Question...NG tube to suction for SBO

  1. 0 Hi, I'm a new nurse (9 months on a med surg floor). I had a pt the other night who came in with a SBO (he had a history of them since his cystectomy many years ago). Anyway, he had an NG tube hooked up to low wall suction and fluids running. Throughout most of my shift the drainage was green and bilous and totalled about 50-100ccs. Toward the end of my shift, he called me into the room and said he thinks the tube moved when he got up in the bed. He tried to push it back a little. I listened as a syringed some air into his tube and could hear a very faint sound. I secured the tape a little better to his nose and for the remainder of the shift (2 more hours) the drainage was thicker and more yellowish brown and very foul smelling, like stool, In the 2 hours I think another 200ccs drained. The tube kept clogging too. I was still trying to unclog it when the day nurse came on shift. She listened and could not really hear anything when she shot air in the tube so I told the doc who ordered a KUB. I'm not sure what happened after that because it was time for me to go home.
    I'm questioning my assessment skills as I probably should have had the doc order KUB when the pt called me into the room. I also feel bad for dumping that situation on the day nurse but it was my last night shift in a big stretch of being on and off days and nights and I was pretty exhausted.
    Do you think the tube ended in the duodenum when it was moved? Is this bad to have a tube in the duodenum attached to suction?
    Any advice would help
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  3. Visit  tcpmom} profile page

    About tcpmom

    From 'Boston'; Joined May '06; Posts: 16; Likes: 3.

    10 Comments so far...

  4. Visit  Be_Moore} profile page
    4
    Usually when the tube is duodenal, the injected air has a more distinct sound..more like a "pop" of air. We used to call it the "post-pyloric pop." It could be there, but it should be fine. I'm guessing it was a salem sump type tube (has the additional blue tubing that allows air into the system)? Either way, a simple KUB and some manipulation will put it right where it needs to be in a matter of minutes. The big thing to remember is that you didn't leave it in the lungs, so you should be good to go! Hah.

    When I place NG tubes I usually place a piece of fabric tape around the tube at the level of the nose as a measurement guide...that way if said tube slips, I can use that taping as a guide to get it back where I know it needs to be.
    tcpmom, nursgirl, SandBetweenMyToes, and 1 other like this.
  5. Visit  c_beshore_rn} profile page
    1
    They say the evidenced based practice now is to check placement of NG tubes with an "end tidal CO2 detector" to ensure its not in the lung, of course. (this is just after dropping one), obtain an xray to visualize placement is correct, and test gastric content for pH after placement. The ol' air bolus thing has gone out the window???? Has anyone else heard this new fangled stuff?? Sorry, this only applies to immediatly after one is dropped down the hatch.
    But he could have had BM in the tube if he had a nasty bowel obstruction---I've actually seen it backup into the stomach and out the mouth. Yummy
    leslie :-D likes this.
  6. Visit  RedhairedNurse} profile page
    1
    Quote from tcpmom
    Hi, I'm a new nurse (9 months on a med surg floor). I had a pt the other night who came in with a SBO (he had a history of them since his cystectomy many years ago). Anyway, he had an NG tube hooked up to low wall suction and fluids running. Throughout most of my shift the drainage was green and bilous and totalled about 50-100ccs. Toward the end of my shift, he called me into the room and said he thinks the tube moved when he got up in the bed. He tried to push it back a little. I listened as a syringed some air into his tube and could hear a very faint sound. I secured the tape a little better to his nose and for the remainder of the shift (2 more hours) the drainage was thicker and more yellowish brown and very foul smelling, like stool, In the 2 hours I think another 200ccs drained. The tube kept clogging too. I was still trying to unclog it when the day nurse came on shift. She listened and could not really hear anything when she shot air in the tube so I told the doc who ordered a KUB. I'm not sure what happened after that because it was time for me to go home.
    I'm questioning my assessment skills as I probably should have had the doc order KUB when the pt called me into the room. I also feel bad for dumping that situation on the day nurse but it was my last night shift in a big stretch of being on and off days and nights and I was pretty exhausted.
    Do you think the tube ended in the duodenum when it was moved? Is this bad to have a tube in the duodenum attached to suction?
    Any advice would help
    You're saying NGT was hooked to "low wall suction." I'm hoping just for typo purposes
    that you have left out Intermittent. So was it on ILWS ?

    If it were me, without question......I would have turned it off, notified the doctor,
    immediately. Just my opinion.
    tcpmom likes this.
  7. Visit  RedhairedNurse} profile page
    0
    Quote from c_beshore_rn
    They say the evidenced based practice now is to check placement of NG tubes with an "end tidal CO2 detector" to ensure its not in the lung, of course. (this is just after dropping one), obtain an xray to visualize placement is correct, and test gastric content for pH after placement. The ol' air bolus thing has gone out the window???? Has anyone else heard this new fangled stuff?? Sorry, this only applies to immediatly after one is dropped down the hatch.
    But he could have had BM in the tube if he had a nasty bowel obstruction---I've actually seen it backup into the stomach and out the mouth. Yummy
    Yes, I've heard the air bolus thing is not correct in identifying placement, as
    a bolus of air could also be heard if it were in the lungs. That is what an
    instructor told our class at one time.
  8. Visit  HollyHart} profile page
    0
    Policy where I work is to measure the tube from tip of nose to attachment site when it's placed and if it is adjusted and also Qshift. This helps to make sure once it is in the right spot it stays there. We still do the air bolus too.
  9. Visit  tcpmom} profile page
    0
    Thanks to all for your answers. I'm guessing there is no danger with having the tube lower than it should be???
  10. Visit  cherrybreeze} profile page
    1
    Quote from RedhairedNurse
    You're saying NGT was hooked to "low wall suction." I'm hoping just for typo purposes
    that you have left out Intermittent. So was it on ILWS ?

    If it were me, without question......I would have turned it off, notified the doctor,
    immediately. Just my opinion.

    It doesn't have to be on intermittent, it depends on how it's ordered...we have docs that order continuous suctoin rather than intermittent quite frequently. Some do continuous exclusively.

    Not sure on why it would need to be turned off. It actually sounds, if it was pulling more drainage, that is was better positioned? That's just my thought. The fact that the drainage was thicker doesn't mean it wasn't in the right spot, per say. I don't see it as a problem.
    tcpmom likes this.
  11. Visit  RN1982} profile page
    0
    Was it continuous or intermittent suction the patient was on? I never use continuous suction, I find that the tubing clogs more easily.
  12. Visit  Magsulfate} profile page
    1
    As long as there was drainage from the stomach,, even though it may have advanced a little farther,, this is not a reason to turn off the low intermittent suction. That would actually be worse... you don't want to turn off the suction if you're still getting drainage, specially in pt with SBO. Contacting the doctor would have been the correct thing to do.

    Also, do not worry about leaving the day nurse with work. Nursing is a 24 hour job and you do not stay and keep working just because it is something that started on your shift. If that were the case, we would never leave.. don't feel bad about this!
    tcpmom likes this.
  13. Visit  rnmi2004} profile page
    1
    At the start of my shift, if the previous nurse hasn't done so, I make a mark on the tube at the nares so I know if it's been repositioned. Auscultation is no longer considered a reliable indicator of placement.

    What did the patient's belly look like? Was it still distended and firm? If the tube isn't in the proper place, there isn't going to be much improvement in the symptoms that brought the patient into the hospital in the first place. Did he still feel nausea? You mentioned he has a hx of obstructions. These patients usually are able to tell you if they think the tube is working.

    It is very common for patients with NGs for SBOs to have quite a bit drainage that's stool-y in nature. It can't go out the end, so it comes back up. In fact, if they have as little drainage as you're describing I'd be suspicious of the placement unless they'd had the tube in place for a while and the obstruction was resolving.

    Since it is an NG tube, you don't want it in the duodenum (Then it would be an ND tube). It's possible that the tip was in the upper part of the stomach and when it was repositioned it landed further in the stomach.

    In the situation you're describing, the only real way to verify where in the GI tract the tip is placed is with an Xray. It's tought to think things through at the end of a shift.
    tcpmom likes this.


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