Dear UMMC, Fairview patient care staff, Because of safety concerns, the American Association of Critical Care Nursing has changed the practice guidelines for verification of correct placement of NG and OG tubes being used for instillation of liquids. Verification by auscultation is no longer considered safe practice. This represents a change from what has been taught for decades. This learning packet presents the changes required for our practice, and our policy, as well as the documentation requirements. The gold standard for verification of placement continues to be an X-ray. There are certain clinical conditions which pose extra risk for incorrect placement. Patients with these conditions will always require X-ray verification. Those patient populations are identified in this packet. There are situations however, when other criteria can be safely utilized to determine placement. This packet identifies when and under what circumstances we can utilize the different methods of verification. The process begins with making the determination if the patient fits into one of the “high risk” populations. The self-learning packet presents initial procedures for verification of placement after blindly placing a gastric tube, and then presents verification procedures to use when caring for patients receiving intermittent or continuous medications and feedings. Please make special note that there may be situations where a tube is placed in the OR but not used for any instillation of meds or feedings and that initial placement verification must then occur when or if the tube is later used for these purposes. All UMCH, Fairview staff that insert and/or use feeding tubes are required to complete this packet

Note contraindications to blind placement:

• Patients with head trauma, maxillofacial injury, or anterior fossa fractures

• Patients with esophageal varices

Must verify placement prior to instillation of fluid or medication

Assess if patient is high or low risk for error in placement.

*High Risk Patients Include Patients With Any of the

Following • Cervical spine injuries • Craniofacial trauma • Reduced or absent cough

and/or gag reflexes • Confusion • Decreased LOC or who are

sedated • Retching or vomiting • ETT or trach in place • Recently extubated • Restless, agitated or have

increased levels of activity • All ED patients • Abdominal distention

*High Risk (see above)

Verify and document placement by X-ray (requires MD order)

Low Risk=anyone who is not high risk

**Verify and document placement by two of the three following methods.

#2 Aspirate and

inspect appearance

#1 Aspirate

And Test pH

#3 Verify that respiratory

status has not changed

following insertion

If you are unable to verify by two methods you must go back and

verify by X-ray

**Low Risk Verification Methods #1. pH needs to be 5 or less to confirm placement by this method (send specimen to lab to do pH fluid panel for ng/og placement) #2 Inspection of aspirate must confirm gastric contents which appear grassy green or clear and colorless with off-white mucus shreds or residual food/formula #3. Verification that respiratory status has not changed:

• No increase in respiratory distress • No change in O2 sats if monitored

or change in skin color • No persistent coughing • No change in ability to vocalize (if

applicable)

Blind placement of an oro/nasal gastric tube.

Once placed, mark tube where it exits the mouth/nose, tape in place, and chart tube length in kardex and FCIS.

Assess risk for tube migration or dislodgement.

Is the patient experiencing retching, vomiting, severe bouts of coughing, or

frequent nasotracheal suctioning?

Yes=High Risk No=Low Risk

Ongoing assessment of oro/nasal gastric tube use

(Placement needs to be confirmed prior to every intermittent use.)

Intermittent Use Continuous Use Intermittent Use Continuous Use

Confirm and document placement verification at the

beginning of the shift. Visual confirmation that original placement mark is at the

nose/mouth must be made before each instillation for the

remainder of the shift.

Confirm and document placement verification at the beginning of the shift.

Confirm and document placement verification at the beginning of the shift and

before each instillation.

Confirm and document placement verification at the beginning of the shift.

Verification for the high-risk patient

must include assessing and documenting one of the following methods of verification:

1. Aspirate and test pH 2. Aspirate and inspect appearance 3. A recent X-ray that verifies location

If at any point the tube

has moved from its original position,

reposition and confirm by the initial placement

process.

If unable to verify and risk is high, replace tube and verify placement

again or get an order for X-ray

confirmation.

Verification for the low-risk patient

can be made by assessing and documenting that the tube is secure and that the landmark or length has not changed since

initial placement.

Documenting ng/og placement and assessment in FCIS.

1. Select assessment flow sheet and under GI add the parameter for naso/oral tube.

2. Click on type of tube and indicate the type of tube if known or free text in the type of tube being inserted or used.

3. Select risk and document if the patient is: • High or low risk for placement error when tube being inserted OR • High or low risk for migration of a previously inserted tube

4. Select placement and identify where the tube is placed and how initial placement verified. Identify if any change in respiratory status following insertion here. If verified by pH as one method make sure to document pH in free text area at the bottom of the box. If verified by aspiration as one method, chart this under step 6. Chart distance from insertion site to end of tube hub in free text area here and on the kardex.

5. Select tube securement and • Check appropriate choice for tape securement • Check landmark visible when assessing for migration before intermittent use

6. Select consistency and color • Identify aspirate consistency and color selecting the correct items or free text data in the free text box.

Category: 7/27/2006 revised 8/18/06 revised

Subject: NG/OG Tube, Inserting and checking placement

Purpose: To provide guidelines for insertion and verification of placement of a gastric tube prior to its use to instill fluids.

Refer to NICU web site for procedures appropriate to the NICU population

Policy:

1. Blindly placed oro/nasal gastric tubes must be verified for correct placement before the tube may be used for instillation of fluid or medication.

2. Prior to every intermittent use, nasal and oral gastric tube placement must be confirmed.

3. X-ray verification of initial placement is required for ED patients and for all patients for whom blind placement is contraindicated and all patients assessed to be high risk as defined below.

4. Note: gastric tubes placed only for decompression or suction (such as in the operating room) do not need to have placement verified as per this policy. If the tube should be used at a later date for instillation, placement would have to be verified at that time.

Contraindications to blind placement: • Patients with head trauma, maxillofacial injury or anterior

fossa fractures. • Patients with esophageal varices

High risk patients: Certain patient populations are at increased risk for mal-positioned

oral or nasal gastric tubes:

• Patients with cervical spine injuries • Patients with craniofacial trauma • Patients with reduced or absent cough and/or gag reflexes • Patients who are confused

• Patients who have decreased level of consciousness or are sedated.

• Patients who are retching/vomiting • Patient with endotracheal tubes in place • Patients recently extubated • Patients who are restless, agitated or have increased levels of

activity • Patients with abdominal distension

Placement of a tube into the small bowel requires an X-ray to confirm placement.

Nursing considerations: 1. Use the smallest tube possible to minimize stress on the esophageal

sphincter. 2. If possible, elevate the head of the bed to 30-45 degrees to prevent

aspiration 3. If the patient is unconscious, advance the tube between respirations

Procedure:

to reduce the likelihood of the tube entering the trachea. 4. Watch for symptoms of hypoxia and remove if necessary 5. If the patient has a nasal condition that prevents insertion through the

nose, the tube is passed through the mouth. 6. Even if initially placed correctly, all types of tubes may dislocate,

frequently with no outward sign that dislocation has occurred. (Ellet, et al, 1998); therefore, placement must be checked prior to every intermittent use.

7. Pre-printed order sets exist which cue physicians to authorize nursing to initiate either/or X-ray verification or fluid pH verification.

Initial Tube Placement Procedure Emergency Department policies require x-ray verification of tube placement on all patients.

1. Obtain order from physician to insert tube. 2. Explain procedure to the patient, emphasizing how mouth

breathing, panting and swallowing will help in passing the tube. 3. Place the patient in a sitting or high Fowlers position if at all

possible. 4. Measure the desired length and mark the tube with tape or a

marker as a guide for the length to insert. Measure the tube from tip of the nose to tip of the earlobe and then down to the xiphoid process.

5. Have patient blow nose to clear nostrils, if possible.

6. Inspect the nostrils for any obstruction. 7. Lubricate the tip of the tube with water-soluble lubricant. 8. Tilt the patient’s head back before inserting the tube into the

nostril, and gently pass the tube into the posterior nasopharynx, directing it downward and backwards towards the ear.

9. Have the patient tilt the head slightly forward, have the patient swallow, with or without water, while continuing to advance the tube.

10. Gently rotate the tube 180 degrees to redirect the curve in the tube towards the front of the body.

11. If tube appears obstructed, do not use force. Try rotating the tube and directing the tip in a slightly different angle. If unable to pass, remove the tube and try the other nare.

12. Monitor for symptoms of respiratory distress indicating the tube may be placed in the airway. If the patient experiences coughing, gasping, cyanosis or inability to vocalize, remove the tube immediately.

13. Advance the tube until the pre-marked area reaches the patient’s nostril.

14. Have someone stabilize the tube while another person verifies the tube is in the correct position.

15. Verify and document placement by X-ray (requires MD order) or by using two of the three following ways: a. Aspirate and test pH through the Acute Care Lab. A pH

of 5 or less indicates placement in the stomach. If the patient is receiving continuous feeds or H2 blockers (Cimetidine, ranitidine), the pH could be higher than 5, even if the tube is

properly placed. In this case this method may not yield useful data.. • If placed in the small bowel, the pH is usually 6 or

greater. • If placed in the tracheobronchial tree or pleural

space, the pH is usually 6 or greater. b. Aspirate and inspect the appearance of the aspirate.

• Gastric contents are usually grassy-green or clear and colorless, with off-white or tan mucus shreds or residual food/formula.

• Small bowel aspirate is usually bile stained, ranging in color from light to golden yellow or brownish-green, and is usually thicker and more translucent than fluid withdrawn from the stomach.

• Tracheo-bronchial aspirate has the appearance of fluid obtained during tracheal suctioning: straw colored with water, perhaps tinged with bright red blood

c. Confirm and document that the patient’s respiratory status has not changed following insertion of the tube, as evidenced by: • Respiratory sounds have not changed (no wheeze or other

change)

• Respiratory distress has not appeared or become greater • There is no persistent coughing • There is no change in SaO2 (if monitored) or change in

skin color

• There is no change in ability to vocalize, if appropriate 16. If unable to obtain aspirate, an X-ray will be necessary to confirm

placement. 17. Anchor the tube with tape or other securement device.. 18. Anchor the tubing to the patient’s gown to prevent pulling and

minimize discomfort 19. Keep head of bed elevated to minimize gastro-esophageal reflux..20. Record the time, type and size of tube inserted. Document

method of verification of placement. 21. Measure the length of tubing from the insertion site to the end

(from nare/mouth to the very end of the connection piece) and record that length on the Kardex or patient record. Mark the tube at the insertion site to facilitate identification of movement of the tube.

Ongoing assessment Procedure:

1. Confirm placement prior to every intermittent use (nasal and oral gastric tube). See algorithm-- LINK here

a. Assess patient as low risk or high risk for tube migration. See chart below. Patients who display retching, vomiting, severe bouts of coughing or are frequently being suctioned nasally are defined as high risk for tube migration.

b. Measure and document the distance from the tube’s exit site at the nose or mouth to the end of the tube or visualize external landmark. A change in the length of the tube is

frequently an indication that the tube has migrated “If the risk of dislodgement is low” “and the tube has remained taped in its original position, it is reasonable to begin the next feeding.” (Metheny and Titler, 2001) Standard practice includes confirmation and documentation of placement verification at the beginning of the shift and visual confirmation of tube placement throughout the shift for low risk patients before instillation.

c. If the risk of migration is high, assess securement and external length of tube/visible landmark, then aspirate and test for pH or inspect appearance of fluid to confirm gastric placement. Documentation for high risk patients will be done with each use.

d. A recent chest or abdominal x-ray may verify location.

2. If unable to verify and risk is high, replace the tube and verify placement again or get an order for X-ray confirmation.

3. During continuous feeding or medication, use techniques above and document verification every shift.

LINK TO algorithm

External Ref: AACN Procedure Manual Fifth Edition 2005 AACN Practice Alert “Verification of Feeding Tube Placement” Vol 22 No 5, May 2005.

Internal Ref:

Source: AACN News, Practice Alert: Verification of Feeding Tube Placement, Vol 22, No 5, May 2005.

Ellet M, Maahs J, Forsee S. Prevalence of feeding tube placement errors and associated risk factors in children. Am Journal of Maternal Child Nursing. 1998;23(5):243-239.

Lippincott Manual of Nursing Practice, 8th ed., p. 631-635, 1406-1407.

Metheny, NA, Titler MG. Assessing Placement of Feeding Tubes. American Journal of Nursing, May 2002, Vol 101, # 5, 36-45.

Gottsclich MM. The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. American Society for Parenteral and Enteral Nutrition (ASPEN). Kendall/Hunt Publishing. Dubuque, IA. 2001. (Chapter 9: Complications of Enteral Nutrition Therapy).

Approved by: Nursing Practice Council

Date Effective: 9/06

Date Revised:

Date Reviewed:

Category: 7/27/2006 revised 8/18/06 revised

Subject: NG/OG Tube, Inserting and checking placement

Purpose: To provide guidelines for insertion and verification of placement of a

gastric tube prior to its use to instill fluids.

Refer to NICU web site for procedures appropriate to the NICU population

Policy:

5. Blindly placed oro/nasal gastric tubes must be verified for correct placement before the tube may be used for instillation of fluid or medication.

6. Prior to every intermittent use, nasal and oral gastric tube placement must be confirmed.

7. X-ray verification of initial placement is required for ED patients and for all patients for whom blind placement is contraindicated and all patients assessed to be high risk as defined below.

8. Note: gastric tubes placed only for decompression or suction (such as in the operating room) do not need to have placement verified as per this policy. If the tube should be used at a later date for instillation, placement would have to be verified at that time.

Contraindications to blind placement: • Patients with head trauma, maxillofacial injury or anterior

fossa fractures. • Patients with esophageal varices

High risk patients: Certain patient populations are at increased risk for mal-positioned

oral or nasal gastric tubes:

• Patients with cervical spine injuries • Patients with craniofacial trauma

• Patients with reduced or absent cough and/or gag reflexes • Patients who are confused • Patients who have decreased level of consciousness or are

sedated. • Patients who are retching/vomiting • Patient with endotracheal tubes in place • Patients recently extubated • Patients who are restless, agitated or have increased levels of

activity • Patients with abdominal distension

Placement of a tube into the small bowel requires an X-ray to confirm placement.

Nursing considerations: 8. Use the smallest tube possible to minimize stress on the esophageal

sphincter. 9. If possible, elevate the head of the bed to 30-45 degrees to prevent

aspiration 10. If the patient is unconscious, advance the tube between respirations

to reduce the likelihood of the tube entering the trachea. 11. Watch for symptoms of hypoxia and remove if necessary 12. If the patient has a nasal condition that prevents insertion through the

nose, the tube is passed through the mouth. 13. Even if initially placed correctly, all types of tubes may dislocate,

frequently with no outward sign that dislocation has occurred. (Ellet,

Procedure:

et al, 1998); therefore, placement must be checked prior to every intermittent use.

14. Pre-printed order sets exist which cue physicians to authorize nursing to initiate either/or X-ray verification or fluid pH verification.

Initial Tube Placement Procedure Emergency Department policies require x-ray verification of tube placement on all patients.

22. Obtain order from physician to insert tube. 23. Explain procedure to the patient, emphasizing how mouth

breathing, panting and swallowing will help in passing the tube. 24. Place the patient in a sitting or high Fowlers position if at all

possible. 25. Measure the desired length and mark the tube with tape or a

marker as a guide for the length to insert. Measure the tube from tip of the nose to tip of the earlobe and then down to the xiphoid process.

26. Have patient blow nose to clear nostrils, if possible. 27. Inspect the nostrils for any obstruction. 28. Lubricate the tip of the tube with water-soluble lubricant. 29. Tilt the patient’s head back before inserting the tube into the

nostril, and gently pass the tube into the posterior nasopharynx, directing it downward and backwards towards the ear.

30. Have the patient tilt the head slightly forward, have the patient swallow, with or without water, while continuing to advance the

tube. 31. Gently rotate the tube 180 degrees to redirect the curve in the

tube towards the front of the body. 32. If tube appears obstructed, do not use force. Try rotating the tube

and directing the tip in a slightly different angle. If unable to pass, remove the tube and try the other nare.

33. Monitor for symptoms of respiratory distress indicating the tube may be placed in the airway. If the patient experiences coughing, gasping, cyanosis or inability to vocalize, remove the tube immediately.

34. Advance the tube until the pre-marked area reaches the patient’s nostril.

35. Have someone stabilize the tube while another person verifies the tube is in the correct position.

36. Verify and document placement by X-ray (requires MD order) or by using two of the three following ways: a. Aspirate and test pH through the Acute Care Lab. A pH

of 5 or less indicates placement in the stomach. If the patient is receiving continuous feeds or H2 blockers (Cimetidine, ranitidine), the pH could be higher than 5, even if the tube is properly placed. In this case this method may not yield useful data.. • If placed in the small bowel, the pH is usually 6 or

greater.

• If placed in the tracheobronchial tree or pleural space, the pH is usually 6 or greater.

b. Aspirate and inspect the appearance of the aspirate. • Gastric contents are usually grassy-green or clear

and colorless, with off-white or tan mucus shreds or residual food/formula.

• Small bowel aspirate is usually bile stained, ranging in color from light to golden yellow or brownish-green, and is usually thicker and more translucent than fluid withdrawn from the stomach.

• Tracheo-bronchial aspirate has the appearance of fluid obtained during tracheal suctioning: straw colored with water, perhaps tinged with bright red blood

d. Confirm and document that the patient’s respiratory status has not changed following insertion of the tube, as evidenced by: • Respiratory sounds have not changed (no wheeze or other

change) • Respiratory distress has not appeared or become greater • There is no persistent coughing • There is no change in SaO2 (if monitored) or change in

skin color • There is no change in ability to vocalize, if appropriate

37. If unable to obtain aspirate, an X-ray will be necessary to confirm placement.

38. Anchor the tube with tape or other securement device.. 39. Anchor the tubing to the patient’s gown to prevent pulling and

minimize discomfort 40. Keep head of bed elevated to minimize gastro-esophageal reflux..41. Record the time, type and size of tube inserted. Document

method of verification of placement. 42. Measure the length of tubing from the insertion site to the end

(from nare/mouth to the very end of the connection piece) and record that length on the Kardex or patient record. Mark the tube at the insertion site to facilitate identification of movement of the tube.

Ongoing assessment Procedure:

4. Confirm placement prior to every intermittent use (nasal and oral gastric tube). See chart below or algorithm LINK here

a. Assess patient as low risk or high risk for tube migration. See chart below. Patients who display retching, vomiting, severe bouts of coughing or are frequently being suctioned nasally are defined as high risk for tube migration.

b. Measure and document the distance from the tube’s exit site at the nose or mouth to the end of the tube or visualize external landmark. A change in the length of the tube is frequently an indication that the tube has migrated “If the risk of dislodgement is low” “and the tube has remained taped in its original position, it is reasonable to begin the next feeding.” (Metheny and Titler, 2001) Standard practice includes confirmation and documentation of placement verification at the beginning of the shift and visual

confirmation of tube placement throughout the shift for low risk patients before instillation.

c. If the risk of migration is high, assess securement and external length of tube/visible landmark, then aspirate and test for pH or inspect appearance of fluid to confirm gastric placement. Documentation for high risk patients will be done with each use.

d. A recent chest or abdominal x-ray may verify location.

5. If unable to verify and risk is high, replace the tube and verify placement again or get an order for X-ray confirmation.

6. During continuous feeding or medication, use techniques above and document verification every shift.

LINK TO CHART

External Ref: AACN Procedure Manual Fifth Edition 2005 AACN Practice Alert “Verification of Feeding Tube Placement” Vol 22 No 5, May 2005.

Internal Ref:

Source: AACN News, Practice Alert: Verification of Feeding Tube Placement, Vol 22, No 5, May 2005.

Ellet M, Maahs J, Forsee S. Prevalence of feeding tube placement errors and associated risk factors in children. Am Journal of Maternal Child Nursing. 1998;23(5):243-239.

Lippincott Manual of Nursing Practice, 8th ed., p. 631-635, 1406-1407.

Metheny, NA, Titler MG. Assessing Placement of Feeding Tubes. American Journal of Nursing, May 2002, Vol 101, # 5, 36-45.

Gottsclich MM. The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. American Society for Parenteral and Enteral Nutrition (ASPEN). Kendall/Hunt Publishing. Dubuque, IA. 2001. (Chapter 9: Complications of Enteral Nutrition Therapy).

Approved by: Nursing Practice Council

Date Effective: 9/06

Date Revised:

Date Reviewed: