Policy and Procedure for Insertion of Nasogastric Feeding Tubes
This operational guideline is used for the assessment of alterations in gastrointestinal status and there is a clinical indication for the use of a nasogastric feeding tube.
Purpose
To administer oral medications via a nasogastric feeding tube when there is an alteration in gastrointestinal status related to: toxicity of radiation/chemotherapy preparative regimen, graft versus host disease, infection, veno-occlusive disease, and pre-existing disease/condition.
Knowledge Base
A nasogastric tube, inserted into the stomach through the nose, can be used to administer medications. It requires careful monitoring. The tube can become dislodged and slip into the airway. It is necessary to check for placement before instilling any fluid into the tube.
Target Audience
This policy is intended for anyone who is providing care for blood and marrow transplant patients.
Process
1. Outcome Criteria: Patient will maintain adequate or improved gastrointestinal status.
2. Process Criteria: Assessment for alterations or abnormalities in any of the following:
a) Abdominal evaluation
· Appearance (distended, ascites).
· Bowel sounds (decreased, absent)
· Palpation (firm, rigid)
· Tenderness (RUQ, rebound)
b) Stool pattern and description (watery, green, bloody, odorous, frequent)
c) Nausea/vomiting (mucus, bloody, frequent)
d) Abdominal girth (increased)
e) Pain (Cramping, tenderness)
f) Fluid status (weight increased, edema, mismatched intake & output)
g) Hydration status (dry mucous membranes, decreased urine output, eyes sunken)
h) Color (jaundice)
i) Vital signs (tachycardia, hypotensive)
j) Refer to BMT unit nursing standard of care for pain.
3. Interventions
a). Nurse notifies appropriate practitioner (NP, PA, fellow, Hospitalist, Attending,)
b). Nurse implements preventative, supportive and diagnostic interventions in a timely
manner per physician order
· Monitors and records accurate intake and output
· Implements diet and fluid restrictions
· Administers medications (diuretics, immunosuppressive agents, antimicrobials narcotics)
· Administers fluids and blood products
· Documents stool and nausea/emesis pattern and characteristics
· Obtains cultures, lab tests
· Facilitates radiological evaluation (AXR, abdominal CT, ultrasound)
· Facilitates surgical evaluation (endoscopy, biopsy)
· Education for patient/family/caregivers
- Nurse discusses rationale for treatments and plan of care related to changes in
patient’s status
- Nurse explains purpose and possible side effects of medications and fluid
administration
- Nurse explains potential complications related to altered gastrointestinal status
(transfer to the PICU)
c) Evaluation
* Nurse documents patient’s responses to gastrointestinal interventions
- Abdominal appearance
- Bowel sounds
- Palpations
- Tenderness
- Stool pattern and description
- Abdominal girth
- Pain
- Fluid status
- Nausea/vomiting
- Hydration status
- Color
- Vital signs
* Nurse documents patient/family/caregiver’s response to gastrointestinal interventions
- Emotional and behavioral response
- Verbal understanding of interventions
- Involvement in ongoing plan of care
* Nurse develops plan of care related to gastrointestinal interventions in collaboration
with other health care team members
- Plan of care includes gastrointestinal assessment and interventions
- Nurse documents evidence of collaboration with other health care team members
Procedure
Personnel
1. For insertion- RN with appropriate education
2. For maintenance – all RN’s, LPN’s, with appropriate education
Equipment and Preparation
1. Nasogastric tube
2. Towels or linen saver pads
3. Non-allergenic tape or naso-tube band aid
4. Exam gloves
5. Water-soluble lubricant
6. Glass of water (or glass of ice)
7. Tongue blade
8. Catheter-tipped syringe
9. Stethoscope
10. Sterile normal saline
11. Emesis basin
12. CO2 detector
Patient Education
1. Explain procedure to patient/family/caregiver using age appropriate play therapy according to child’s level of understanding. Provide family/caregiver with Health Topic Nasogastric Feeding Tube Insertion.
2. Wash hands with soap and water
3. Sit patient on side of bed or in chair, if unable to sit, elevate patient’s head of bed
4. Starting with the holes in the end of the tube, measure form the tip of the nose to the ear lobe to the top of the xiphoid process.
5. At the measured length, mark the tube with a permanent marker or tape.
6. Check the tube for any damage. Check position of wire or stylet in the feeding tube. The wire should not be coming through the hole near the end of he feeding tube.
7. Lubricate the end of the tube with water. Do not use gels or Vaseline.
8. Insert the tube through a nare until the marked point on the feeding tube is reached. Small sips of water may be given to the child while passing the tube to help facilitate placement.
9. Assess the patient during and after tube insertion for signs of breathing difficulty.
Note: Withdraw the tube immediately if the patient becomes cyanotic or develops breathing difficulty. These are indications that the tube may be in the trachea and not in the esophagus.
10. Check for position of the tube by:
a) Placing the stethoscope over the stomach and quickly insert 3-5ml of air into the tube (1-2ml for neonate or less than 2kg infant) – auscultation of a “pop” or “whoosh” ascertains placement in the stomach.
b) Aspirating fluid from tube
c) CO2 detector
- Open package, check the CO2 detector to make sure the color matches the CO2 not present color (purple). DO NOT USE IF COLOR DOES NOT MATCH
- Any color in the non-purple area indicates CO2
- If water was placed prior to insertion, use a syringe and remove excess water
- Firmly connect the CO2 detector to the NG tube using the bard connector
- Attach the bellows to the female end of the CO2 detector
- Cap the stylet
- Advance the NG tube into the patient’s nare to the pre determined length
- Squeeze the bellow to remove any secretions that may have collected at the tip of the tube
- Slowly release the bellow to remove any secretions or air
- If the CO2 detector changes color then this indicates the presence of CO2, and the tube should immediately be withdrawn from the patient
- If the tube needs to be re-inserted, pull off the CO2 detector with bellow and squeeze air through to change the color back to purple. If this is unattainable discard get another CO2 detector
- If there are no signs of respiratory distress and no color change then proceed with placement
11. If either auscultation or aspiration do not confirm proper tube placement, have another RN or MD assess. If you are still unsure of placement, then an x-ray must confirm placement BEFORE using the tube. Call physician to write an order for such x-ray.
12. After inserting a silastic feeding tube with guide wire, remove the guide wire gently while holding the tube at the patient’s nose, place it in the envelope provided, label it and keep it at the patient’s bedside. (Note: After placement verified, flush with 3-5ml of water to help loosen guide wire for easier removal).
13. Secure the tube to the patient’s nose and face. Place tube over the closest ear and pin to the back of patient gown.
14. Cap tube if feeding is not to begin immediately.
Documentation
1. Documentation teaching method
2. Record initial set up of system
3. Correct placement of tube each time feeding bag is filled
4. Intake and output readings
5. Type, amount and rate of feeding and any flush given or medication given if not on continuous drip feedings
6. Tolerance of feeding
7. Response to feeding
8. Position of patient
9. Condition of nares and surrounding skin
Implementation
The Nursing Clinical Director and the divisional Nursing Practice Council maintain this operational guideline. This policy will be reviewed every 2 years or more often as needed.
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