Safe Practice Guidelines for the Application and Care of mittens to aid retention of nasoenteral tubes ( NETs ) and other essential medical equipment
|Publication: 05/09/2012 --|
|Last review: 16/01/2019|
|Next review: 16/01/2022|
|Approved By: Trust Clinical Guidelines Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2019|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Safe Practice Guidelines for the Application and Care of mittens to aid retention of nasoenteral tubes (NETs) and other essential medical equipment
- What are Mittens?
- Appendix 1: Mitten assessment tool
- Appendix 2: Information sheet for patients
- Appendix 3: Information sheet for carers
- Appendix 4: Procurement information
- Appendix 5: Competency documentation
- Ethical considerations
Essential medical equipment may be dislodged by patients and carefully tailored restraint may be required to ensure optimal therapy, whilst minimising restriction and loss of autonomy for the patient. This equipment may include vascular lines, tracheostomy and other assisted breathing devices, catheters, feeding tubes and surgical drains.
This guideline will focus on NETs but the principles of mitten usage are the same whatever the indication. Naso-enteral nutrition is an essential part of patient care which is used when patients are unable to meet their nutritional requirements via the oral route but have a functioning gastrointestinal tract. They may be essential to provide sufficient nutrition, fluids and medication.
Naso-enteral feeding tubes can frequently become dislodged or removed which is a major limitation, leading to loss of feeding hours, uncomfortable reinsertion procedures and exposure to radiation if an X-ray is used to confirm tube position, as well as significant cost implications in terms of health care practitioners’ time, cost of X-rays and tube usage (Popovich, M (1996)).
Patients who repeatedly remove Nasoenteral Tubes (NETs – these include both nasogastric (NG) tubes and nasojejunal (NJ) tubes) despite other measures should be assessed for mittens. This assessment should be made by suitably qualified staff. An alternative measure is to use a nasal retention loop (NRL) also known as a nasal bridle. Use of NRLs is covered in another Trust guideline (ref 16)
Mittens are easy to use and optimise the ability of the feeding tube to meet nutritional requirements by reducing the chance of removal, whether by accident or purposefully.
Use of Mittens would constitute Restraint and so staff must be familiar with policy and guidance in the proportionate use of Restraint - see section on restraint
Consent is a difficult but important issue. Informed verbal consent should be obtained prior to using mittens whenever possible and must be documented in patient’s notes. For those unable to consent refer to section on consent
This guideline should be used in conjunction with the enteral feeding policy and naso-gastric tube insertion guidelines (ref 15).
All aspects of decision making, placement technique and aftercare will be addressed in the guideline.
Fine bore naso-enteral feeding tube: -
Defined as between a 6fg - 8fg tube. The length of the tube is measured in cms starting at the distal tip). Measurements are seen along the length of the tube, but the tube length will vary depending on manufacturer. The tube is made of silicone or polyurethane which is passed through the nostril via the naso-pharynx into the oesophagus, then stomach (NG tubes) or through the stomach and duodenum, sitting in the jejunum (NJ tubes).
Duties and Responsibilities
Registered Nurse: It is the nurse’s responsibility to judge the appropriateness of mitten usage and to care for the NET and manage the mittens as per the Trust Guideline.
Doctors: It is a medical and nursing decision to commence enteral feeding and decide on the appropriateness of the use of mittens after consultation with the patient and/or carers and multidisciplinary team (MDT).
It is recognised that an initial decision to use a mitten may be needed by nursing staff in order to retain a NET, but this should be discussed with the rest of the team as soon as possible.
- The use of NETs is a common procedure across many different specialties. This procedure is documented in the LTHT Policy for Insertion and Maintenance of Fine Bore Feeding Tubes in Adults (Appendix 1, ref 15).
- Naso-enteral tubes become displaced for a variety of reasons and a small group of patients appear to be particularly intolerant of the tube and require repeated reinsertions. This can be distressing for the patient and their family, detrimental to their recovery as it means missing feed and medication due to delays until the tube is replaced and may also increase the risk of misplacement.
- This guideline has been written to enable suitably trained practitioners to follow an agreed decision making, assessment and procedural process.
- The main purpose of mittens is to ensure the provision of feed, fluid and medication via NETs by reducing the chance of dislodgement.
- They are a form of restraint and must meet standards set out in the LTHT restraint guidance (ref 13). They interfere with the ability of the patient to manipulate small objects such as tubes, but allow comfort and cleanliness.
A registered practitioner is needed who has completed relevant education and training in the use of mittens (see appendix 5)
Training for use of mittens should be available on all wards as they may be a good first option to allow tube retention before more invasive options, like nasal retention loops (NRLs) are considered.
All staff who use mittens must have completed the ward based training and competency assessment (see appendix 5).
- Staff are required to be skilled in the consent process. They need to consider the patient’s capacity to be involved in the decision-making process (ref 14). If the patient has capacity to decide, staff should gain the patient’s consent to the use of mittens and record this in the notes. When patients lack capacity to decide on this issue, their best interests are taken into account given all the circumstances and following consultation with persons close to the patient. The least restrictive method of restraint, with the lowest risk and discomfort, should be used at any point.
Restraint is defined as: “use or threat of force to help do an act which the person resists, or the restriction of the person’s liberty of movement, whether or not they resist.”
Use of Mittens is therefore a restraint technique and should only be used:
- When absolutely necessary to protect a person from harm, and
- is proportionate to the likelihood and seriousness of harm.
LTHT staff using any form of Restraint should be familiar with Policy on use of Restraint (ref 13)
Identifying appropriate patients
Suitable patients are:
- Those with documented evidence of inadvertent displacement of the NG/NJ tube.
- Patients who are pulling at other devices such as urinary catheters and intravenous cannulas, and who require an enteral tube for feeding or medication.
- Patients who demonstrate skin irritation from the tape used to secure to the tube to the nose.
- A nasal retention loop may be more effective for those patients who have elective nasogastric or nasojejunal tubes when replacement is of high risk or technically difficult. If this is not acceptable, mittens may be an alternative.
- Those who have refused a nasal retention loop.
Cautions for use of mittens:
- If neurological or musculo-skeletal impairments of the hand or wrist their use must be discussed with the medical and therapy teams to ensure appropriateness of use and agree timetable for wearing of mittens
- Mittens must be used with extra care if a cannula is sited in the hand or wrist
- Assess the patient for appropriateness for mittens. (Appendix 1)
- If the patient has capacity the procedure should be explained to gain verbal consent. If the patient is deemed to lack capacity, then a best interests decision should be made and documented in the medical notes. The options should be discussed with any people close to the patient who are available and this discussion should also be recorded. The procedure should be explained and an information leaflet provided. (see ethical considerations)
- The purpose of the mittens and use should be explained to the patient, or people close to the patient if they lack capacity, to decide on the issue. The information sheets should be provided.
- Verbal consent or assent should be obtained and recorded in the care plan (appendix 1).
- Document outcome in medical notes leaving clear instructions re ongoing management for nursing staff.
Need to include: reason for use and who decided it was required (appendix 1), whether patient gave verbal consent or assent received from carers and whether there were any complications eg hygiene or poor tolerance.
Care of patient with mittens
- Mittens are supplied to fit either hand
- If the patient has neurological or musculo-skeletal impairments of the hand or wrist their use must be discussed with the medical and therapy teams to ensure appropriateness of use and agree timetable for wearing of mittens
- Mittens must be used with extra care if a cannula is sited in the hand or wrist
- Times when mittens are taken off should be timetabled, for example around visiting times, meal times etc.
- The hand(s) must be washed, dried carefully and mittens reapplied at least three times per day to ensure skin is visualised and any changes, potential problem areas recorded, treated appropriately and handed over.
- Patients will not be able to use the nurse call system if mittens are used so extra care must be taken to ensure safety and dignity by increased observation
- Mitten use may be discontinued at anytime by any practitioner if:-
- The patient becomes more agitated distressed when wearing the mittens
- Consent/assent is withdrawn
- Deterioration in skin condition is noted
- Patient’s condition changes and mittens are no longer required
- The assessment in appendix 1 should be completed and updated daily
Control of Infection
- Mittens must be checked frequently and at least daily for contamination
- Clean mittens are supplied if contamination is found
- The mittens may be laundered following manufacturer’s guidelines and according to infection control guidelines
- Mittens are for single patient use
- Each unit/area is responsible for purchasing (see appendix 4 for procurement information), labelling and sending to the laundry service.
- It is recommended that a record of number and date mittens sent is made for tracking purposes.
- Mittens are checked for damage after laundering for tears, damaged stitching etc and taken out of use and replaced if found to be faulty.
According to the Mental Capacity Act, when a decision-maker for someone who lacks mental capacity is working out what is in that person's best interests, they should consult the following people 'where it is practical and appropriate to do so:
- anyone the person has previously named as someone they want to be consulted
- anyone involved in caring for the person
- anyone interested in their welfare (for example, family carers, other close relatives, or an advocate already working with the person)
- an attorney appointed by the person under a Lasting Power of Attorney, and
- a deputy appointed for that person by the Court of Protection.
The role of those who are consulted is to give their opinion about what is in the patient's best interests. They are not really being asked to consent, but they are able to provide information that supports a broader interpretation of best interests than a purely clinical one and to raise any objections or issues on behalf of their family member.
The exception to the role of family and friends in the consent process is the more authoritative one of attorneys holding a 'Lasting Power of Attorney' for health and welfare decisions. They must be consulted and formal consent obtained from them.
Also check if the patient has completed an Advance Decision to Refuse Treatment in relation to Mittens, enteral feeding etc as this should be respected if applicable to the clinical situation.
The MCA doesn't refer to relatives as 'next of kin' as they may not be the people who are closest to the patient. The MCA prefers to use the term 'people close to a person who lacks capacity.' This could include family, friends or anyone specifically nominated by the patient to be involved.
When might restraint be ‘necessary’?
Anybody considering using restraint must have objective reasons to justify that restraint is necessary. They must be able to show that the person being cared for is likely to suffer harm unless proportionate restraint is used. A carer or professional must not use restraint just so that they can do something more easily. If restraint is necessary to prevent harm to the person who lacks capacity, it must be the minimum amount of force for the shortest time possible.
What is a ‘proportionate response’?
A ‘proportionate response’ means using the least intrusive type and minimum amount of restraint to achieve a specific outcome in the best interests of the person who lacks capacity. On occasions when the use of force may be necessary, carers and healthcare and social care staff should use the minimum amount of force for the shortest possible time.
To provide evidence-based recommendations for appropriate diagnosis, investigation and management of patients who might benefit from using mittens.
|Target patient group:||Adults|
|Target professional group(s):||Secondary Care Doctors
Secondary Care Nurses
References and associated documentation
- Norton B. et al. 1996. A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. British Medical Journal; 312:13-16.
- Eisenberg P, Spies M, Metheny N., 1987. Characteristics of patients who remove their nasal feeding tubes. Clinical Nurse Specialist; 1(3):94-98.
- Meer J., 1987. Inadvertent dislodgement of nasoenteral feeding tubes: incidence and prevention. Journal of Parenteral and Enteral Nutrition; 11(2):187-189.
- Ciocon J.O. et al., 1988. Tube feeding elderly patients: Indications, benefits and complications. Archives of Internal Medicine; 148:429-433.
- National Collaborating Centre for Acute Care, 2006. Nutrition Support in Adults, oral nutrition support, enteral tube feeding and parenteral nutrition. National Collaborating Centre for Acute Care, London
- Kee K et al, 2006. Evaluating the use of hand control mittens in post stroke patients who do not tolerate naso-gastric feeding. Poster presentation UK Stroke Forum Conference, Harrogate
- Mahoney C. et al 2006. The acceptability of interventions used to maintain naso-gastric feeding in acute stroke patients. Poster presentation UK Stroke Forum Conference, Harrogate
- Bray K. et al, 2004. British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units. Nursing in Critical care;9(5):199-212
- Royal College of Nursing, 2004. Restraint revisited –rights, risks and responsibilities. RCN, London
- Royal College of Nursing, 2008. “Let’s talk about restraint” Rights, risks and responsibility. RCN, London
- Great Britain National Patient Safety Agency (2005). Patient Safety Alert 05. Reducing the harm caused by misplaced nasogastric tubes. NPSA, London.
- Pancorbo-Hidalgo, P.L., Fernandez, F.P., Rimirez-Perez, C. et al (2001).
Complications associated with enteral nutrition by nasogastric tube in an internal medicine unit. Journal of Clinical Nursing. 104 p482-90.
- Trust best interests and restraint information
- Trust capacity assessment information.
- Trust NGT guideline
- Trust nasal retention loop guideline
Trust Clinical Guidelines Group
LHP version 1.0
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