Table 1 Nasogastric taping method assessment
Patient Name_________________
History Number_______________
	1. Circle/check all that apply 2. Complete one sheet for each securing episode 3. Make additional notes as necessary on this form
Type of Tube:		DATE AND TIME SECURING METHOD DONE
	Salem Sump _________	_____________initial
	Keofeed ____________
How was tube placed:
	Nasal ______________
	Oral _______________
Patient's cognitive status: (usual)
	Alert _______________
	Alert/oriented _______________
	Confused _______________
	Combative _______________
	Restrained _______________
	Comatose _______________
	Chemically paralyzed/sedated (circle) _______________
Patient's respiratory status:
	Intubated orally _______________
	Intubated nasally _______________
	Trached _______________
	Mechanically ventilated _______________
	0 2 (other) _______________
Unsecured tape documentation:
	DATE AND TIME TAPE UNSECURED _______________
Reason for unsecured tape:
	Inadequately secured ________	Reason ________
	Moisture ________	Reason ________
	Tape failed to stay secured ________	Reason ________
	Nurse DC'd ________	Reason ________
	Other ________	Reason ________