Procedure

Author

Author’s job title Community Children’s Nurses (CCN) Team Leader

Directorate Planned Care and Surgery Sub-directorate Women & Children Mental Health Interface

Department Team/Specialty Acute Paediatrics Paediatrics & Community Children’s Nursing

Version Date

Issued Status Comment / Changes / Approval

0.1 2011 Draft Initial version for consultation

0.1 Aug 2011

Draft Original initial draft document from NHS Devon, original Author Ruth Davies, Professional Lead Community Children’s Nurses.

0.2 Nov 2011

Final Draft

Final Draft to be presented to Quality and Safety Group on 10th November.

1.0 May 2012

Final Approved by Quality and Safety Group on 10th May. changes following NPSA guidance March 2012.

1.1 Oct 2012

Revision Corporate Governance converted document into Trust template. NHS Devon-Naso-gastric tube placement SOP and Administration of Medications via Nasogastric Tube SOP documents modified for NDHT Paediatric Dept use.

2.0 Jun 2013

Final Approved at Drug and Therapeutics Committee on 20th June. Corporate amends to document control report and formatting.

2.1 May 2017

Revised Section 3 –(Scope) Amendments to applicable practitioners who can carry out NG Tube insertion and contra-indications added Section 5- minor amendment to NG Tube types short/long term tubes Section 7.13- Additional solutions to gaining aspirate and additional links to NPSA Decision Tree Section 10- minor amendment to incident management reporting Section 15 (Associated documentation)- links to NPSA NHS resources added



2.2 Sept 2017

Revision Approved at Nutrition Steering Group, with further amendments necessary for Enteral Medicine Administration based on advice & comments indicated by Paediatric Pharmacist. Document to also be ratified through Drug and Therapeutics Committee Section 11.6 Seeking pharmacy guidance for tablet/capsule administration Section 11.8 Documented verbal Consent obtained from parent/carer for the off licensed use of medication Section 12.7 Reference to drug chart for dosage Section 12.8 Reference to Enteral feeding guidelines and NEWT guidelines for administration via enteral routes 12.13 Removal of “adult” flush volumes as this is a SOP for children only 12.16 New section added to cover preparation of medicines and seeking pharmacy advice; three previous sections removed

2.3 Nov 2017

Revision Approved by Drug and Theraputics Committee on 16/11/2017 with minor amendments to: Section 5.1 Clarification on when to change short Term NG Tube, amended from following manufacturer’s guidance to recording and documenting in patient records weekly changes as required for short-term NG Tubes.

3.0 Nov 2017

Final Formatted SOP to new NDDH Template as per guidance from Corporate Governance

Main Contact

Community Children’s Nurse Team Leader Ladywell Unit Level 0 North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB

Tel: Direct Dial – Tel: Internal – Email:

Lead Director

Sharon Hinsley Document Class

Standard Operating Procedure

Target Audience

All staff working with children and young adults 0-18years

Distribution List All Paediatric Department Leads for dissemination Senior Management

Distribution Method Trust’s internal website Copy to Paediatric G-Drive

Superseded Documents Nasogastric Tube and Medicine Administration for Paediatrics Standard Operating Procedure v2.3

Issue Date November 2017

Review Date November 2020

Review Cycle Three years

Consulted with the following stakeholders: (list all)

NGT NPSA Alert Group

Dietetics Department

Head of Learning & Development

Contact responsible for implementation and monitoring compliance:

Senior Nurse Paediatrics Paediatric Ward Managers CCN Team Manager



Senior Nurse Paediatrics

NPSA Alert Group

Dietetics Dept

Paediatric Depts

All users of this document

Education/ training will be provided by:

Workforce Development Department E-learning Paediatric Staff competent to teach procedure in paediatric clinical settings

Approval and Review Process

Nutrition Steering Group

Drugs and Therapeutics Committee

Local Archive Reference G:\Paediatric Resource Local Path

Enteral Feeding documents folder Filename

Nasogastric Tube Paediatrics SOP v2.4 24-11-2017

Policy categories for Trust’s internal website (Bob) Standard Operating Procedure, nutrition

Tags for Trust’s internal website (Bob)

NGT, Feeding, Enteral Feeding, Paediatric, SOP, Children and Young People



CONTENTS

Document Control ............................................................................................................... 1

1. Background .................................................................................................................. 5

2. Purpose ........................................................................................................................ 5

3. Scope ............................................................................................................................ 5

4. Location ........................................................................................................................ 6

5. Equipment .................................................................................................................... 6

Short-term tubes ............................................................................................................ 6

Long-term tubes ............................................................................................................ 6

6. Procedure ..................................................................................................................... 6

7. Checking the Position of a Nasogastric Tube............................................................ 7

8. Care of a nasogastric tube .......................................................................................... 9

9. Unblocking a Nasogastric tube ................................................................................. 10

10. Datix Incident management Reporting ..................................................................... 10

11. Prescribing of medication for the enteral route ....................................................... 10

12. Procedure for administration of drugs via nasogastric feeding tube: ................... 11

13. Additional Information ............................................................................................... 12

14. References ................................................................................................................. 12

15. Associated Documentation ....................................................................................... 13



1. Background

The Trust provides care for children who may require nutritional support or medicines via a nasogastric (NG) tube. All children who require nutritional support via a nasogastric tube will have been assessed by the Multi-Disciplinary Team and in conjunction with the parents.

Care and management of NG tubes may be undertaken by a registered practitioner or a non-registered practitioner who has been delegated the task and have achieved the required competencies in all aspects of the care. Non registered healthcare staff will not insert a nasogastric tube.

2. Purpose

The Standard Operating Procedure (SOP) has been written to:

Identify the procedure for the assessment and delivery of basic NG Tube care within a ward/community setting

Improve personal care for the patient and reduce the risks associated with poor NG Tube Nursing care

3. Scope

This Standard Operating Procedure (SOP) relates to the following staff groups who may be involved in the assessment and delivery of NG Tube care on the wards and within the Community Setting, only staff trained and assessed in this procedure should undertake insertion & management of NG feeding tubes.

1. Registered Practitioners

2. Practitioners and medical staff in training, supervised by registered practitioners under direct supervision.

3. Practitioners are responsible for ensuring that their skills, knowledge and competencies are up to date, and maintained.

Please note: Nasogastric tubes may be contra-indicated if the child, young person has any of the following:

Cranio-facial and upper airway deformities

Maxillo-facial trauma

Recent oral/nasal or oesophageal surgery

Severe gastro/oesophageal reflux

Basal skull fracture

Low platelets/clotting disorders



4. Location

This Standard Operating Procedure ~ Nasogastric Tube and medicine administration for Paediatrics acute and Community Nursing care can be implemented in all clinical areas where competent staff are available to undertake this role.

Staff undertaking this procedure must be able to demonstrate continued competence as per the organisations policy on assessing and maintaining competence.

5. Equipment

Only purple enteral syringes compatible for use with enteral feeding equipment should be used. Intravenous syringes should never be used to access enteral feeding equipment.

Short-term tubes

Short-term radio opaque tubes are made of polyvinylchloride (PVC) and can remain in place for between 3-10 days; record/document in patient medical record the date when NG Tube needs changing. If a tube is accidentally removed prematurely a new tube should be used. “Single use” is usually recommended.

Long-term tubes

Long-term radio opaque tubes 6F or 8F 56cm (Paediatric) or 92 cm (adult) polyurethane tubes should be used; these have a wire to aid passing the tube.

The wire is removed once the tube has been passed but should be kept in a safe place in case the tube has to be re-passed. The manufacturer will provide guidance regarding the length of time the tube can remain in place, cleaning and storage of the tube.

For the purpose of this document child will mean child and young person. Parent will mean parent/carer

6. Procedure

This task should only be undertaken by registered practitioners and parents/carers who have been assessed as being competent.

Wash your hands before and after the procedure.

Obtain and record consent for the procedure.

Collect equipment (nasogastric tube, enteral use 50mls syringe, pH indicator paper or strip, water to flush, tape to secure, glass of water/juice if appropriate).

Explain the procedure to the child and or parent and gain informed consent. Explain to the child/young person and parent/s that you are going to pass the nasogastric tube. If possible (depending on age/ cognition) agree with the patient a signal (i.e. hand signal) that can be used should they want the nurse to stop.

Babies can be wrapped in a blanket or towel to help keep them secure and laid flat on their back (unless another adult is available to assist holding the child); older children may prefer to sit up with their head tilted slightly forward.



Determine length of tube to be inserted by measuring the tip of the tube from nose to ear and then measure from ear to stomach note the mark on the tube or keep your fingers on the point measured.

Ensure end cap is firmly in place on the end of tube, to prevent leakage of gastric contents.

Select a nostril that is clear; where possible alternate the nostril being used.

Lubricate tip of the tube using water and/or follow manufacturer’s guidelines.

Insert tip of tube into nostril and slide backwards along the floor of the nose

If there is any obstruction, pull tube back and turn it slightly and advance again.

If obstruction is felt again try the other nostril.

As the tube passes to the back of the nose, advise child/young person to take sips of water (if appropriate) to help the tube go down or in the case of a baby offer them a dummy if they have one.

If at any time the child/young person starts coughing or their colour changes stop the procedure immediately and remove the tube.

Advance the tube until you reach the point where the tube was measured.

Once the tube is in the correct position, if using a long-term tube remove the guide wire, following manufacturers guidelines, and close the port after flush the tube with recommended amount of tap water or sterile water if immunocompromised or under 1 year of age.

DO NOT introduce anything down the tube before gastric placement has been confirmed

DO NOT flush tube or lubricate guidewires / stylets before gastric placement is confirmed

Secure the tube in position using a barrier product such as hydrocolloid dressings to protect the skin and secure the tube using 3m Blenderm tape at the nose, which is clear and will enable repeat reading of markings, keep the skin clean and dry; clean with soap and water daily.

The position of the tube must be confirmed after passing it and prior to using it for administering any feed or medications.

Record the following details in the notes (using nasogastric tube insertion record sticker) – inserted by, make/size of tube, nostril used, internal length (cm) and aspirate obtained yes/no, ph of aspirate; also record correct position confirmed by and method of confirmation.

Continue to document the pH reading and the centimetre reading of the tube on nasogastric tube position confirmation chart (kept at bed end) before each feed/medication/flush.

7. Checking the Position of a Nasogastric Tube

The responsibility for ensuring correct tube placement lies with the registered practitioner, parent or carer caring for that child and he/she must be satisfied that the tube is correctly placed before commencing or continuing with feeding or medicine administration via the nasogastric tube.

The only method (described below) to be used to check the position of the nasogastric tube is using pH paper.



The following methods are not reliable for confirming tube placement and must not be used:

Auscultation of air insufflate through the tube (‘whoosh’ test).

Testing pH using blue litmus paper.

Monitoring bubbling at the end of the tube immersed in liquid.

Observation of feeding tube aspirate.

Interpreting absence of respiratory distress as an indicator of correct positioning.

Aspirated fluid is tested using only pH strips or paper that must be CE marked and manufactured specifically for the purpose of checking the pH of human gastric aspirate.

If no aspirate is obtained or the position of the tube in the stomach is

not confirmed then do not feed via the tube.

If there is any doubt about the pH value (especially in the 5-6 range) then feeds and /or medicines should not be administered via the tube. Refer immediately to the independent prescriber for the patient concerned if medicines cannot be administered.

A pH value of less than 5.5 excludes tube pulmonary placement and it is safe to commence administration of feed/medicines via the tube.

A pH value greater than 5.5 indicates possible placement in the intestine or tracheobronchial tree. Do not administer anything via the tube.

The position of the nasogastric tube must be checked:-

On initial insertion. Before administering each feed or water flush.

Before giving medication if not during a feed. (When children are receiving continuous feed it may be impossible to obtain an aspirate within the pH range. In this circumstance, so long as tube placement has been confirmed at the start of feeding and that there are no other reasons to suspect tube displacement, it is acceptable to check that the external length of tube has not changed before cautiously administering medicines via the nasogastric tube.)

If there are any new or unexplained respiratory symptoms or if oxygen saturations decrease.

Following episodes of vomiting, retching, coughing or other potential causes of tube displacement.

If there is evidence of possible tube displacement (e.g. loose tape or external tubing appears longer).

At least every 24 hours.

Wash your hands before and after the procedure

Explain to the child that you are going to check their tube

Remove the end cap from the tube

Attach a 50ml syringe to the end of the tube unless contraindicated by manufacturer’s instructions



Aspirate gastric contents from the child/young person’s stomach by gently pulling back on the plunger until a small amount of fluid appears in the syringe

Detach the syringe from the tube remembering to replace the end cap of the tube

Test the pH of the fluid using pH indicator paper or strip. The indicator paper or strip should change colour to read a pH of 5.5 or less

If it is difficult to obtain aspirate any or all of the following should be attempted:-

Check the external markings of the tube against recorded length. Changes in external markings will indicate possible migration to the oesophagus or duodenum. It is still possible for migration to have occurred without external change.

Attempt to push the tube’s end away from the stomach wall by inserting 3-5ml of air via a 50ml enteral syringe, down the nasogastric tube.

Lie the child/young person on their left side.

Ask the child/young person to take a small drink, if allowed.

Try advancing or pulling the tube back 1-2cm and try again.

If on supplementary feeding try giving a coloured drink and aspirate back, if aspirate is the expected colour it indicates stomach placement

If the patient is nil by mouth, try mouth care as this may encourage the acidity in the stomach

If unsure if the tube is correctly positioned, remove and re-pass the tube or seek further advice from community children’s nurses or hospital professionals.

Advice may be sought from senior colleagues or medical staff, who may consider an x-ray. All troubleshooting efforts as per NPSA Decision tree for nasogastric tube placement checks in children and infants npsa.nhs.uk/resources must be documented on the CXR

request form, so it is clear what interventions have taken place prior to the request for x -ray.

Document on the child’s enteral feeding records

8. Care of a nasogastric tube

Check tube position every time it is used and at least every 24 hours.

Flush with between 5 and 20mls of drinking water for children prior to and after feed or medication.

Check skin around insertion site and around taped site.

Change tube as directed by manufacturer.

The tube should be positioned either on the front of the nose and then fixed on the forehead or to the side of the nose and fixed to the cheek.

A hydrocolloid dressing should be placed under the tube at the nostril and secured with 3M Blenderm tape in order to prevent skin breakdown.

Once the tube is securely fixed mark the position by winding a small strip of tape around the point of entry into the nostril. Also measure the length of external tubing from the tip of the nose and document this in the patient record.

Only use the nasogastric tube to administer prescribed feeds or medication.

http://www.nrls.npsa.nhs.uk/resources/?EntryId45=129640



To avoid tube blockages wherever possible use liquid formulations of medicines, or

those explicitly for enteral tube use. Where this is not possible, discuss with ward pharmacist or pharmacy whether tablets can be crushed or the most suitable alternative formulations including PR or transdermal routes. Where tablets are used they should be

crushed to a fine powder and administered as prescribed with adequate water flushes before and after administration.

9. Unblocking a Nasogastric tube

To unblock a nasogastric tube any or all of the following can be attempted:

Using a 20 ml syringe push 1 – 5 mls air into the tube.

Using a 20 ml syringe gently push 1 – 5 mls of warm water or soda water (no other liquids will be used) using a push/pull technique to create turbulence.

If this is not successful then the tube should be removed and a new tube should be inserted.

10. Datix Incident management Reporting

The line manager/nurse in charge must be informed of incident or error relating to the insertion, care of or use of a nasogastric tube. The parents will also be fully informed.

Any error or incident must be reported in accordance with NDHT Incident Management and Investigation Policy

If any equipment used is faulty or inappropriate, the equipment must be removed and retained in addition to the completion of an incident form.

11. Prescribing of medication for the enteral route

Northern Devon Healthcare NHS Trust (NDHT) care for individuals (Children and young People) who may require medication to be administered via an enteral route; all individuals who require the administration of medication via the enteral route will have been assessed by the multi disciplinary team and in conjunction with the patient/carers. This should be reviewed on an agreed basis with regard to the medication required, the route of administration and the alternatives if appropriate.

The medication should be administered by a registered practitioner who has achieved the required competencies in all aspects of the care. Training will be provided by the registered practitioner to parents/carers & non-registered practitioners to facilitate care.

All Medications should be administered as outlined in the NDHT Medicines Policy, the NDHT Enteral Feeding Policy and other related literature available on BoB (please see links below)

Medicines-Policy-V1-0-26May15

Enteral Feeding Policy

http://ndht.ndevon.swest.nhs.uk/policies/?p=6259


http://www.northdevonhealth.nhs.uk/wp-content/uploads/2012/04/Medicines-Policy-V1-0-26May15-BOB-Version.pdf




The prescribed medication will be required to meet the clinical need of the individual and is not available in another formulation which is acceptable to the patient and therefore has to be administered via the enteral route.

The prescribing of medication for the enteral route will be in accordance with the NDHT Medicines Policy, Enteral Feeding Standard Operating Procedures and associated policies/protocol and in line with the local joint formulary choices.

The prescriber will complete NDHT Prescription and Medication Administration Documentation Record.

The prescription must stipulate the name of the medication, dose, strength, route of administration and have a review date.

The formulation of the medication will be considered and a liquid formulation is preferable.

If tablets/capsules are the only available formulation, a pharmacist should be consulted as per 11.7

A pharmacist must be consulted to discuss compatibility of medications prescribed for administration via enteral routes.

Patient/Parent/Carer must give consent to the off licensed use of medication – verbal consent acceptable, should be noted in patient’s notes

12. Procedure for administration of drugs via nasogastric feeding tube:

Staff administering medication must have knowledge of the medication being given appropriates to their role and responsibility.

All equipment required to undertake the procedure must be available to the person administering the medication. The equipment must be recommended for the purpose of enteral medication administration.

If using equipment staff must have been assessed as competent in using the equipment as per NDHT equipment competencies policies.

Staff must check against the administration medication record that the medication has not been administered within the agreed time scale.

Ensure the individual is ready to receive the medication.

Staff must check the identity of the individual to whom the medication is being administered. This may be achieved by verbal response, asking the next of kin.

Staff must check the dose needed against drug chart, not packaging as the recommendation from manufacturer could be different from what has been prescribed.

The instructions to administer should be based on advice from written literatures such as the’ drug administration via enteral feeding tubes or the NEWT guidelines’. Information can be obtained from pharmacy

Staff must check expiry date of medication.

Staff must prepare the medication in accordance with the instructions e.g. Dissolve in water.




Staff must not prepare medication in advance of the administration episode.

The position of the enteral tube must be confirmed by a gastric aspirate of pH less than 5 prior to the administration of any medication.

The enteral tube must be flushed with 5–10 mls of cool boiled water prior to administering any medication, between each separate medication and following the final medication administered. The volume of water flush may need to be modified for fluid limited patients.

If more than one medication is to be administered, each one should be prepared and given separately using an enteral syringe and the tube should be flushed with 5-10mls water between each medication. They should not be added to the feed.

Always record the amount of water administered.

Pharmacy should be contacted for any advice to prepare the medications

Clean or dispose of any equipment used in the administration process as per local protocol.

All medicine administration documentation should be recorded as per NDHT medicines policy.

Administration errors/incidents should be reported and actioned as per NDHT medicines policy.

13. Additional Information

If you are unclear about the appropriate use/administration of any medication by the enteral route there are sources for additional information listed below:

Medical practitioner who may include Out of Hours Doctor or Consultant.

The patients GP or prescriber.

Dispensing Pharmacist.

Prescribing Advisor.

Medicines Information services: North Devon District Hospital – 01271 322393.

British National Formulary and British national Formulary for Children.

Medicines Info Services (Bristol) 0117 3422867.

Electronic Medicines Compendium www.medicines .org.uk/emc

White R and Bradnam V, (2007) Handbook of Drug Administration via enteral Feeding Tubes, Pharmaceutical Press, Cambridge.

14. References

NHS Quality Improvement Scotland (September 2007). - Caring for children and young people in the community receiving enteral tube feeding. Glasgow: NHS Quality Improvement.

Dougherty L, & Lister S Eds (2008), The Royal Marsden Manual of Clinical Nursing Procedures, 7th Edition, London, Blackwell Science.



Trigg E & Mohammed T, (2010) Practices in children’s nursing: guidelines for hospital and community. 2nd Edition Edinburgh: Churchill Livingstone.

National Patient Safety Agency (2011) Reducing the harm caused by misplaced nasogastric tubes in adults, children and infants. London: NPSA

MHRA (2004) Medical Device Alert MDA/2004/026 ‘Enteral feeding tubes nasogastric)’ Medicines and Healthcare products Regulatory Agency.

15. Associated Documentation

15.1. Northern Devon Healthcare NHS Trust Policies for :

Clinical Record Keeping Policy

Consent Policy

Enteral Feeding Policy

Incident Management and Investigation Policy.

Infection Prevention and Control operational Policy

Medicines Policy

Naso/orogastric tube management guidelines for the newborn (up to 28 days old)

Waste Management Procedure








