Question related to giving feeding through NG tube

SolaireSolstice, BSN, RN · Oct 15, 2009

I was taught to aspirate contents first, then reinstill and check for placement with air. Every time I have done a feeding, under guidance of my instructor or with another RN, this is the way we did it. I have no idea why she didn't allow you to check for placement with air, but I would guess because of the excess residual. Did you ask her?

You pull back on the plunger until nothing comes back. I'm suprised you were able to get 156ml. We use 100 ml syringes. Did you have to switch the syringe?

In school they said > 100 ml, "refer to agency policy before feeding", this can mean there is a hospital/floor protocol in place, or it may be covered in the MD order. And yes, you are "checking residual" when you are doing this. Checking to see what has gone through. If none of the previous feeding has gone through, you would be concerned about increased risk for aspiration, and also possible obstruction/lack of bowel mobility.

Yes, the stomach gets emptied completely, all of the gastic juices as well. Well, there may be some hiding within the pilli of the lining, but basically empty. This is why you can also check for placement by checking the pH of the stomach contents.

Generally, you reinstill the aspirated contents. This is to prevent metabolic losses.

Student Cheryl · Oct 15, 2009

"I have no idea why she didn't allow you to check for placement with air, but I would guess because of the excess residual. Did you ask her?"

No. i practice to check for placement with air first. so, if i started aspirate(as she asked), then i will not go back to the procedure to check the placement...(actually should i check again?)

"I was taught to aspirate contents first, then reinstill and check for placement with air."

With reference to the above, may i ask, if we aspirate first and then reinstill it back, then only check for placement , isn't this flow lacking something? what if the location is in other location? what will happen?

and if i choose to instill air first to check for placement, the water which left in the tube (external) will go in right? what would happen and is there any risk?

thank you for your concern and giving me answer.:) i am just too anxious with my quality of care for patient.

You pull back on the plunger until nothing comes back. I'm surprised you were able to get 156ml. We use 100 ml syringes. Did you have to switch the syringe?

Yes, i changed to the syringe which we use for feeding as the nurse asked to.

"Generally, you reinstill the aspirated contents. This is to prevent metabolic losses. "

i have read in the book that some hospital policy need to instill back the juice, but in my hospital, we din practice it. I think it is good to reinstill it back because we need gastric juice to digest food. but i saw my hospital here practice different. ..i wonder whether the nurse work here really think about it or not...

rdsxfnrn · Oct 15, 2009

instill 5 mls air to check placement.... why would you do it after?

aspirate to check for residual, follow md orders, but it is almost always returned. if not, it will cause f/e imbalance.......... check your book and talk to clinical instructor

suanna · Oct 15, 2009

I always check for placement first- that way, when I check residual I am likely to aspirate the air bubble with any gastric contents. If I check for placement after I return the gastric contents I'm just creating a "burp" and an increased chance of vomiting & aspiration. As far as not checking for placement at all- I always check before instilling ANYTHING through a gastric tube. By policy we cannot instill feeding or meds until thte tube placement has been verified with an X-Ray- Air bolus checking can be inaccurate. Better yet, some hospitals check by PH check of aspirate- more accurate but you have to pay for the litmus paper- air is free. Finally, any residual > 100cc holds the feeding unless otherwise ordered by the doctor. Personaly I wouldn't give a feeding not matter what the doctor ordered if the residual was greater that 200ccs.

SolaireSolstice, BSN, RN · Oct 15, 2009

instill 5 mls air to check placement.... why would you do it after?

Why not?

I just checked my notes and it specifically says to check residual first, then instill air and auscultate for placement. And that's the way the RNs did it in my last rotation. (I actually didn't realise how many tube feedings I would see in Pedi. I performed tube feedings on 6 of the 8 patients I had for my pedi rotation)

Honestly I don't see what the difference is, especially since one of the ways to check is to simply aspirate and check the pH.

Looking it up, it actually has a "Nurse alert": auscultation of air bolus is no longer considered a safe method of verifying placement.

"In one study, residents using auscultation incorrectly predicted that 15/16 tubes were properly positioned in the stomach (Neumann et al., 1995). Differentiating between gastric, pulmonary, esophageal, and intestinal placement cannot be accomplished by auscultation alone (Metheny, 1988; Rakel et al., 1994)." Perhaps the OP's RN was going by hospital policy that was using different means to verify placement.

http://www.medscape.com/viewarticle/707617_4

SolaireSolstice, BSN, RN · Oct 15, 2009

"I was taught to aspirate contents first, then reinstill and check for placement with air."
With reference to the above, may i ask, if we aspirate first and then reinstill it back, then only check for placement , isn't this flow lacking something? what if the location is in other location? what will happen?
and if i choose to instill air first to check for placement, the water which left in the tube (external) will go in right?

The way I was taught (and I want to say here you should do it the way YOU were taught), is to aspirate first, check for pH if that is policy, the reinstill. Then push 5-10 cc air (less for the itty bitty patients, we used about 2 ccs air). I can see why it would be a better flow to do the air first, then aspirate, but it's just the way my school taught it, and incidently, the way the RNs I worked with recently did it as well. Maybe they went to the same school I do. After a week of practising it one way, I'll have to unlearn that to try a new way, but I'll give it a try next time.

You check for placement via air auscultation with an empty syringe, never one with water in it? Or did I misunderstand your question?

what would happen and is there any risk?

If it's not in the right location, most serious would be in the lung, risk of aspiration pneumonia, pneumothorax, etc, but that is why we were talking about the failure factor of just listening for the air to check placement. But you would only be aspirating and reinstilling what is already in there. And unless your patient is seriously sedated (even if they were, having watched a bronchoscopy with brochial washing and biopsy, that patient sounded like they were choking to death and she was snowed) you would know pretty quickly that something was wrong. You will not be aspirating 10+ cc from the lung. Checking pH is more accurate, X-Ray is the only 100% method.

i have read in the book that some hospital policy need to instill back the juice, but in my hospital, we din practice it. I think it is good to reinstill it back because we need gastric juice to digest food. but i saw my hospital here practice different. ..i wonder whether the nurse work here really think about it or not...

You want to reinstill the residual because that gastric juice contains a huge amount of electrolytes and you can cause metabolic imbalances if it is discarded. However, on one of the patients I took care of in the NICU, who was devoloping necrotizing entercolitis, the MD asked us to dump the residual when the patient was made NPO. It's going to be up to the situation, the orders and the policies of the hospital. And often what we are taught is simply not the way things are done out there in the real world.

Student Cheryl · Oct 15, 2009

"You check for placement via air auscultation with an empty syringe, never one with water in it? Or did I misunderstand your question?"

It is like that actually. Normally after feeding, we will not let the air go in to the the tube right? so, our last feeding is flush with water and left the water content inside the external tube. There will have no air bubbles or the formula left at external tube. So, since the water is there already...when it is my turn to do feeding, i must check the placement. Then if i instill some air inside, the water along the external tube will go in right? will i cause any harm to my client?

Student Cheryl · Oct 16, 2009

If it's not in the right location, most serious would be in the lung, risk of aspiration pneumonia, pneumothorax, etc, but that is why we were talking about the failure factor of just listening for the air to check placement. But you would only be aspirating and reinstilling what is already in there. And unless your patient is seriously sedated (even if they were, having watched a bronchoscopy with brochial washing and biopsy, that patient sounded like they were choking to death and she was snowed) you would know pretty quickly that something was wrong. You will not be aspirating 10+ cc from the lung. Checking pH is more accurate, X-Ray is the only 100% method.

Thanks for answering my question. i appreciate it very much.

SolaireSolstice, BSN, RN · Oct 16, 2009

You check for placement BEFORE feeding, with an empty tube. Once the feeding is done, and you flush with water, you close off the tube. You are done at that point.

The way I was taught was to take the water in another container, like a cup. Do the initial placement check and residual check, then feed, then pour the water in.

If you have already checked for placement, and it is in the stomach, there will be no harm of the water going in.

My instructors were never worried about (a little) air going in the stomach. I remember one of them being asked sort of that same question and her saying "they'll just fart or burp it out".

On the X-Ray, definitely initial x-ray to check placement. After that it will be up to the protocol or MD orders. And no, you wouldn't use an X-ray to check placement at every feeding.

Student Cheryl · Oct 16, 2009

http://www.medscape.com/viewarticle/707617_4

Thanks for the website given.... it's very informative.

Student Cheryl · Oct 16, 2009

ooh...now i am much clear with the situation. Thanks.

Another question:

1. as for my client, he got 156ml aspirated residual. Then i stop giving feeding with formula but still giving him the medication. Will it influence the absorption of the medication?

i am feeling so insecure with it, cause i already aspirated out all his gastric juice and residual without putting it back and then still give him the medication with water..... i find it really wrong...it might cause irrigation to his stomach right? i think i should have instill back the gastric juice in... what would you do, if you are in my situation?