Prioritizing!!!
You should check tube placement prior to initiating the feeding. You have just received the patient from another floor. The tube may have moved or migrated and could be displaced other than in the stomach. You should always check tube placement prior to feeding. In addition, the nurse’s report did not include that the nurse used any safe or acceptable methods of assessing tube placement.
Once tube placement is confirmed by a safe and acceptable method, you may start the NGT feeding.
Troubleshooting!!!
The most common problems associated with not being able to obtain an aspirate include:
o one of the tubes’ ports remains open
o the tube is not situated in a pocket of fluid.
Use the following approaches to try to address the situation:
Advance the tube (5-10 cm) and repeat the aspirate test. The NG tube may be situated in the air space above the aspirate.
The tip of the tube may be sitting against the gastric mucosa. Inject 10 mL of air into the stomach to push the port away from the mucosa. Repeat the aspirate test.
If intestinal placement is suspected, for example a pH of 4-6, withdraw the tube 5-10 cm and repeat the aspirate test
If still no aspirate is obtained, lie the patient to his/her left side, wait 10-15 minutes and attempt to aspirate again. The change in position will allow the fluid in the stomach to move making aspiration easier.
Further Assessment:
Assess patient’s GI system including: bowel sounds, presence of nausea or vomiting, abdominal distention.
TUBE CHECK KEY
NOTE: You must always check with your hospital/facility protocol when choosing a method of checking tube placement.
Whoosh test: insufflation of air into the into the NGT while listening over the abdomen with a stethoscope for a distinctive “whooshing” sound.
Unsafe: It has been shown to be unreliable because the sound emitted is generalized over the abdomen and there is difficulty differentiating between lung, esophageal, or gastric placement using this method.
Aspiration of gastric contents to check pH
Safe: the NPSA (National Patient Safety Agency) suggests that 0.5 – 1 mL of aspirate is sufficient to test pH. This is a safe method given that the nurse is able to obtain aspirate and is able to accurately read and interpret the readings.
Gastric placement is usually indicated by a pH of <4, but may increase to between 4-6 if the patient is receiving acid-inhibiting drugs.
Aspiration of visually recognizable gastric contents
Safe but has limitations: This method of confirmation can only be used in patients who have an intact swallow and are able to take a drink orally. The patient is asked to drink a visually identifiable liquid such as milk or black currant juice that indicates gastric placement is aspirated back up to the nasogastric juice.
Blue litmus paper
Unsafe: This is insufficiently sensitive in distringuishing between levels of acidity. This is because the paper changes color in the presence of acid rather than defining the exact pH value. A bronchial placement with a pH of 6 will indicate acidity on the litmus paper leading to the possible use of incorrectly placed NGT with disastrous consequences.
XRay
Safe: This is the most accurate method of identifying the position of the tip of a NGT following insertion.
Absence of respiratory distress
Unsafe: Respiratory distress is less likely to occur with the use of small bore tubes. The absence of respiratory distress should not be interpreted as an indicator of correct positioning. Patients who are unconscious or do not have effective gag reflex will not exhibit signs of coughing or cyanosis expected with intubation into the bronhical tract, even in some instances with the use of large bore tubes
Observing for air bubbles
Unsafe: The assumption is that if the tube has been placed in the lungs, the bubbles will be seen on expiration. However, gas bubbles may be produced I the stomach. Reliance on this method could falsely indicate respiratory placement and may result in a correctly positioned tube being needlessly removed.