Professional Documents
Culture Documents
Placement Verification
Continuing
Nursing
In Pediatric and Neonatal
Education
Series
Patients
Michele Farrington Laura Cullen
Sheryl Lang Stephanie Stewart
This article reports an evidence-based practice project using the Iowa Model of Evidence-Based Practice to
Promote Quality Care for a common nursing procedure, nasogastric tube placement verification in children.
Little research exists regarding the care of nasogastric tubes in children, and traditional verification methods
prevail. Auscultation of air insufflation over the abdomen is still used to check placement in many settings,
despite research dating back to the 1980s questioning this approach. X-ray remains the only certain way to
verify placement, but getting an X-ray before each feeding would be costly and impractical. Additional bedside
methods are needed. Project results demonstrate a decrease (93.3% to 46.2%) in the use of auscultation and
improved use of other, more reliable methods to determine nasogastric tube placement. Changing practice can
be challenging. However, with persistence and re-infusion, this project provides an important example of how
the evidence-based practice process leads to excellence and improves patient care.
ediatric nurses have always based on the strongest research evi- minimize the risk of incorrectly placed
Is this Topic
Consider No a Priority
Other
For the
Triggers
Organization?
Yes
Form a Team
Is There
Yes a Sufficient No
Research
Base?
Is Change
Continue to Evaluate Quality No Appropriate for Yes
Institute the Change in Practice
of Care and New Knowledge Adoption in
Practice?
Copyright © 2001. University of Iowa Hospitals and Clinics and Marita Titler. Reproduced with permission from Marita G. Titler, PhD,
RN, FAAN. For permission to use or reproduce the model, please contact the University of Iowa Hospitals and Clinics, Department
of Nursing, at 319-384-9098.
focus trigger with new information (Wilkes-Holmes, 2006). Expanded Titler, 2001; Swiech et al., 1994).
suggesting use of a patient’s height search strategies included personally However, studies have shown that the
and a graph (graphic method) as a contacting experts about their work expected pulmonary symptoms may
better method for determining depth regarding NG tubes in pediatric not be present to indicate there is a
of NG tube insertion in children patients (J. Beckstrand, personal problem until shortly after the feeding
(Klasner, Luke, & Scalzo, 2002). The communication, April 12, 2003; A.E. has been initiated, as evidenced by
team was developed to support the Klasner, personal communication, symptoms such as shortness of
staff nurse as the project director April 2, 2003 and April 3, 2003; N.A. breath, fever, and even respiratory
through the Evidence-Based Practice Metheny, personal communication, arrest (Swiech et al., 1994). It is also
Staff Nurse Internship. An extensive April 2, 2003). important to remember that these
literature review was conducted, cur- In adult patients, the rate of NG signs may be absent in either uncon-
rent practice was evaluated, and prac- tube misplacement ranges from 1.3% scious patients or those with a poor
tice changes were implemented utiliz- to 89.5% (McWey et al., 1988; Niv & gag reflex (Colagiovanni, 1999).
ing a variety of strategies. This change Abu-Avid, 1988), depending on how Soft, small-bore NG tubes are less
was evaluated at multiple points fol- the error is defined, and averages likely to cause complications and also
lowing implementation. This article about 4% (Ghahremani & Gould, reduce the risk of aspiration because
reports some of the more interesting 1986; Kearns, 1997). The prevalence the lower esophageal sphincter is less
results and processes used to imple- of NG tube placement errors in chil- compromised, decreasing the risk of
ment this change. dren is difficult to determine because reflux (Boyes & Kruse, 1992;
of the differing definitions across stud- Metheny, 1988), but they may migrate
Synthesis of Evidence ies; however, rates of misplacement in out of position, knot, occlude, or rup-
The project began in 2003, with lit- children have been reported at 21% to ture (Williams & Leslie, 2004).
tle evidence supporting use of height 43.5% (Ellett & Beckstrand, 1999; Negative pressure generated when
and the graphic method to determine Ellett et al., 2005; Ellett, Maahs, & attempting to aspirate fluid can cause
proper insertion depth for NG tubes. Forsee, 1998), which is concerning these flexible NG tubes to collapse.
Therefore, the project focus changed for these vulnerable infants and chil- Certain types of NG tubes are report-
from measuring for tube insertion to dren (Crisp, 2006). Poor reporting of ed to collapse in 50% of aspiration
using other evidence-based methods tube misplacement has hindered the attempts (Gharib et al., 1996; Rakel,
to ensure NG tube placement verifica- adoption of effective protocols to pre- 2004). In these cases, nurses are
tion. vent such errors (Metheny et al., unable to use aspiration of gastric
The traditional method of assess- 2007). In children, several risk factors contents as a method to verify NG
ing NG tube placement has been aus- have been identified for initial tube tube placement (Ellett & Beckstrand,
cultation over the abdomen after air misplacement or subsequent dis- 1999; May, 2007; Metheny et al.,
insufflation because it is a simple and lodgement, including age (younger), 1986; Metheny, Stewart et al., 1999).
low-cost method (Eisenberg, 1994), is level of consciousness (comatose or In some situations, even if fluid is not
easy to perform (Metheny, Wehrle, semicomatose), abdominal distention, obtained with aspiration, the NG tube
Wiersema, & Clark, 1998), and was vomiting, and dysphagia (Ellett & is later found to be properly positioned
taught for years in nursing schools. Beckstrand, 1999; Ellett et al., 1998). by another verification method, usual-
Although this is a frequently used Although NG tubes are identified ly X-ray (Swiech et al., 1994).
method in the clinical setting, research as being misplaced infrequently, sig- However, aspiration of fluid alone is no
literature does not support the reliabil- nificant adverse outcomes can result, guarantee that the NG tube is correct-
ity of this method (Ellett, 2004; Ellett, such as aspiration pneumonia or ly placed in the stomach (Widmann,
Croffie, Cohen, & Perkins, 2005; pneumothorax (Burns, Carpenter, & 1985).
Metheny, Aud, & Ignatavicius, 1998; Truwit, 2001). Tube misplacement Ellett (2004) published the follow-
Metheny, Meert, & Clouse, 2007; into the lungs is most common and ing information regarding methods to
Swiech, Lancaster, & Sheehan, 1994; is estimated to occur in 5% of all NG determine NG tube placement that
Winterholler & Erbguth, 2002), and tube insertions (Ellett, 2004), and have been studied in adults: aspirating
malpractice cases have been based on feeding through an NG tube mis- gastric contents and measuring the
this research (McWey, Curry, Schabal, placed into the airway will result in pH; measuring bilirubin, pepsin, and
& Reines, 1988; Metheny, Wehrle et al., pulmonary aspiration (Ellett et al., trypsin levels; examining the visual
1998). The primary problem with aus- 1998). Even when the NG tube characteristics of the aspirate; placing
cultation is that sounds can be trans- remains taped in place, the tube’s the proximal end of the tube under
mitted to the epigastrium regardless of distal tip could spontaneously shift water and observing for bubbles with
whether the NG tube is placed in the upward or downward from its origi- expiration; measuring the carbon
lung, esophagus, stomach, duode- nal position (Huffman, Pieper, dioxide (CO2) level at the proximal
num, or proximal jejunum (Cannaby, Jarczyk, Bayne, & O’Brien, 2004; end of the NG tube; auscultating for a
Evans, & Freeman, 2002; Eisenberg, Metheny, Spies, & Eisenberg, 1986; gurgling sound over the abdomen;
1994; Ellett & Beckstrand, 1999; Richardson, Branowicki, Zeidman- and measuring the length from the
Gharib, Stern, Sherbin, & Rohrmann, Rogers, Mahoney, & MacPhee, nose to the proximal end of the tube.
1996; Metheny, McSweeney, Wehrle, & 2006), something that is even more In the end, the conclusion for adult
Wiersema, 1990; Metheny, Wehrle et likely with the soft, small-bore NG patients was that only pH and bilirubin
al., 1998). tubes (Sanko, 2004). When placing of aspirates have proven to be reliable,
The majority of research or evi- NG tubes, it is common to observe for inexpensive bedside tests. Aspiration
dence regarding the use of NG tubes is coughing or cyanosis because they of gastric contents and pH measure-
in adult patients and was pioneered by may indicate respiratory placement ments are both simple and cost-effec-
Norma Metheny in the late 1980s with (Boyes & Kruse, 1992; Chen, Paxton, tive ways to determine NG tube place-
scant evidence for pediatric patients, & Williams-Burgess, 1996; Metheny, ment (Chen et al., 1996; Westhus,
possibly due to ethical considerations Smith, & Stewart, 2000; Metheny & 2004). Based on the work completed
tice changes adopting use of this evi- Colagiovanni, L. (1999). Nutrition: Taking the tutional protocols on adverse events
dence have not occurred at the same tube. Nursing Times, 95(21), 63-64, 67, related to feeding tube placement in the
rate. Despite the fact that auscultation 71. critically ill. Journal of the American
is ineffective, changing long-standing Crisp, C.L. (2006). Esophageal nasogastric College of Surgeons, 199(1), 39-47.
tube misplacement in an infant following May, S. (2007). Critical care. Testing nasogas-
traditional nursing care practices can laser supraglottoplasty. Journal of tric tube positioning in the critically ill:
be difficult. This project demonstrated Pediatric Nursing, 21(6), 454-455. Exploring the evidence. British Journal
that verification of NG tube placement Cullen, L., & Titler, M.G. (2004). Promoting of Nursing, 16(7), 414-418.
in children and neonates is a complex evidence-based practice: An internship McWey, R.E., Curry, N.S., Schabal, S.I., &
patient care issue, and that more for staff nurses. Worldviews on Reines, H.D. (1988). Complications of
research is needed to support many Evidence-Based Nursing, 1(4), 215- nasoenteric feeding tubes. American
pediatric nursing practices. Despite 223. Journal of Surgery, 155(2), 253-257.
the challenges, basing practice on the Eisenberg, P.G. (1994). Nasoenteral tubes. Metheny, N. (1988). Measures to test place-
best available evidence will improve RN, 57(10), 62-70. ment of nasogastric and nasointestinal
Ellett, M.L. (2004). What is known about feeding tubes: A review. Nursing
patient care. The key to evidence- methods of correctly placing gastric Research, 37(6), 324-329.
based practice is involving the staff tubes in adults and children. Gastro- Metheny, N.A. (2006). Preventing respiratory
who “do the work” to ensure their enterology Nursing, 27(6), 253-261. complications of tube feedings:
input in problem-solving and process Ellett, M.L.C., & Beckstrand, J. (1999). Evidence-based practice. American
changes, closing the gap between Examination of gavage tube placement Journal of Critical Care, 15(4), 360-369.
research and practice. in children. Journal of the Society of Metheny, N.A., Aud, M.A., & Ignatavicius,
Pediatric Nurses, 4(2), 51-60. D.D. (1998). Detection of improperly
Ellett, M.L.C., Croffie, J.M.B., Cohen, M.D., & positioned feeding tubes. Journal of
References Perkins, S.M. (2005). Gastric tube Healthcare Risk Management, 18(3),
Arbogast, D. (2002). Enteral feedings with placement in young children. Clinical 37-48.
comfort and safety. Clinical Journal of Nursing Research, 14(3), 238-252. Metheny, N.A., Clouse, R.E., Clark, J.M.,
Oncology Nursing, 6(5), 275-283. Ellett, M.L.C., Maahs, J., & Forsee, S. (1998). Reed, L., Wehrle, M.A., & Wiersema, L.
American Association of Critical-Care Prevalence of feeding tube placement (1994). pH testing of feeding-tube aspi-
Nurses. (2005). Practice alert: Verifi- errors and associated risk factors in rates to determine placement. Nutrition
cation of feeding tube placement. Re- children. MCN: The American Journal of in Clinical Practice, 9(5), 185-190.
trieved December 30, 2008, from Maternal/Child Nursing, 23(5), 234-239. Metheny, N.A., Eikov, R., Rountree, V., &
http://classic.aacn.org/AACN/practiceAl Freer, Y., & Lyon, A. (2005). Nasogastric tube Lengettie, E. (1999). Indicators of feed-
ert.nsf/Files/VOFTP/$file/Verification%2 aspirate pH values associated with typi- ing tube placement in neonates.
0 o f % 2 0 F e e d i n g % 2 0 Tu b e % 2 0 cal enteral feeding patterns in infants Nutrition in Clinical Practice, 14(6), 307-
Place ment%2005-2005.pdf admitted to an NICU. Journal of 314.
Beckstrand, J., Ellett, M.L.C., & McDaniel, A. Neonatal Nursing, 11(3), 106-109. Metheny, N.A., McSweeney, M., Wehrle,
(2007). Predicting internal distance to Ghahremani, G.G., & Gould, R.J. (1986). M.A., & Wiersema, L. (1990). Effective-
the stomach for positioning nasogastric Nasoenteric feeding tubes: Radio- ness of the auscultatory method in pre-
and orogastric feeding tubes in children. graphic detection of complications. dicting feeding tube location. Nursing
Journal of Advanced Nursing, 59(3), Digestive Diseases and Sciences, Research, 39(5), 262-267.
274-289. 31(6), 574-585. Metheny, N.A., & Meert, K.L. (2004).
Bercik, P., Schlageter, V., Mauro, M., Gharib, A.M., Stern, E.J., Sherbin, V.L., & Monitoring feeding tube placement: A
Rawlinson, J., Kucera, P., & Armstrong, Rohrmann, C.A. (1996). Nasogastric review. Nutrition in Clinical Practice,
D. (2005). Noninvasive verification of and feeding tubes: The importance of 19(5), 487-495.
nasogastric tube placement using a proper placement. Postgraduate Metheny, N.A., Meert, K.L., & Clouse, R.E.
Magnet-tracking system: A pilot study in Medicine, 99(5), 165-168, 174-176. (2007). Complications related to feeding
healthy subjects. Journal of Parenteral Grant, M.J.C., & Martin, S. (2000). Delivery of tube placement. Current Opinion in
and Enteral Nutrition, 29(4), 305-310. enteral nutrition. AACN Clinical Issues: Gastroenterology, 23(2), 178-182.
Bockus, S. (1993). When your patient needs Advanced Practice in Acute and Critical Metheny, N.A., Reed, L., Berglund, B., &
tube feedings: Making the right deci- Care, 11(4), 507-516. Wehrle, A. (1994). Visual characteristics
sions. Nursing, 23(7), 34-42. Greenhalgh, T., Robert, G., MacFarlane, F., of aspirates from feeding tubes as a
Bowers, S. (2002). All about tubes:Your guide Bate, P., & Kyriakidou, O. (2005). method of predicting tube location.
to enteral feeding devices. Nursing, Diffusion of innovations in health serv- Nursing Research, 43(5), 282-287.
30(12), 41-47. ice organisations: A systematic litera- Metheny, N.A., Reed, L., Wiersema, L.,
Boyes, R., & Kruse, J. (1992). Nasogastric ture review. Malden, MA: BMJ Book and McSweeney, M., Wehrle, M.A., & Clark,
and nasoenteric intubation. Critical Blackwell Publishing. J. (1993). Effectiveness of pH measure-
Care Clinics, 8(4), 865-878. Huffman, S., Pieper, P., Jarczyk, K.S., Bayne, ments in predicting feeding tube place-
Burns, S.M., Carpenter, R., & Truwit, J.D. A., & O’Brien, E. (2004). Methods to ment: An update. Nursing Research,
(2001). Report on the development of a confirm feeding tube placement: 42(6), 324-331.
procedure to prevent placement of feed- Application of research in practice. Metheny, N.A., Smith, L., & Stewart, B.J.
ing tubes into the lungs using end-tidal Pediatric Nursing, 30(1), 10-13. (2000). Development of a reliable and
CO2 measurements. Critical Care Kearns, P.J. (1997). Evaluation of diagnostic valid bedside test for bilirubin and its
Medicine, 29(5), 936-939. tests: Verification of feeding tube place- utility for improving prediction of feeding
Cannaby, A., Evans, L., & Freeman, A. ment using electromagnetic principles. tube location. Nursing Research, 49(6),
(2002). Nursing care of patients with Nutrition in Clinical Practice, 12(1, 302-309.
nasogastric feeding tubes. British Suppl), S61-S65. Metheny, N., Spies, M., & Eisenberg, P.
Journal of Nursing, 11(6), 366-372. Khair, J. (2005). Guidelines for testing the (1986). Frequency of nasoenteral tube
Chen, C.A., Paxton, P., & Williams-Burgess, placing of nasogastric tubes. Nursing displacement and associated risk fac-
C. (1996). Feeding tube placement veri- Times, 101(20), 26-27. tors. Research in Nursing & Health,
fication using gastric pH measurement. Klasner, A.E., Luke, D.A., & Scalzo, A.J. 9(3), 241-247.
Worldviews on Evidence-Based (2002). Pediatric orogastric and naso- Metheny, N., & Stewart, B.J. (2002). Testing
Nursing, 3(1), 79-85. gastric tubes: A new formula evaluated. feeding tube placement during continu-
Christensen, M. (2001). Bedside methods of Annals of Emergency Medicine, 39(3), ous tube feedings. Applied Nursing
determining nasogastric tube place- 268-272. Research, 15(4), 254-258.
ment: A literature review. Nursing in Marderstein, E.L., Simmons, R.L., & Ochoa, Metheny, N., Stewart, B.J., Smith, L., Yan, H.,
Critical Care, 6(4), 192-199. J.B. (2004). Patient safety: Effect of insti- Diebold, M., & Clouse, R.E. (1999). pH