Checking "residuals" q4hr-capped NG

[theLostRN]

Quick question

I had a patient who had a NGT to low intermittent suction after exploratory lap for possible small bowel obstruction. The pt was hooked up to suction for at last 5 days. The MD wanted to cap the NG and check "residuals" every so often. MD wanted to see if the pt GI motility was good enough to completely stop suction and remove the tube. After checking the "residual" wouldn't you return the aspirate? Essentially, if you discard it, we won't get a clear picture of pt's motility if we are removing the stomach content. Some nurses were periodically hooking the pt to suction for a minute or two and discarding the drainage. Need some advice.

[Up2nogood RN, RN]

I've never seen any NG drainage being returned after checking residuals. The body will produce more on it's own and thats what they're interested in seeing if the body reabsorbs what it produces.This is how it's done sorry I don't have a clear cut answer as to why it's not returned.

[morte, LPN, LVN]

yeah, return it, not only for your reason, but chemical balance...

[Bumashes, MSN, APRN, NP]

I was always taught to return it for fear of upsetting the acid/base balance in the stomach. Unless for some reason it's a dangerous amount withdrawn and the pt is an aspiration risk. Or if the pt was becoming nauseated, then I would remove any contents and discard. In either situation, I would then chart either the amount retained or discarded in my notes for the dr to review. If there was a crazy amount building up, say > 200cc since the last 4hr residual check, then I'd call the dr to report this and see if he wants to continue with the current regimen or restart suction.

I guess it all comes down to what your facility's policy is, or else you can ask the dr when he makes rounds what is the preferred method. Although I'm sure even then you'd end up with conflicting opinions between drs. Sheesh.

[mamiekay]

As always, FIRST check your facility's policy. In our hospital, when checking residuals through a NG on someone who's been hooked up to suction, we don't return the residuals. The reason behind it is that it's just sitting there, it's not going anywhere on its own, and the body continues to produce fluids that are being backed up by a bowel obstruction or ileus. Returning the residuals would add to the volume of fluid building up in the stomach.

We DO RETURN residuals when checking someone who's on a tube feed. That's because not returning them could result in an electrolyte or pH imbalance. Rather than removing bilious, acidic fluids that the body produces in response to an empty belly, the gastric contents in a patient on a TF have nutrients and electrolytes needed by the body. In this case, the residuals also determine the timing and volume of the next TF.

A good rule of thumb for checking/returning residuals is, if something's going back in, put it back. If things are only coming out, leave it out.

[turnforthenurse, MSN, NP]

I was always taught to give it back due to risk of electrolyte/pH imbalances!

[mamiekay]

If you place a NG due to bowel obstruction or ileus, the gastric contents are not moving through the gut. The body is continuing to produce fluids that are building up in the stomach, causing nausea, vomiting and severe discomfort. You hook the NG up to suction and empty the gastric contents to relieve the pressure, nausea & vomiting. Once suction is pulling off a minimal amount, the MD will usually order the NG to be capped and residuals checked Q4. The sole purpose of NG to suction is to empty the stomach. Now think about this: do you replace what the suction has pulled off? IF the NG is placed to relieve N/V, abdominal distention, due to obstruction or ileus, at least in our facility, the residuals are measured and discarded. They are not returned. 1) The gut is still not functioning enough to move gastric contents from the stomach through the bowel. Anything put into the stomach will just sit there and add to the accumulation (and discomfort). 2) With an ileus or obstruction, the body is not receiving any nutrition from the gastric contents. The balance has already been upset and is hopefully being somewhat restored through IVF's. Discarding gastric residuals in this case will not upset the pH or electrolytes any more than they already are. This sounds really gross but a NG to suction does the same thing vomiting would do. If you threw up, would you put it back to keep the balance? Or would you try to replace it another way (e.g. IVF)?

>>>"Essentially, if you discard it, we won't get a clear picture of pt's motility if we are removing the stomach content." (some number), reconnect to LIS and notify MD."

***IF a NG has been placed to facilitate a tube feed, it's a whole different ballgame and a different set of rules applies. As previously stated, check your facility's policy. Ask your charge. Ask the MD writing the order what she/he wants done. If you tell them what you've been taught, that you hear varying and conflicting advice, and what your thought process is, most are more than happy to explain why you would or wouldn't want to discard in a particular situation.