Confirm accurate placement of gastric tubes in ED patient

A single method is not enough

Although gastric tube placement is commonly performed at the bedside by ED nurses, it can result in serious complications such as misplacement of the gastric tube into the pulmonary system, resulting in respiratory distress or death, according to a December 2010 Emergency Nursing Resource (ENR) on Gastric Tube Placement Verification, developed by the Emergency Nurses Association (ENA).

Is an evidence-based protocol in place in your ED to prevent patient harm involving gastric tube placement? "Nurses should review the ENR, and work with their institutions' nursing practice council" to ensure this is the case, advises Jean A. Proehl, RN, MN, CEN, CPEN, FAEN, chairperson of the ENA's ENR Development Committee and the ENR's primary author. (To access the ENR, go to http://www.ena.org/IENR/ENR/Pages/Default.aspx).

If you're not confirming tube placement by X-ray, a single method of confirming tube placement is not enough, emphasizes Proehl. "If X-ray is not used, then a combination of bedside methods is necessary to help ascertain correct placement," she says. (See clinical tip, below, on the "whoosh" test.)

If the gastric tube accidentally passes through the larynx and into the trachea, a conscious patient may show signs of respiratory distress, such as a drop in oxygen saturation or cyanosis, says Shanna McBride, RN, a pediatric ED nurse at Georgia Health Sciences Children's Medical Center in Augusta. "For the conscious patient, uncontrollable coughing may also occur," she adds. McBride says to use these practices when inserting a gastric tube:

• Have patients touch their chin to their chest and mimic swallowing while the tube is being placed.

"Have the patient sit on their hands to remind them not to grab the tube and pull it out," says McBride. "It is a natural instinct for the patient to try to remove it during this process."

• Prior to inserting the tube, measure from the patient's nose or mouth, depending on where the tube is being inserted, to the earlobe and down to the xiphoid process.

"The tube should be marked at this place," says McBride. "If you are placing the tube in the nose, examine the nostrils prior to placement to see if there is a nostril that is larger that may be a better site for placement."

If you are right-handed when facing the patient, you should be on the left side of the patient's bed, says McBride, and vice/versa if you're left-handed.

• Use a lubricant, such as lidocaine jelly, to help ease the tube down.

Aim the tube downward, and instruct the patient to swallow with insertion and move his or her chin to the chest, says McBride. "If the tube seems too stiff, place it in warm water to make it more flexible. If it is too flexible, use ice to stiffen the tube," she advises.

• Slowly advance the tube, while reminding the patient to swallow.

"Unless contraindicated, you can have the patient drink water from a straw so they can actually swallow during insertion instead of having to mimic swallowing," McBride says.

When the tube reaches the mark, stop and try to aspirate for stomach contents. "If no stomach contents are aspirated, and the patient is conscious and cooperative, instruct them to lay on their left side and attempt to aspirate again," says McBride.

When securing the tube in a pediatric patient, McBride says, "I like to use a strip of thin duoderm on the face, put the tube over the dressing, and tape over the tube with pink tape. This helps to prevent skin breakdown."

Clinical Tip

Warning: "Whoosh test" can be dangerous

The classic method of auscultating over the abdomen while instilling air through the tube — the "whoosh" test — is dangerous if used as the sole method of verifying gastric tube placement, advises Jean A. Proehl, RN, MN, CEN, CPEN, FAEN, chairperson of the Emergency Nurses Association's Emergency Nursing Resource Development Committee.

"Many patients have been injured, and some have died, when a 'whoosh' was heard over the epigastrium, but the tube was actually in the lungs," says Proehl.