Checking G-tube placement

[Compassion_x]

So, I'm curious. (I'm not really sure where to post this!)

In class we are taught to check placement by residual pH.

The hospitals in our area still have policies saying to inject air and listen. Despite that there is evidenced based practice saying it's not an effective way to check placement. Other hospitals in the state have realized that and changed policies EIGHT years ago.

So my question is, is this really just my area that still does it that way?

[hgt219]

I was taught in school that you are to use two methods to verify placement and that x-ray is most accurate because you can see it is in the right spot. Checking ph and the whoosh test were others but my instructor told us the whoosh test is not that accurate but the hospital we have clinicals at has it in the policy. Hopefully one day that will change, but that's just what I learned.

[nurseprnRN, BSN, RN]

All of you for whom your facilities or clinical placements or faculties are apparently not aware of the current clinical guidelines: Feel perfectly free to print out multiple copies of them and share. In facilities, make sure your risk management department has one.

Because I can swear to you that when (not if) someone is injured because someone checked NG placement with "whoosh" or even xray (unless they do AP and laterals, and maybe not even then), the very first question the plaintiff attorney will ask the legal nurse consultant is, "What's the standard of practice for this procedure?" And hospital policy or no, when they ask you if you knew that in deposition, you'll never have to testify in court because the case will settle in a heartbeat. And your facility will lose big.

[hgt219]

Just wondering why an X-ray would not be okay? I've only done my first term of nursing school and have 5 more to go so I'm not an expert by no means so I just want to know why.

[hgt219]

My book was published in 2011 and says otherwise

[JustBeachyNurse, LPN]

My book was published in 2011 and says otherwise

Just curious, what does your text reference as a source? My texts always had references in the chapters and in the back reference index to indicate the source of the evidence based practice recommendations.

GrnTea posted the national guidelines which clearly explain the various methods of checking placement and the evidence based rationale as to why each is or is not recommended.

Single view X-rays are not fully recommended as one view is not sufficient to accurately determine placement. An AP & lateral ("2-view") would be a better choice to determine placement

[Here.I.Stand, BSN, RN]

NG tubes? Noooo....never inject air. I want to say you can hear the whoosh if the tube is in the lower part of the esophagus, and at best putting air into a belly increases the pt's discomfort/nausea. Aspiration of gastric contents is the best way to verify that the tube is in the stomach.

At our facility we feed and push meds through NJ's or PEGs; we confirm placement with x-rays. NGs/OGs are used if the pt needs gastric suctioning (i.e. keep the stomach empty).

[hgt219]

Where can I find these national guidelines? I even did a small google search and every page said x-ray was the gold standard. I'm not looking at my text right now but it doesn't have a reference after every sentence so I'm not sure exactly right now as to what they used exactly but it says x-ray should be used before initial feeding but since it's costly it doesn't need to be done every time but to use ph along with another method and the air is least reliable

[Compassion_x]

X-ray is the gold standard for when the tube is just placed. But the tube can become dislodged and you should check placement in another way before flushing or giving meds or tube feelings. The secondary way of checking placement is what I am questioning.

[hgt219]

Oh of course you check placement before you would do anything to prevent harming the patient. There are many ways to check placement other than the methods already mentioned.

[JustBeachyNurse, LPN]

It's not "the wonderful world of NCLEX" and I would caution you to stop being so cavalier about that. It is never just a joking matter to assure that best practices for patient safety are observed in any patient care setting. There are plenty of references available to determine what best practices are, and I am pleased to see the OP using the critical thinking process to find out more. Correct placement of nasogastric tubes is critical for patient safety, and pH testing offers an evidence-based method to assist in this process (Tho PC, Mordiffi S, Ang E, Chen H. Implementation of the evidence review on best practice for confirming the correct placement of nasogastric tube in patients in an acute care hospital. Int J Evid Based Healthc. 2011;6:51–60. doi: 10.1111/j.1744-1609.2010.00200.x. [PubMed][Cross Ref]) Please also see the National Guidelines Clearinghouse, National Guideline Clearinghouse | Gastric tube placement verification.

See the links here posted by GrnTea from the national guidelines clearing house.

[hgt219]

See the links here posted by GrnTea from the national guidelines clearing house.

Thank you! That reference has radiographic verification as the "gold standard"

[wooh, BSN, RN]

So what about when there are continuous feeds through an NGT? Checking pH then is just checking the pH of the formula that's infusing, which could have come from the lungs or wherever else just as easily...