Assessing Placement of a Small-Bore Feeding Tube - Overview of the Skill

Overview: Clients with a small-bore feeding tube must have placement of the tube verified at
time of insertion and every shift to prevent insertion/migration of the tube into the
esophagus, trachea, or lungs and aspiration of feeding. Placement of a feeding tube
is easy to disrupt because the tubes are small, flexible, and secured only with tape
on the nose. There are three effective methods of verifying placement.

The first method is to inject air through the feeding tube and simultaneously
auscultate the air bubble over the stomach. The second is to aspirate a sample of
gastric contents and check pH levels. Finally, the most precise way to verify
placement is to obtain an abdominal X-ray.
Assessment: 1. Assess client for any signs of respiratory distress such as choking,
coughing, shallow breathing, or decreasing oxygen
saturations. These symptoms could be indicative of aspiration of
the feeding tube.
2. Check for a tape marker on the tube, near the nose, which indicates
the length of tube inserted. If tube has become displaced,
marker will be farther away from nose.
3. Assess sputum for distinguishing features that would indicate
aspiration, such as blue color (tube feeding formula is mixed with
blue food coloring to distinguish feeding from normal white
sputum). Blue sputum could signify aspiration of feeding, which
could lead to pneumonia.
4. Assess for latex allergy. Determines need for latex-free tube.

Diagnosis:  Imbalanced Nutrition: Less Than Body Requirements

 Risk for Aspiration

Planning

Planning Needs: Equipments Needed:

 Syringe: 30 or 50 cc for adults, 5 or 10 cc for pediatrics (varies with size)

 Stethoscope
 pH testing equipment (see Figure 6-3-1).
 Progress notes/flow sheets

Expected 1. The client's feeding tube will be intact in the ordered area of the
Outcomes: GI tract.
2. The client will not experience aspiration secondary to tube
feedings.

Client Education 1. Explain reason for verifying placement.

Needed: 2. Explain steps of procedure.
3. Answer questions from client/family.
4. Instruct client to notify staff immediately if experiencing respiratory
distress or blue sputum.
5. Explain purpose of X-rays, if needed.

Assessing Placement of a Small-Bore Feeding Tube - Implementation - Action/Rationale

Implementation ACTION RATIONALE

Action/Rationale 1. Wash hands and apply clean gloves. 1. Practices clean technique.
2. Prepare equipment; put pH testing 2. Promotes efficiency.
equipment nearby.
3. Clamp the tube feeding infusion if it 3. Prevents wasting of feeding.
has already been running (see Figure
6-3-2).
4. Locate the connection between the 4. To disconnect the tubing.
feeding tube and feeding bag tubing
(see Figure 6-3-3).
5. Disconnect infusion tubing from 5. Prevents contamination of tubing.
feeding tube and attach a cap to
tubing and feeding tube (see Figure
6-3-4).
 6. Draw 30 to 50 cc of air into syringe.
7. Attach syringe to proximal end of
feeding tube.
8. Place diaphragm of stethoscope in
epigastric area over stomach: upper
left quadrant near midline.
9. Inject air quickly into feeding tube and
listen for air rush.
10. If unsuccessful in hearing rush of air,
repeat Actions 6 to 9. It may be
necessary to reposition stethoscope
over stomach, use more air, or inject
more slowly. Remove air.
11. Use syringe to aspirate approximately
10 ml of gastric contents (see Figure
6-3-5).
12. Check the contents and obtain pH
level (see Figures 6-3-6 and 6-3-7).
6. Provides enough air to hear an air bubble
as it is inserted.
7. Allows for insertion of air.
8. Facilitates accurate auscultation.
9. Facilitates auscultation of air rush.
10. Air bubbles may be difficult to hear
because of client position or gastric
contents. Decrease risk of distention and
discomfort.
11. To provide gastric contents for visual
inspection and pH testing.
12. The pH of the fluid aspirate can help to
verify tube placement.

 pH below 4 means tube is in  The pH reading can be altered by

stomach. the presence of medication or
 pH range of 6 to 7 means tube formula, so pH should be tested
is in intestine. after the client's stomach has been
empty for approximately 1 hour.

13. Assess the color of aspirate
(see Figure 6-3-8).
14. If unable to aspirate contents or
unsure of results of visualization, call
health care provider and consider
confirmation with X-ray.
15. Record method of verification and
results of placement in flow
sheets/progress notes.
16. If placement in stomach is verified,
reattach feeding tubing and resume
tube feedings (see Figure 6-3-9).
Recheck placement in 4 hours if
feeding is continuous.
17. Wash hands.
13. Gastric contents may be green, tan, off-
white, bloody, or brown. Intestinal contents
may be clear yellow or bile-colored.
Pleural contents may be tan, off-white, or
pale yellow.
14. X-ray is most precise method of verifying
placement of tube in stomach. Keep
health care provider informed of progress.
15. Provides continuity for other staff and legal
documentation.
16. Ensures adequate nutrition and consistent
prevention of aspiration.
17. Reduces transmission of microorganisms.

Assessing Placement of a Small-Bore Feeding Tube - Post-Skill

Evaluation:  The client's feeding tube continues to be intact in the ordered area of the GI
tract.
 The client has not experienced aspiration secondary to the tube feedings.

Documentation: Nurses' Notes

 Document the time and method of verification of tube placement.

 Note the color of any aspirate and the pH if it was tested.
 Note any unusual findings or suspicion of migration.
 If migration is suspected or placement cannot be verified, note the
interventions implemented.
 Record the client's condition and responses to tube; especially be
alert for signs and symptoms of possible aspiration.

Variations

Geriatric Variations:  Older clients may have problems with confusion. Secure the tubing well
and monitor the client closely.

Pediatric Variations:  Infants will require less air for the injection into stomach. Use a pediatric
stethoscope and a smaller syringe.
  Because of the much smaller anatomy of a child, a feeding tube has a
much shorter distance to migrate before it is in the trachea or lungs. Be
sure to assess the tube feeding placement prior to instilling anything into
the feeding tube or at least every 4 hours during a continuous feeding.

Home Care Variations:  Teach family members to verify tube placement when
administering tube feedings.
 Teach the client or caregivers what to do if tube migration is
suspected.

Long-Term Care  Clients with long-term respiratory conditions may cough

Variations: intensely enough to dislodge a feeding tube. Be sure to
assess tube placement regularly.
 Be sure the staff members caring for a tube feeding client
are aware of the signs and symptoms of aspiration and tube
migration.
 Teach the staff what to do and whom to notify if they believe
a feeding tube has migrated into the pulmonary tree.

Assessing Placement of a Small-Bore Feeding Tube - Common Errors

Prevention: Keep the stethoscope firmly in place over the epigastric region. If you are unable to hear
air rush, always re-assess or ask a coworker to assist. Use one hand for syringe and one
hand to hold diaphragm of stethoscope.

Nursing Tips:  Elevate the bed to a height that is good for you.
 A 50-ml syringe works best if you expect a large amount of
aspirate.
 Involve the client; ask client to hold the tubing if you need help.
 Remove tube and replace if unable to verify placement in stomach
or small intestine.
 Re-evaluate placement before starting a new feeding or giving
boluses, every 4 hours while continuously feeding, or every shift
when the tube is not in use.
 Keep the client's head elevated at 30° while receiving feeding to
prevent aspiration.
 Small, thin feeding tubes may collapse with attempted aspiration.
The inability to aspirate anything via the feeding tube is not
necessarily an indication of a misplaced tube. Use a second
method to verify placement.
 Always check placement before anything is injected into tube.

Critical Thinking Skill

Introduction: Feeding tubes are generally secured only by tape to the nose and face. It is easy to
disconnect or completely remove a tube.
Possible Clara is an 80-year-old woman who is now disoriented and restless at
Scenario: midnight. Upon arrival, her nurse discovers Clara with a respiratory rate of
35, productive cough of blue-tinged sputum, and the tape marker on her
feeding tube pulling a fair distance away from her nose. The tape, which
secured the tube to her nose, has been pulled off.
Possible When the nurse tries to verify placement, she is unable to hear the air
Outcome: rush. The nurse removes the feeding tube and pages the doctor to the
room immediately. She assesses for additional signs and symptoms of
aspiration.
Prevention: Secure the tube well with tape to the nose, a transparent dressing over the
tube on the cheek or forehead, and tape around the tubing secured to the
gown. Observe confused clients very closely and restrain as needed to
prevent injury and aspiration.