checking gtube placement

[KelAyne]

This is my first time posting - not sure if this is the correct area to post in.

I have been a registered nurse for exactly 2 months, a LPN for 5 years prior to that with 2 years experience in a sub acute rehab facility. Today, for the first time, a patient's Gtube dislodged from her stoma site while she was coughing. The stoma site had enlarged over the past year and had been leaking her feed/stomach contents from her stoma site for awhile.

It caught me off guard, especially when I saw the balloon was still inflated with 10ml's of fluid. I called my supervisor who came down, reinserted a larger bore tube, instilled 10ml's of fluid into the proper port then asked me to check for placement.

I instilled 10ml's of air into the tube and placed my stethoscope over her epigastric area, as I injected the air the second port popped open and I heard nothing - big surprise. When I told my supervisor I didn't hear the familiar gurgle she said 'no wonder, look where you put your stethoscope'. She then told me to place it well below where I had placed it around the umbilicus region - I did as she said and heard the 'gurgle'.

My question is if I can hear the 'gurgle' over the epigastric area (as I had earlier in the day when I gave her meds) and over the much lower umbilicus section - how do I really know if it's been properly placed? Especially since the stoma is now so large and the caustic stomach contents are constantly in contact with surrounding tissue.

I'm concerned and confused and I more than a little upset - my supervisor went on to make a few derogatory comments about my nursing practice. As an aside, during clinicals, I was discouraged from using the air instillation method the main reason was that it is often ineffective at determining placement and used to say why would you want to just keep pumping the stomach full of more and more air all day. That is the way we are required to check for placement at my current job so I have continued even though I would like to use the pH method.

Eh, frustrated, sorry for the long post.

~k

[FLArn]

We are no longer allowed to replace g tubes as it is impossible to definitively determine proper placement by auscultation of air bolus. All tube replacements are sent out to ER for MD to do and are X-rayed prior to use.

Your fears are well founded as there have been instances where in house placements have lead to feedings being instilled into the abdominal cavity and resulting in sepsis.

[Asystole RN]

Auscultation is a very poor method of verifying placement of any feeding tube.

Aspiration of stomache contents with pH verification is a better method but xray is the best.

NSO has a case study lawsuit in their LTC section where a gtube was misplaced and dumped feeding into the peritoneal cavity resulting in the death of the patient. The method of verifcation in the lawsuit was auscultation...

[NeoPediRN]

I almost want to say it sounds like it migrated to the jejunum. I've only ever auscultated the epigastric region for a G and would imagine if you have to go below the umbilicus you're in the intestine. Was the PH higher than 5?

[jrw03282009]

So.... I just started my 1st position as an LVN in a LTC facility. In school we were taught to auscultate before feeding and flushing; this is the way that I do it at my facility (as well as all other nurses). If this is the improper way to do it, I dont see how xray would be a proper way to do it either, they would be glowing after the first week!

I would truely, honestly like to know the answer (ideas) to this one... I worked too hard for my license to loose it over a gtube!

[NeoPediRN]

Xray will show the exact placement of the gtube...with auscultation you can only be sure you're in the general area, you can't differentiate if it's in the actual stomach or peritoneal cavity.

[Fribblet]

You were right to put something in the stoma as it will close quite quickly. When nursing home patients are sent to us for a G-tube that has come out we will immediately place an appropriate sized foley catheter into the stoma to keep it open so the surgeon can evaluate and replace as necessary.

Of course we do not administer anything though there, but it will make replacement much easier. And, to just reiterate what other posters have said, auscultation is not a definitive method of determining placement.

[FLArn]

Once placed by the MD and verified by X-ray, a g tube shouldn't migrate and verification of placement by auscultation would be sufficient for general purposes. However if the balloon ruptures or as in the OP the stoma enlarges through leakage of stomach contents (which IMHO requires eval by the MD -- but that's a separate issue for another day) and the g tube comes out replacement would require verification via X-ray to be sure of proper placement.

[KelAyne]

Thank you all so much for your replies. I really appreciate the input.

We don't ever check pH levels - we don't even have test strips available that I know of. Until about 6 months ago we would insert a foley to keep the stoma patent and send them to the ED for eval and replacement - then suddenly we had a supply of extra gtubes and the RN's were expected to replace when necessary. I was uneasy about it but never having been in the situation I didn't voice all of my concerns (stupid, I know). Tomorrow I'm going to ask another supervisor if we can have an in-service.

I'm still confused about the proper way to determine placement after x-ray. As a LPN student I was taught auscultation, as a RN student I was taught aspiration with or without pH and that auscultation is too hit and miss. Nobody seems to be on the same page - I just want to do right the right thing for my patients.

Sometimes nursing makes my head spin

Thanks again guys,

~k

[NeoPediRN]

I work in peds and most of the kids have Mics which I think are much easier to replace. We only replace if the tract is mature, we don't even put a Foley in if it's not. Our nursing policy states that we must aucultate and aspirate prior to administration of meds and bolus feeds, as well as check PH if replacing. I don't think any of it is helpful because auscultation just tells you the general area you're in, PH can be affected if the pt recently had a feed running, and to aspirate every time you have to give a med doesn't always work in the pt DIDN'T recently have a feed and to just look at the gastric contents can be misleading.

[vindy]

Hello,

"Draw up 30 ml of air into a 60 ml syringe and then attach to end of feeding tube. Flush tube with 30 ml of air before attempting to aspirate fluid. Draw back syringe slowly and obtain 5-10 ml of gastric aspirate for pH testing. Observe appearance of aspirate to help assess position of tube. Measure pH of aspirated GI contents by dipping pH strip into cup of the fluid or by applying a few drops directly to the test strip" (Elkin et al, 2007). Note: Auscultation of insufflated air is no longer considered a reliable method because a tube inadvertently placed in the esophagus, lungs, and pharynx can make a sound similiar to air entering the stomach.

When a tube is first placed, Xray is the best placement check, after that, pH appears to be the next reliable source.

I did however flush air into the G tube to check for placement with my professor next to me when administering meds, and within a half hour, the G Tube was leaking. When I become licensed, I am most likely going to carry pH strips with me if I know I am going to have a patient with a g tube so I can cover myself when administering meds via that route.

If your facility doesn't have pH strips, maybe it is something you can bring up with management due to evidence based practice that pH testing is more reliable?

Reference:

1)Elkin, M., Perry, A., & Potter, P. (2007). Nursing intervention and clinical skills (4th ed.). Mosby: St Louis, MO.