NGT/aspiration pneumonia/shot nerves

[artsmom, BSN, LPN]

I had a patient new admit to the floor with a new NGT placed, not x-ray'd (no policy), but had good placement with air bolus. Patient was vented, on tele and oximetry, restless, not agitated- with a history of anxiety. He came in with vent assoc pneumonia, and on antibiotics for it. He was stable overnight, no issues at all.

So I go home, and later in the day get a call from the president of nursing wondering what happened with my patient as they had developed aspiration pneumonia from the ngt being coiled around the trach. I told her how the night was, and that the patient was stable. She questioned why his heart rate was elevated at one point (103), I informed her I was in his room straight cath'ing him at that time, and since the elevated hr wasn't sustained, I assumed it was just anxiety from the procedure. She asked why I wrote in my note "large amount of yellow tracheal secretions"- well he has pneumonia and a trach, again it didn't concern me. I have been a nurse 7 years, I can tell the difference between tube feed and phglem. I was at work until 9 am doing documentation, and the patient was stable up to that point. She told me he vomited during the morning, and then they discovered the NGT coiled around his trach.

Finally, to get to my question, one, did I miss something? I know an xray is golden rule, and I am sure that will become policy again, but if my patient began aspirating on tube feed overnight, wouldn't the vent/tele/oximetry alarms have been telling me something was going on? His sats were good- 96-97%. He wasn't agitated, lungs were rhonchi... I am not above admitting a mistake if I made it, but I don't think there was cause for concern. Two, if he vomited on days, couldn't that have brought the NGT to the trach, thus resulting in the asp pneumonia. Considering he already had pneumonia, he was clearly very prone to it.

Any advice, or similar stories please. I am nervous about having gotten a call from the president, though my boss explained it was just policy for a reportable event. Did I overlook a sign? Please help!

[ckh23, BSN, RN]

You would know if you had been dumping tube feeds into his lungs all night long. Yes a CXR should have been done, but you can't write the order for it and if your facility doesn't have a policy in place then there is only so much you can do. NGT are squirmy little suckers and they move all the time. If he did in fact vomit it is very possible that the NGT came up. Perhaps the day nurse tried to advance it back down, but instead sent it down into the lungs. Something about their story doesn't make sense and I feel something is being omitted. Also I would question that if he did in fact vomit, what did he vomit? If the TF had been going into his lungs all night I would thing that his stomach would be pretty empty.

From the information you provided, I don't really see anything that points to the NGT being in the trach all night long.

[artsmom, BSN, LPN]

Thank you! Any affirmation makes me feel a little better. Another nurse I spoke with felt they were just trying to shift the blame off the day nurse. Maybe nobody is to blame and the patient just happened to vomit up the NGT. We will never know, but getting questioned made me question myself and my assessments. Thanks again.