NG Tube placement and tube feeds??/ (M)

[pink2blue1]

Hi everyone, new LVN here. Been working about 4 months now. I work in and acute care hospital on Med-surg. Came into work yesterday and had a patient that had a CVA, He was on NG tube feedings and awaiting for a peg tube placement. Anyways, I came onto the floor and went into his room, stopped the feeding and disconnected the tubing and got ready to check for placement. I grabbed my syringe and put air in. My charge nurse was with me. I pushed the air in and all of a sudden the formula that was in the tube came flying out of the patients mouth! OMG! it was then I realized, this tube was NOT in the stomach. My charge RN tried and sure enough I heard air, but in his mouth! when I pulled the tube out of his nose, literally only about the last 3 inches of the tube came out! It had NOT been in the stomach. The patient began spitting out all kinds of stuff. His lungs were gurgly (if that makes sense). So I charted everything. Then out of curiosity I decided to look to see if anything was charted about placement being verified on the last shift. I found nothing. We computer chart, not paper. The feeding was going at 45cc/hr.

Ok, so my question is: #1 aren;t we supposed to be verifying tube placement by either injecting air or removing stomach contents? and #2 arent we supposed to chart it?

When the night nurse came back in (She had handed this patient off to me in the morning) I told her what happened. I wasn't accusing her of not doing anything, I just said, this is what happened. She immediately got defensive and said she had given him meds at 5:45 and it was fine. Ok, fine. But she didn't chart that she checked placement.

I am so scared that this pt will have aspirated!

[leosrain, BSN, RN]

Yes, placement should be checked!

Different hospitals/regions differ, but on my unit we chart by exception. This means that the placement checks are an expected part of our care (it's in the policy and procedure that guides our practice) and we do not need to chart that we did them. We're only expected to chart, as you did, when something is abnormal.

However, as we all know, charting that we checked placement is a better idea than not! So, frequently we will chart it. Pumping tube feed into someone's lungs rarely has anything but a negative outcome...

Just remember, you did a great job by checking the placement and finding the error! Good catch!

Sean

[GregRN]

There's a reason you're worried about aspiration. Between the tube feeds going that long, the NG being curled in his mouth and the fluid sound in his lungs, I would have called the doc immediately and ordered a STAT chest x-ray. Also, when you say the patient had a CVA, can they swallow and do they have a gag reflex? Even more reason to check placement AND chart it.

This does not look good early on for this patient.

[Bluehair]

At our hospital we have a policy that the patient has a portable Chest X-ray to confirm NG tube placement for tube feedings before the feedings are initiated.. We then document that the placement is confirmed by air auscultation q shift. I had a new nurse who balked at the initial CXR, said it wasn't necessary. She inserted the NG , got the CXR anyway because it was our policy.....low and behold the NG was NOT in the stomach! She is now an advocate of that initial CXR. It's the most solid evidence that it at least started off in the right place. Yes, they can get pulled back, but you do have those length markers you can mark with tape, or in report, as to it's X cm at the nare at the time of insertion.

Hope this patient does okay!

[Lorie P.]

:) you did the right thing, check placement and corrected what as wrong. at our facility, with any peg or ngt ( except a dobbhoff) placement must be checked every 4 hours and before giving any meds. i always document i checked placement. it was drilled in to my head by a nurse who also does legal consulting if it wasn't charted, it wasn't done!!

remember, it is your licenses that you worked so hard to get .

again great job!!:)

[pink2blue1]

There's a reason you're worried about aspiration. Between the tube feeds going that long, the NG being curled in his mouth and the fluid sound in his lungs, I would have called the doc immediately and ordered a STAT chest x-ray. Also, when you say the patient had a CVA, can they swallow and do they have a gag reflex? Even more reason to check placement AND chart it.

This does not look good early on for this patient.

Did I fail to mention that I called the Dr immeditely? I did call and he did order a chest x-ray.

[GregRN]

Did I fail to mention that I called the Dr immeditely? I did call and he did order a chest x-ray.

Perfect!

You did everything right. Hopefully this patient will suffer no ill effects from this.

[TraumaICURN]

At my facility we have to have an CXR after the placement of NG tubes and Dobb-Hoffs. The doctor has to write an order that it is ok to use. With that being said, over the days, the tube can come out little by little. That's why it's so important to check placement (even though it isn't always accurate). You definitely did the right thing.

[RedCell]

I never stopped the TF until the patient spiked a fever! Seriously though, I believe the gold standard is to verify NG placement with gastric pH testing. I realize this is not available in all institutions. The craziest thing I have ever seen is a dude with a cribriform plate fracture who got a pneumocephalus and croaked from having an NG tube curled up in his frontal lobe after the nurse checked for placement with a 30cc air bolus. Made out to be a really cool skull X-ray.

[RN92]

the pt could have aspirated. i know you probably reported it to the md, right? he should have ordered a chest xray. was the tube secured? and how? just curious.

[pink2blue1]

the pt could have aspirated. i know you probably reported it to the md, right? he should have ordered a chest xray. was the tube secured? and how? just curious.

Yes called the MD immediately, after cleaning the patient up and making sure he wasn't choking of course. Yes he ordered a chest x-ray. The tube "looked" secured and when I re-inserted a new ng tube, I did secure it with the tape on the nose, half split and wrapped around tube and back up to nose. Also left my tape marker on the tube. There wasn't a marker on the one I pulled.

[sanctuary, BSN, MSN, RN]

I never stopped the TF until the patient spiked a fever! Seriously though, I believe the gold standard is to verify NG placement with gastric pH testing. I realize this is not available in all institutions. The craziest thing I have ever seen is a dude with a cribriform plate fracture who got a pneumocephalus and croaked from having an NG tube curled up in his frontal lobe after the nurse checked for placement with a 30cc air bolus. Made out to be a really cool skull X-ray.

I've seen that X-ray. Totally obscene. That's why a primary check should be an X-ray, not air... And BTW, I hate feeding pumps. :angryfire (Antique nurse here.) Back In The Old Days, food was gravity fed, at meal time with the patient sitting up, either at the bedside, or if available, in a dining room. Food was a puree of what every body else was having, and poops were normal, not this semi-liquid diaper fill you get nowadays.