Charlene Roberts

2/10/2012

Tube Team Rotation

-1On Friday, February 10, 2012, I had the opportunity to follow the tube team at Mission Memorial Hospital. I am now aware of the responsibilities this team is accountable for. The tube team consists of four individuals. This team of experts provide safe and accurate placement of nasogastric feeding tubes. Many patients have these tubes inserted to reduce the risk of aspiration during feeding or if they are not meeting their nutritional needs. I was following Steve, one of the four. Steve is very patient and thorough, with explanations that were very clear. His skills on the placement of feeding tubes are those of an expert. The other three team members also demonstrate skills of expertise. Every year, competency frameworks and supervision are reviewed within the team to ensure each member involved are competent with the care provided. This sets the bar high, ensuring quality patient care and safety. Out of the approximated amount of 43,000 placements, Steve is responsible for approximately 10,000 of them, since the team was organized in 1997. He has never misplaced a tube. A misplaced tube is inserted into the lungs instead of the stomach or small intestine, which could mean serious problems for the patient involved, including death from unintentional feeding and the infection that would follow.

-2Two different feeding tubes were mentioned. The Dobbhoff Nasogastric Feeding Tube and the Corflo Fine Bore Feeding Tube. As far as comparison, they each have similar features. The Corflo is Steves preference, so I will go into depth describing the features of that feeding tube. It has a patented anti-clog outlet port that greatly reduces the occurrence of clogging. A large selection of sizes is available to accommodate most any size patient in need of a feeding tube, from neonatal to adult. All the tubes are printed with centimeter marks to increase patient safety and accurate placement. They are made of polyurethane, which is more beneficial than silicone.

Polyurethane is kink resistant, stronger, and provides maximum durability. The internal lumen is larger in comparison to silicone tubes of the same French size. (1 Fr = 0.33mm) Corflo feeding tubes are color coded to correspond to the varying lengths. The stylets are braided stainless steel. The stylet lengths are matched to the Corflo feeding tubes. The flow-through stylets are convenient when flushing, auscultating, and aspirating during the insertion procedure. The tubes have a water activated lubricant (C19) on the tip and internal lumen that makes intubation less uncomfortable for the patient and making the stylet easy to remove. The entire feeding tube is 100% radiopaque for x-ray confirmation with or without the stylet. The feeding tubes contain 20% barium sulfate and the tip has 40%. Weighted tubes use multiple tungsten weights that allow flexibility and greater comfort for the patient during intubation. These Corflo feeding tubes have a unique dual component, universal Y adapter that makes flushing easier and simplifies co-administration of medicines. Touch contamination is also minimized with the closed system, reducing the infection potential and simplifying feeding protocols. Enteral nutrition, also known as tube feeding, consists of a nutritionally balanced liquefied food, delivering nutrients distal to the oral cavity. It may be ordered for a patient with a functioning GI tract but unable to take any or enough oral nourishment. This may include patients with anorexia, orofacial fractures, head and neck cancer, neurologic or psychiatric conditions that prevent oral intake, extensive burns, critical illness, and those receiving chemotherapy or radiation treatment. Enteral nutrition provides nutrition by the route of the gastrointestinal tract either alone or as a supplement to oral or parenteral nutrition. A nasogastric tube is most commonly used for short term feeding requirements. Transpyloric placement (into jejunum) is used when physiologic conditions require feeding the patient below the pyloric sphincter. Placement into the small intestine reduces the risk of regurgitation and aspiration. The use of a stylet makes it possible to place a feeding tube when the ability to swallow is compromised.

-3It is important to explain the procedure to the patient. Position them in a sitting or Fowlers position. They dont need to lean forward or have the head or neck extended. Remove the tube and stylet from the package. Close the access port. Seat the stylet connector firmly into the tube connector. Make sure stylet connector stays firmly seated during intubation. The stylet is packaged with the tube, but use is optional and may not be needed in the conscious and cooperative patient. Measure the length of the

tube to be inserted to assure the tip enters the gastric region. Place exit port of the tube at the tip of the nose. Extend the tube to the earlobe, then to the xiphoid process. Use the centimeter marks on the feeding tube as a reference. Premeasuring is essential. Never insert too much tubing because it may kink, causing an occlusion. Determine the preferred nostril for insertion. Provide cooperative patient with a glass of water with a straw. Activate the lubricant on the tip of the tube by dipping into tap water. If more than several minutes elapse before the tube is inserted, additional dipping of the tip may be needed. Direct the tube posteriorly, aiming the tip parallel to the nasal septum and the superior surface of the hard palate. Advance on to the nasopharynx, allowing the tip to seek its own passage. Ask the patient to swallow water while advancing the tube into the stomach. If the patient coughs, this could be an indicator the tube is misplaced into the trachea. If this is suspected, remove the tube and begin the process again when the patient is comfortable. Relaxation is important. Even the scrunching of the face adds difficulty to successful placement of the feeding tube, causing resistance. If resistance continues to be a problem, contact the doctor.

-4Confirmation of the feeding tube position can be done with or without the stylet in place. Gastric position can be confirmed by aspirating the contents of the stomach and putting it onto litmus paper. When aspirating, use a 50 milliliters female Luer or cath tip syringe inserted into the access port. Withdraw the plunger slowly. If it is difficult to obtain gastric aspirate, the tip may be above the level of fluids in the stomach. The internal lubricant of the feeding tube must be activated before removing the stylet. Open the side arm access port and flush the tube with 10 milliliters of water. Remove the stylet immediately. It is extremely important that the position of the tube has been confirmed before flushing with water. If gastric placement is all that is required, tape the tube securely to the nose and cheek.

-5The feeding tube is taped securely to the nose and cheek to prevent dislocation. The tube team monitors the patients regularly to make sure the tape is secure to prevent dislocation. If a patient does not want to leave the feeding tube in place and it is needed or required, a bridle can be placed after the feeding tube has been inserted. This is placed around the septum with a magnetized kit. The feeding tube is taped to the bridle. If the patient attempts to tug at the tube it causes discomfort.

-6The feeding tube is prone to obstruction if oral medications are not crushed appropriately and dissolved in water. They can become dislodged by vomiting or coughing. They can also become knotted or kinked while in the GI tract. Vomiting or aspiration can happen if there is a delay in gastric emptying, which increases residual volume. Diarrhea can be a problem that could be caused by several factors such as feeding too fast, contaminated formula, and some medications. The fluid components can also be the cause of constipation. Constipation can also be caused by some medications and deficient intake of fluids. Dehydration may be a problem if there is excessive diarrhea, vomiting or poor fluid intake.

-7As with any procedure, it is important to accurately document the details to paint a clear picture. A thorough understanding of the procedure and the assessment of the patient is important for the next person and how they interpret and determine the plan of care for the patient.

-8The patient was prepared psychologically by receiving a thorough explanation of everything that was happening. Every question was answered and the patient was given choices. The patients LOC was assessed regularly from the moment we walked in the room. Steve would ask questions that would indicate if the patient was competent enough to make decisions and know what was really going on during the placement.

-9The Tube Team is definitely beneficial to the nursing staff and the hospital. They provide expert care. Steve informed me of the possibility of nurses becoming responsible for the placement of the feeding tubes. That procedure can be devastating to the patient and the hospital when a nurse misplaces a tube into the lung. It becomes a life threat to the patient and unnecessary cost for the hospital.

-10I thoroughly enjoyed my day shadowing Steve. He taught me, in comprehensive detail, the process of placing a feeding tube. There were only two patients needing feeding tubes placed, but that didnt stop me from understanding everything he was telling me

about tube placement. The communication Steve provides to others he becomes involved with while caring for a patient is amazing. He leaves nothing out and makes sure others are informed completely.

-11The first client was an older gentleman, about 73 years old. He had hip replacement surgery but he fell and dislocated the replacement. He was confused, but not steadily confused. Based on the simple question of being retired, he struggled with an answer several times. The orders from the doctor were clear to insert the NG tube. He was scheduled to have a swallow study at noon. We were in there around 10:00 am. After inserting the tube, the doctor came into the room yelling out, Halt! Stop the presses! meaning for Steve to stop with placement. He had just finished checking placement by aspirating stomach content. The doctor said the tube was not supposed to be placed until after the swallow study was complete. The nurse from the previous night had a miscommunication and didnt relay the proper information. Steve had to remove the tube. He made sure the doctor was aware the orders in the computer didnt indicate waiting for placement of the feeding tube.

-12I was very surprised by the number of tubes placed by the Tube Team and by Steve, alone. Learning there is only four individuals that are on the team was unexpected. I was able to see different areas of the hospital. I didnt see the need to ask many questions simply because the information he was relaying to me was so thorough. He explained everything so completely.