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RNinCali15 RNinCali15 (New Member)

NG tube question

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Hi everyone, so I am a new grad working in a level III NICU. I am almost done with my orientation and had a bit of a disagreement with my preceptor last night. So my patient was full term, stable, and had an NG which we were using q 3 feed and to infuse any left over ML's from their bottle feedings. I did my assessment, and fed my patient the bottle which they took 100%. Later that night my preceptor asked why I did not chart any residual prior to that feed. I explained that because I did not use the NG and was not concerned about the patients gut, I did not check. The patient had no spits, emesis and girths were the same 2x. I told her that I also felt that checking for placement before offering the bottle seemed odd because I was under the impression you would want to check tube placement as close to initiating the gavage feeding as possible. In theory, the NG/OG could move during feeding or burping. It should be noted that I used the NG three times prior that night, and each time when checking residual there was none. Naturally, I injected air and checked placement with my stethoscope each time.

What do you guys think, should I have checked for placement/residual prior to the bottle feed like she said? Would you have?

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I work in a level III NICU as well, and we check residual or PGA, from the NG with each assessment. Even if a baby is nippling most of their feeds, we will still check a residual before the feeding.

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Yes I would normally check the residual. I check again for placement if I have to give the remainder of a feeding via NG. But there have been times I haven't in a situation you described. Usually because the baby is screaming to eat and Mom wants to start.

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I explained that because I did not use the NG and was not concerned about the patients gut, I did not check. The patient had no spits, emesis and girths were the same 2x. I told her that I also felt that checking for placement before offering the bottle seemed odd because I was under the impression you would want to check tube placement as close to initiating the gavage feeding as possible.

Checking for placement and checking residuals are two different things. Checking placement is to ensure that the formula is going into the stomach and not the lungs when using the NG. Residual is to determine how much undigested formula is in the stomach prior to the next feed. If you fed a baby 60 cc by bottle at 12p, then get ready to feed them another bottle at 3p. You check residuals and pull off 20 cc of formula. Do you think that is an issue? If you hadn't checked before feeding the 3pm bottle, you would not have known that there was an issue. You would attempt to bottle feed and the baby stops at 30 ccs. You feed the remainder of the formula by NG. Now the baby has 20cc from previous feed, 30 cc from bottle, and now you are attempting another 30 cc by NG.

Edited by NICU Guy

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I am also RN NICU resident about to be on my own too and also work at a Level III NICU...it is also a big teaching hospital. So there are always different providers, nurses etc and sometimes I get conflicting information/ orders. So, I am a per policy RN -- if I do not know who it right -- I look up our policy and follow it.

Our policy is prior to each feed, I must evaluate/ document tube placement. I have to verify that external placement/landmark hasn't changed. I have to document that I verified that the tube is secured to the infant. If all that checks out then, I aspirate stomach for residuals. I do this even if the baby took the whole bottle during the previous feed. This is to ensure he digested his previous feeds. Per policy, there are different steps we have to take if the residuals are > 10- 20%.

A full-term baby most likely would not have random digestive issues but if I fed the baby without checking for residuals and the patient's status changed in the 3 hours. And I fed him, his next full feed -- that could really bad.

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If a baby is having feeding issues and has an NG (even a term kid), I want to know what's in the stomach before I start, even if the baby is going to nipple. If he doesn't feed well, was it because he still had a bunch of milk in there from three hours ago? We don't know at that point. You can't check a residual after he nipples so you run the risk of over stuffing him by putting the remainder down the tube if he doesn't take it all. (Which I understand didn't happen this time but it could have.)

You're correct that placement wasn't an issue in this case, but residual is a little different.

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Practices are different in different units. Where I work, it's acceptable to

not check residual if you are going to attempt a nipple feed. Checking placement right before gavaging is a must. Here's the thing, all common practices for checking placement are not supported by the evidence: residual appearance, air auscultation, pH testing. . . None are proven in a neonatal environment. I still do auscultation, but we are not given an alternative. It bothers me but not my current battle.

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We check position with every GT feed, but only check residual q4H when the baby is q2 feeding. When the baby gets to q3H feeding, we only check for position and we use pH strips for that. I work in a level 3 NICU.

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I spoke with my educator about this matter, and checked the policy. We are not required to check residual or placement before a PO feed. We are only required to before we initiated an NG feed. She thought it seemed odd to check residual before a PO feed, and then check placement/residual again 15 minutes later if your infant needed the remainder gavaged.

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In the absence of any related issues one does not need to check a residual. You only need to check placement if you're going to put something in the tube.

Think of the effect on an infant to have the bulk of their stomach contents removed then shoved back in. Reasonably speaking, whatever amount is aspirated should be given back at the same rate the original feed was given. If you gavage an infant with 30 mls over a half hour and then aspirate 15 mls before the next feed, your going to have to give that 15 mls back over 15 minutes. Doing this without any supporting reason to do so is more likely to cause harm.

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There's some evidence that we probably don't need to check residual at all unless there is an indication (emesis, distention), just aspirate a small amount for placement. Several of our neo's have mentioned this preference too. I think it's a matter of time before our facility changes policy.

Saying that, we currently only check residual right before tube feeding. If they nipple first, then it's just aspirate for placement... I really don't want to pull out that 30 mLs I just fed the baby. Then push it back fairly quickly, that can't feel good.

You should read your facility's policy and do whatever it tells you to do. And don't rock the boat with your preceptor. You can get involved with quality and evidence based projects later.

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In nearly 40 years I have never known of an NGT/OGT going into the lungs on a neonate. Honestly its hard enough sometimes to ge the ETT in place and that you are trying for the trachea! Anyway...we have never checked Ph for placement....xray or ausculation. We no longer are to check residuals but I often do out of habit. Also sometimes babys swallow so much air and it's an easy way to get rid of it! So with babys that are doing bottle/NGT feeds I do check.

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