AACN News—December 2000—Practice

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Vol. 17, No. 12, DECEMBER 2000

Research Corner: Myth vs. Reality Checking Feeding Tube Placement

Editor’s note: Welcome to the “Research Corner,” a new AACN News feature devoted to research and evidence-based practice issues. These articles, many of which will be written by members of AACN’s 2000-01 Research Work Group, are designed to help nurses move away from ritual in practice. The “Myth vs. Reality” that is introduced here will not only address commonly held practice myths, but also provide data to support evidence-based practice. The following article was written by Kristine J. Peterson, RN, MS, CCRN, who was a member of the 1999-2000 Research Work Group.

By Kristine J. Peterson, RN, MS, CCRN

Mr. Dodge is a 62 year-old patient, who has been in the ICU for eight days with pneumonia and acute respiratory distress syndrome. He is receiving feedings via a gastric, small-bore feeding tube, which he has tolerated at 65cc/hour for several days. When I add feeding for the next four hours, I use a large syringe to inject 30 cc of air into the feeding tube. I hear a loud rushing sound in the upper left quadrant as I inject the air, and assume that the tip of the feeding tube is in the correct position. Am I correct in my assumption?

Myth: Air insufflation gives a reliable indication of the location of the tip of the feeding tube.

Reality: Research has shown that air insufflation is an unreliable indicator of placement. It does not distinguish between respiratory and gastric placement, nor does it distinguish location within the gastrointestinal tract. In a series of studies,1-5 Metheny and colleagues described the false reassurance air insufflation gives regarding placement. In one study, air was heard in the epigastrium 100% of the time. However, 18 tubes were found to be in the stomach, 11 in the duodenum, three in the jejunum and two in the esophagus. In another study, nurses correctly identified tube location via air insufflation 34% of the time, the same rate one would expect by chance. In yet another study, nurses reported hearing air in the epigastrium in nine of 10 patients whose tubes were found to be in the respiratory tract.

The recommended practice for checking feeding tube placement is whenever feeding is added and whenever placement is questioned.

How would I check placement? There are a number of alternatives to air insufflation.
• Immediately after placement confirmation by x-ray, measure the tube from the nares to the proximal end of the
tube. Track and note this measurement.
• Mark the tube at the nares with indelible marker and track the location of the mark, as well as the length of the
• Visually examine aspirate for bile color. Because the color may vary, this method is less accurate. Generally,
stomach contents would be the color of feeding, or yellow to green; intestinal contents would be yellow; and
respiratory secretions would be white.
• Check the pH of aspirates. This method requires that the feeding be stopped for one hour before
measurement. Measuring pH is usually not recommended when a patient is on continuous feedings, because
doing so would interfere with adequate caloric intake. Other variables that interfere with pH of stomach
contents are H2-receptor antagonists, antacids, HIV infection, pernicious anemia, medications given orally
within the last hour and advancing age.

To measure the pH accurately, the following conditions must be met:
a. No feedings or medications given orally for one hour prior to test
b. No antacids within last hour
c. Flush tube with 30-mL air before aspirating contents for pH testing

The range for stomach contents if above conditions are met is pH 4 to 5. Only 1% of intestinal secretions and no respiratory secretions is 4; 94% of intestinal and 99% of respiratory secretions are pH 7. With H2-receptor blockers, the range of pH for stomach contents may expand to pH 6.

1. Metheny NA, Spies MA, Eisenberg P. Measures to test placement of nasoenteral feeding tubes. West J Nurs Res. 1988;10:367-383.
2. Metheny NA, McSweeney M, Wehrle MA, Wiersema L. Effectiveness of the auscultatory method in predicting feeding tube location. Nurs Res. 1990;39:262-267.
3. Metheny NA, Dettenmeier P, Hampton K, Wiersema L, Williams P. Detection of inadvertent respiratory placement of small-0bore feeding tubes: A report of 10 cases. Heart Lung. 1990;19:631-638.
4. Metheny NA, Williams P, Wiersema L, Wehrle MA, Eisenberg P, McSweeney M. Effectiveness of pH measurements in predicting feeding tube placement. Nurs Res. 1989;38:280-285.
5. Metheny NA, Wehrle MA, Wiersema L, Clark J. Testing feeding tube placement: Auscultation vs. pH method. Am J Nurs. 1998;5:37-42.

Grants Fund Research Relevant to Critical Care Nursing

AACN offers grants to AACN members for research or projects that are relevant to critical care nursing. Unless otherwise specified, all grant proposals must be relevant to critical care nursing practice, address one or more of AACN’s research priority areas and link with AACN’s vision. Following is information about available grants for which application deadlines are approaching.

AACN Clinical Inquiry Grants for Projects
These grants provide awards of up to $500 each to qualified AACN members who are carrying out clinical research projects that will directly benefit patients or families. Interdisciplinary projects are especially invited. This grant may be applied to new projects, projects in progress or projects required for an academic degree.
To qualify for a Clinical Inquiry Grant, the principal investigator must be a regular or affiliate member of AACN, employed in a clinical setting, directly involved in patient care and not currently receiving funding by another AACN research grant.

Proposals must be received by Jan. 15, 2001.

Datex-Ohmeda-AACN Research Grant

This new $5,000 grant to study the issue of nutritional assessment in the critically ill patients is funded by Datex-Ohmeda.

Examples of study topics might include the impact of continuous metabolic monitoring; the assessment of the nutritional and metabolic condition of the critically ill patient; current practices of nutritional assessment of the critically ill patient; the use of the Harris-Benedict Equation vs. indirect calorimetry in nutritional assessment; and the evaluation of the accuracy or efficacy of continuous metabolic monitoring in the critically ill patient.

To qualify for this grant, the principal investigator must be a regular or affiliate member of AACN and not currently conducting a study funded by another AACN research grant.

Proposals must be received by Feb. 1, 2001.

AACN Critical Care Grant
This grant awards up to $15,000. The funds may be used to support project expenses and may include research assistance or secretarial support, equipment, supplies, and consultation assistance. Principal investigators must be current AACN members. The proposed research may not be used to meet requirements of an academic degree. The principle investigators cannot currently be conducting a study funded by another AACN research grant.

Proposals for this grant must be received by Feb. 1, 2001.

AACN Mentorship Grant
This $10,000 grant provides research support for a novice researcher who is working under the direction of a mentor with expertise in the area of proposed investigation. The funds may be used to support project expenses and may include research assistance or secretarial support, equipment, supplies, and consultation assistance.

The mentor cannot serve as a mentor on an AACN Mentorship Grant for two consecutive years. Principal investigators must be current AACN members. The proposed research may not be used to meet requirements of an academic degree.

Proposals must be received by Feb. 1, 2001.

AACN Certification Corporation Grant

Up to four $10,000 grants are funded by AACN Certification Corporation to support research related to
certified practice. Examples of eligible projects include studies that focus on continued competency; the Synergy Model; the value of certification as it relates to patient care or nursing practice; and credentialing concepts. The proposed research may be used to meet the requirements of an academic degree. Membership in AACN is not required to apply for this grant.

Proposals must be received by Feb. 1, 2001.

Data-Driven Clinical Practice Grants
This grant funds up to six $1000 awards to stimulate the use of patient-focused data or previously generated research findings to develop, implement and evaluate changes in acute and critical care nursing practice.
New projects, projects in progress and projects required for an academic degree are eligible for funding.
The principal investigator must be a member of AACN and not currently conducting a study funded by another AACN research grant

Applications must by received at AACN by March 1, 2001.

For more information about these and other AACN nursing research grants, or to obtain application materials, instructions and information regarding restrictions, call (800) 899-AACN (2226), or visit the “Research” section of the AACN Web site at www.aacn.org.

How Do Religion and Spirituality Guide Our Practices?

By Natalie Correll-Yoder, RN, MN, CCRN
Member, AACN Ethics Work Group

With technological growth comes the social and moral responsibility to do the right thing. As critical care nurses, we match the patient’s needs and characteristics with a specialized set of nursing competencies to create synergy.

Advocacy is one of these competencies. The critical care nurse advocates for the rights and desires of the patient but what does he or she do when the patient’s desires are in direct conflict to the belief structure of the hospital as an institution? At times, what is right medically may conflict with our religious beliefs and spirituality.
Catholic hospitals and health systems provide healthcare to patients of a variety of faiths and continue to advocate for the rights of patients, including the indigent. Although values and traditions may vary slightly among the Catholic institutions, all abide by the Ethical & Religious Directives of Catholic Health Care Services. These directives are the basis for policy and procedure with regard to ethical dilemmas at all Catholic healthcare institutions. The following case study demonstrates a conflict that one patient had and the choices the healthcare professionals made to try and do what is right for the patient.

Case Study
M.V. was a 26-year-old woman who presented to the emergency department (ED) with severe pain in her left arm. The ED nurse assessed her pre-existing medical, family and social history. M.V. had been separated recently from her husband and had one child at home. She had no history of illness or other medical problems. Upon admission, the radial and ulnar pulses in her left arm were very weak. Further diagnostic work-up revealed a clot in her left subclavian artery. While in the ED, her pulses weakened, and it was determined that surgery for an emergent embolectomy was the only option.

The surgery went well and the clot was removed. However, upon arrival in the ICU, she began to lose pulses in her lower extremities. The surgeon began a further examination and was very puzzled as to why there was now a new clot. After further discussion with the patient to determine why she might have developed a clotting disorder, he discovered that she was pregnant. He also learned that M.V.’s sister had developed a similar clotting disorder during the delivery of her last child.

The surgeon consulted an obstetrician to assist with this complex case. After reviewing M.V.’s physical exam, the obstetrician said he felt the problem was beyond his scope of practice, and an oncologist was subsequently requested to deal with the clotting disorder. A nephrologist was also brought in to the case, because M.V. began to develop acute renal failure as a result of her clotting dysfunction.

After consultation, all four physicians concluded that the cause of M.V.’s life-threatening clotting disorder was her pregnancy. The only choice for curative treatment was an abortion. At this point, a bioethics consultation was scheduled.

At the consultation, each member of the healthcare team shared his or her professional opinion as to the correct course of action. The ICU nurse shared M.V.’s point of view. Because M.V. had separated from her husband, she did not want the child that she was carrying. She had actually planned to abort the fetus, but had become ill before she had the chance. M.V. did not want her husband to be informed of her illness, and she did not want to carry this child to term.

Advocacy and moral agency are part of the nurse’s role to serve as the patient’s voice when identifying and helping resolve ethical and clinical concerns. But, how could the nurse advocate for the patient in this instance? The fact that the patient had requested an abortion was clear. However, although an abortion was also medically indicated, it was not an acceptable choice for the Catholic healthcare providers. Ethical & Religious Directives #47 allows for operations, treatments and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman, when they cannot be safely postponed until the unborn child is viable, even if they result in the death of the unborn child.

For example, this directive allows for treatment of the disease, such as a mitral valve replacement in a pregnant woman with pre-existing mitral prolapse and fulminant heart failure. The patient may be treated with cardiac surgery, even if the fetus is lost, because it is not a direct abortion.

However, in this case, the treatment for M.V. was the abortion. There was no other way medically or surgically to treat the clotting disorder. Directive #45 clearly states the limitation for Catholic healthcare providers: Abortion (that is, the direct intended termination of pregnancy before viability or the directly intended destruction of a viable fetus) is never permitted. Every procedure whose sole immediate effect is the termination of pregnancy before viability in an abortion, which, in its moral context, includes the interval between conception and implantation of the embryo.

Because of this dilemma between the directives and the choice of the patient and recommendations for medical treatment, the entire healthcare team struggled with this decision. M.V. could be transferred to another facility for the abortion, though her medical stability was questionable. How would M.V. feel if she was transferred? She trusted the nurses and physicians caring for her at the hospital. Would she feel comfortable with the new medical and nursing team? Would there be any other risks in transferring an unstable critically ill patient to another facility for treatment?

The team reviewed all the options and the existing policy. The choices came down to abort the fetus or transfer M.V. to another facility for the abortion. Although the team sought counsel from the local bishop and ethicists about other options, the choices that remained were to perform the abortion or transfer the patient. Yet, the abortion was not an appropriate option for this facility.

The critical care nursing staff supported the patient’s wishes and tried to keep the rest of her environment as stable as possible. As described in the Synergy Model, the staff provided caring practices through nursing activities that were responsive to the uniqueness of the patient and family. To make M.V. more comfortable, the staff focused on pain management and decreasing the stress in the environment. The critical care nurses continued to advocate for the patient’s wishes and work with the medical team to find the right solution for this patient.

When M.V.’s husband learned from her family that she was in the hospital, he tried to see her. Supporting M.V.’s wishes, the nursing staff initially prevented her husband from visiting. However, M.V. finally decided she wanted to talk to him. The ICU staff arranged a safe environment for them to talk. During the next few hours, M.V. became more stable. The team decided to transfer her to another facility for the abortion.

M.V. was transferred in the morning, had the abortion and returned to the original facility within a 24-hour period. Her condition was stabilized and the clotting disorder was reversed completely. M.V. required hospitalization for another 48 to 72 hours, prior to her being discharged. As a final note, M.V. and her husband reconciled, and, following medical advice, M.V.’s husband decided to have a vasectomy.

This case reflects how difficult our choices can be. The medical and nursing teams were not sure if M.V.’s condition would stabilize. And, in trying to honor religious beliefs and practices of the institution, the right decision became more difficult. The critical care nurses in this unit focused on the patient, allowing her to speak of her desires and wishes so that she could be part of the clinical decision making. This is the strength that critical care nurses have—the ability to serve as the advocate for the patient. It only takes one of us to stand and speak to the patient’s wishes. In this case, several nurses stood together, speaking and advocating for this patient. This is the “power of one,” helping all of us work together to find the right decision for each patient.

Natalie Correll-Yoder is a clinical specialist at Queen of the Valley Hospital, Napa, Calif. She is cochair of the hospital Ethics Committee and Bioethics Consult Team.

Practice Resource Network: Frequently Asked Questions

Packets containing responses to questions frequently asked through AACN’s Practice Resource Network (PRN) are available online. This information, as well as a wealth of other practice resources, can be accessed by visiting the “Practice” area of the AACN Web site at www.aacn.org.

These PRN packets are updated to reflect the trend in questions as they are received. You can also read past “Practice Resource Network Q & A” columns that appeared in AACN News. If you have a question related to your practice, call the PRN (800) 394-5995, ext. 217, or post your question in the “Infolink Discussion” area to receive feedback from your colleagues.

Following is information presented in one of the PRN packets online:

QDoes AACN have a standard program for orienting new graduates and nurses who are new to critical care, or a way to validate knowledge of nurses transferring to critical care nursing areas?

ASeveral resources to help orient new nurses are available. AACN offers the “Orientation to the Care of the Acute and Critically Ill Patient” program, which consists of eight comprehensive modules that are designed to instruct in all areas of critical care. The program can be used for up to 94 hours of continuing education contact hours (CERP Category A).

Covered by the modules are basic ECG interpretation and all major body systems, including specifics on diagnostics; nursing and medical intervention; and assessment and evaluation. Each module includes an instructor manual, a participant manual, examinations, a course evaluation tool and a final exam.

To receive a faxed copy of the entire table of contents for each module, call AACN Fax on Demand at (800) AACN-FAX (222-6329) and request Item #6506. The price for the “Orientation to the Care of the Acute and Critically Ill Patient” (Item #120799) is $495 for AACN members and $575 for nonmembers.

In addition, the Basic Knowledge Assessment Tool (BKAT) examination, which is available from the School of Nursing at Catholic University of America, Washington, D.C., can be used not only to evaluate new graduates or new nurses, but also as a knowledge validation tool. Although the BKAT is copyrighted, it is being provided at cost to nurses who work in critical care. A payment of $11.50 is requested to cover photocopying, postage, handling, the BKAT Research Award, and continued validity and reliability testing. You will receive a copy of the BKAT-5, the answer sheet, a score sheet and information related to validity and reliability, uses and scoring, as well as selected references. Contact BKAT, Catholic University of America, School of Nursing, Washington, D.C. 20064.

Resources that provide competency checklists for use in orientations and annual competency validation requirements are also available. Procedure manuals often include these checklists.

The “AACN Critical Care Competency Checklists” are available on CD-ROM. You can use this tool to create checklists for competency assessment, cross training and orientation. Each of the 55 critical care skills can be modified and customized to meet your facility needs. This CD-ROM can be ordered from the publisher, Lippincott Williams & Wilkins, by calling (800) 527-5597. Request Item No. 0-683-40323-0. Price is $395.

A list of references related to this topic is also included in the packet online.

Geriratric Corner: AACN Honored for Excellence in Promoting Best Practices

AACN has again been recognized by the John A. Hartford Foundation Institute for Geriatric Nursing and the Nursing Organization Liaison Forum (NOLF) for excellence in promoting geriatric best practice information.
As one of two recipients of the inaugural Hartford Institute for Geriatric Nursing/Nursing Organization Liaison Forum (NOLF) Award, in 1999, AACN was not eligible to receive the award this year. However, the Hartford Foundation Institute and NOLF found that the work AACN had done in the last year had been so exemplary that they presented the association with a special award to applaud its sustained excellence in this arena.

In accepting the Certificate of Sustained Excellence at the NOLF meeting in October 2000 in Washington, D.C., AACN President Denise Thornby, RN, MS, highlighted the association’s specific activities to the nursing community.

AACN’s participation in the Specialty Nursing Activities Partnership Program for Care of Older Adults (SNAPP), which was established by the Hartford Foundation institute, has provided AACN with information, tools and support. The institute can be accessed directly through the “Practice” area of the AACN Web site at www.aacn.org and clicking on “Continuum of Care.” With a goal of promoting best practices in the care of the older adult, this partnership makes practice information, resources and up-to-date aging references easily available to AACN members.

AACN will continue to provide age-related practice information though this “Geriatric Corner” in AACN News. Is there a specific topic or concern that you would like to see featured? Have you made any changes to your practice because of reading the information presented? Do you have suggestions regarding this feature? Contact AACN Practice Director, Justine Medina, RN, MS, at (800) 394-5995, ext. 401; fax, (949) 448-5520; email, Justine.Medina@aacn.org with your feedback.
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