Module 13 Lesson 3 P by linzhengnd


									1. The nurses are discussing feeding tube migration and prevention. Which of the
following statements indicates correct understanding?

a) As long as the external portion of a feeding tube is taped in place, the tube will be
unable to migrate out of position.
*b) A feeding tube can enter the airway without causing obvious respiratory
c) The nurse should have the patient deep breathe and cough and suction the patient
d) The nurse should keep the head of the bed flat to reduce the risk of tube

Feedback: Absence of signs and symptoms does not ensure nonrespiratory
placement, especially in patients with decreased level of consciousness or altered
cough and gag reflex. The nurse is responsible for ensuring that the tube has
remained in the intended position before administering formula or medications
through the tube. Coughing and frequent suctioning may increase the risk of feeding
tube migration. A tube's distal tip can migrate upward or downward from its original
correct position, even when the external portion of the tube is taped in place. The
nurse should keep the head of the bed elevated 30 degrees at all times to reduce the
risk of aspiration.

2. If the nurse suspects the NG feeding tube has migrated, the nurse should:

a) Instill 10 mL of water into the feeding tube, reinsert the stylet, and reposition the
*b) Stop any enteral feedings and obtain an order for a chest x-ray to determine
c) Irrigate the tube with tap water.
d) Reposition the patient from side to side.

Feedback: If the nurse observes signs of respiratory impairment, the feeding tube
may have migrated from the stomach to the airway or if the nurse obtains a larger
amount of gastric residual, the tube may have migrated from the intestine to the
stomach. The nurse should stop any enteral feedings, notify the physician and
prepare to obtain a chest x-ray as ordered. A stylet should never be reinserted in a
patient as this can cause perforation of the tube and injure the patient. Irrigating the
tube with water would be appropriate if the tube were clogged. Turning the patient
from side to side may help in obtaining aspirate.

3. The nurse suspects the patient’s feeding tube has migrated. Which of the following
would indicate the greatest risk related to tube migration?
       *a) Dyspnea and decreased oxygen saturation

       b) Pain and gastric aspirate hemoccult positive

       c) Absence of bowel sounds

       d) Inability to flush the feeding tube

The risk for aspiration of regurgitated gastric contents into the respiratory tract is
increased when the tip of an NI tube accidentally dislocates upward into the stomach
or when the tip of either an NG or NI tube dislocates upward into the esophagus.
When a tube migrates to the lung, complications such as aspiration, pneumonia,
pneumothorax, and peritonitis can develop if feedings are subsequently
administered. Pain and gastric aspirate hemoccult positive would be symptoms
indicating perforation and subsequent bleeding. The absence of bowel sounds is
indicative of paralytic ileus. The inability to flush the feeding tube is indicative of
clogging of the tube.

4. You observe a confused patient pulling at her NG feeding tube. As you retape the
tube to the bridge of the patient's nose, you notice that the mark on the tube has
moved away from the naris. What action should you take?

       *a) Advance the tube until the mark is even with the naris and verify correct
       tube placement.

       b) Secure the tape on the patient's nose well with the tube in the current

       c) Remove the tube.

       d) Restrain the patient's hands before leaving the room.

       e) Pull back on the tube.

            An increased external length of tube may indicate that the distal tip is
incorrectly positioned. Using the tube in its current location could place the patient at
greater risk for aspiration. You need to advance the tube until the mark reaches the
patient's naris and then verify correct tube placement. It is unnecessary to remove
the tube unless you are unable to advance the tube the desired length. Pulling back
on the tube will only increase the external length of the tube, thus preventing the
tube from being inserted the desired depth.
5. Identify signs and symptoms of accidental respiratory migration of a feeding tube.

       *a) Coughing

       *b) Choking

       *c) Cyanosis

       d) Sore throat

       e) Distention

            Signs of respiratory distress such as paroxysms of coughing, choking, or
persistent gagging; cyanosis; or change in respiratory patterns (e.g., increase in
rate) are symptomatic of accidental feeding tube migration into the airway. A sore
throat may occur because of irritation by the feeding tube. Distention of the
abdomen is not a symptom of accidental respiratory migration of a feeding tube.

6. Identify the appropriate times to verify enteral tube placement by pH testing.

       *a) Before each intermittent feeding

       *b) At least once every 6 hours during continuous feedings

       *c) Before administration of medications through the tube

       d) After administration of medications through the feeding tube

            Verification of correct tube placement is performed before each
intermittent feeding, at least once every 6 hours when continuous feedings are
given, and before medications are administered through the tube. The nurse should
wait at least 1 hour after medication administration before aspirating gastric
contents. Premature aspiration of gastric fluid will remove medication, reducing the
dose delivered to the patient. Medication may also interfere with pH testing.

7. Which of the following, if exhibited by the patient, may increase the risk for
spontaneous enteral tube dislocation? (Select all that apply.)

       a) Nausea

       b) Ambulation

       *c) Retching

       *d) Vomiting

       *e) Frequent nasotracheal suctioning
       *f) Severe bouts of coughing

       g) H2 antagonists

           Conditions that increase the risk of spontaneous tube dislocation from the
intended position include retching/vomiting, nasotracheal suctioning, and severe
bouts of coughing. Nausea, ambulation, and H2 antagonists are not risk factors for
spontaneous dislocation of an enteral feeding tube.

8. Instructions: Match the pH test result to the likely source.

            [a] 1) Patient with continuous tube feeding

            [b] 2) Stomach of fasting patient

            [c] 3) Pleural fluid from tracheobronchial tree

            [c] 4) Intestine of fasting patient

            a) 5 or higher

            b) 1 to 4

            c) Greater than 6

           Gastric fluid from a patient who has fasted for at least 4 hours usually has
a pH range of 1 to 4. Fluid from an NI tube of a fasting patient usually has a pH
greater than 6. A patient with continuous tube feeding may have a pH of 5 or higher.
The pH of pleural fluid from the tracheobronchial tree is generally greater than 6.

9. Sequence the procedure for verifying feeding tube placement.

       1) Perform hand hygiene. Apply clean gloves. Draw up 30 mL of air into
       syringe, then attach to end of feeding tube. Flush tube with 30 mL of air.2)
       Draw back on syringe and obtain 5 to 10 mL of gastric aspirate. Observe
       appearance of aspirate.
       3)_Measure pH of aspirate. Compare the color of the strip with the color on
       the chart provided by the manufacturer.
       4) Discard used supplies, remove gloves and discard, and perform hand

           Perform hand hygiene to reduce transmission of microorganisms. Apply
clean gloves to provide protection from possible exposure to body fluids. Draw up
and instill 30 mL of air. The burst of air aids in aspirating fluid more easily. Draw
back on syringe, obtaining 5 to 10 mL of aspirate. Observe appearance because color
may provide some indication of tube location. Gently mix aspirate. Mixing ensures
equal distribution of contents for testing. Measure pH by dipping the pH strip into the
fluid and comparing the color of the strip with the color chart provided by the
manufacturer. The pH reading will aid in verifying tube location. Discard used
supplies and gloves, and perform hand hygiene to reduce transmission of

10. The nurse aspirates stomach contents from a newly inserted feeding tube. The
nurse is aware the patient has been on the proton-pump inhibitor omeprazole
(Pepcid). The pH strip reads “3.” Where should the nurse expect the x-ray to
determine placement of the feeding tube?

a) In the lungs
b) In the esophagus
*c) In the stomach
d) In the small intestine

Feedback: Gastric pH should measure 1-4; the proton pump inhibitor would only
increase the pH reading, making stomach contents more alkaline.

To top