Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

NG tube insertion & Nutritional Status Examination DR AMY ROSS (FY2)OSCE EXAMINATION – what is expected Important contra-indications How to find out length of tube to insert PREPARATION INSERTION Check pH CXR Nutritional status examinationBe aware of any contra-indications prior to procedure Understand purposes of NG tube insertion vs Sump tube What to look for on an X-ray, why important? OSCE: hints Be confident in knowing how to measure length of tube to insert… tips Warn the patient - uncomfortable procedure and tell them can stop at any time SIPS OF WATER - swallow as inserting the tube helps aid passage of tube into appropriate position/locationOSCE CHECK LIST - https://geekymedics.com/nasogastric-ng-tube-insertion/ https://geekymedics.com/wp-content/uploads/2020/10/OSCE-Checklist-Nasogastric-NG-Tube- Insertion.pdfIntroduction 1. Wash hands 2. Introduce yourself to the patient 3. Confirm the patient’s name and date of birth. 4. Briefly explain what the examination will involve 5. Gain consent 6. Position the patient on the bed, with the head of the bed at 45°, ensure sat upright. Important - ** ask patient if they are in any pain prior to examining ** OR ** ? Any allergies **Risks Tube misplacement Aspiration pneumonia Discomfort and irritation Nasal soresContra-indications Head injury / Base of skull fractures Nasal carcinomas Nasal/palate defects Recent epistaxis Oesophageal varices Maxillofacial disordersPreparation Cup of water with Vomit straw – does the Gloves bowel/kidney dish patient have a safe Lubrication jelly swallow? NG tube → Fine → Wide bore bore feeding tube Sump tube (14- pH strips Tape (6-8Fr) lasts 16Fr) lasts approx. approx. 6-8 weeks 7 days SyringeMeasuring the length of the tube 1. Ensure sitting upright with head in neutral position. 2. Get patient to blow their nose if required. 3. Estimate how far the NG tube needs to be inserted: measure from the bridge of the nose to the ear lobe and then down to 5-10 cm below the xiphisternum.Inserting the tube 1. Lubricate tip of NG tube prior to procedure. 2. Warn the patient you are about to insert the NG tube. 3. Insert the NG tube through one of the patient’s nostrils (ask if they have preference for what one). 4. Gently advance NG tube past the nasopharynx – usually most uncomfortable part for patient – gag reflex. **If resistance met, rotating NG tube can aid insertion. ** Avoid forcing the NG tube if significant resistance is encountered** ** can inspect patient’s mouth to ensure the NG tube isn’t coiling within the oral cavity ** 5. Continue to advance NG tube down the oesophagus: ask the patient to take some sips of water and then swallow, push tube down fast when swallowing and moving easily. 6. Once you reach the desired nasogastric tube insertion length, fix the NG tube to the nose with a dressing.Aspiration of gastric contents 1. Try to aspirate gastric contents: If aspiration successful, test the pH: a value of <5.5 suggests correct placement. If aspiration is unsuccessful or the pH is >5.5 (CXR) or re-attempt aspiration after lying on side for 20-30 mins. Some hospitals require a CXR regardless of pH (local guidelines). Acceptable pH ranges also vary between hospitals, so always check local guidelines. 2. Once the NG tube is deemed safe for use, the radiopaque guidewire can be removed – ** NEVER TRY TO REINSERT GUIDEWIRE **Stomach pH can be altered by medications (e.g. proton pump inhibitors) **Order a CXR.. 1. NG tube must vertically pass down the oesophagus (transecting the carina) in the midline to below the diaphragm 2. NG must not follow the course of either of the main bronchi below the carina 3. Tip of the NG tube must be visible from at least 10cm beyond the gastro-oesophageal junction below the diaphragm.- Field of view is adequate - Remains in the midline down to the level of the diaphragm - bisects the carina - tip of the NG tube clearly visible & below the left hemidiaphragm - 10 cm beyond gastro- oesophogeal junction (GOJ)and therefore is likely to be within the stomach- View is adequate - NG tube remains in the midline down to the level of the diaphragm (NO) - NG tube bisects carina (NO) - Tip of the NG tube is clearly visible and below the left hemidiaphragm (NO) - tip NG tube is 10 cm beyond the GOJ and therefore likely to be within the stomachNG tube route in this CXR → trachea → left main bronchus → penetrates through the left lung parenchyma & visceral pleura. • adequate view (YES) The NG tube tip situated • midline down to the level of in pleural space (with an the diaphragm (NO) • NG tube transects the associated pneumothorax) carina (NO) - extreme example of misplacement. • Tip of NG clearly visible and below the left hemidiaphragm (NO) • 10 cm beyond the GOJ (NO)NG tube not placed down far enough – inadequate length insertedDifficult to visualise NG tube tip •Adequate view (YES) •Remains in midline down to level of the diaphragm (YES) •The NG tube transects carina (YES) •Tip of NG is clearly visible & below left hemidiaphragm (NO) • 10 cm beyond the GOJ (NO) If not clear – could discuss with the on-call radiologist May need repeat CXR Incorrectplacement of NG tube An NG tube can be positioned in left or right main bronchus but still appears in the midline. Hence - single criterion of an NG tube appearing in the midline not satisfactory evidence to confirm safe for feeding. Can curl up on itself, tip is placed higher than it should be leading to reflux and aspiration. Documentation Include personal details including name, job role and GMC number. Date and time procedure was performed. Confirm verbal consent was obtained. Indication for NG tube insertion. Document insertion length of the NG tube. pH of the aspirate or the failure to obtain an aspirate. CXR interpretation (if performed): “NG tube visible dissecting the carina and sitting below the left hemidiaphragm”. Complications during procedure. Is NG tube currently safe to use.Nutritional Status Examination General Inspection End of the bed: Alert, NG tube Approximate BMI Portals of infection, drains/wounds IN – NG tube/parenteral nutrition/IVF/nutritional Charts – Observation charts / fluid balance supplements, notes for NBM chart / Kardex OUT – Catheter/Stoma/NG tube/VomitHands and Arms Cirrhosis, IBD, Coeliac disease Pulse rate & blood pressure – dehydrationHead and Neck bleeding gums, rough dry scaly skin, anorexiaChest and Abdomen Sternum – Cap refill, skin turgor Ascites, Adiposity, StriaeLegsDeficiency of which Vitamin…?? Wernicke’s encephalopathy = ophthalmology + ataxia + confusion apathyoff syndrome = anaemia + confabulation +Further investigations Calculate MUST score Calculate BMI Send refeeding bloods Further OGD/colonoscopy for IDA etc Thank you! Please complete feedback.. https://app.medall.org/training/feedback/anonymous?organisation=osce-prep-3rd-year&keyword=8391a88ba49cece38cbfef4dReferences https://geekymedics.com/assessing-nasogastric-ng-tube-placement/