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Abstract

Describe about the Avoiding Common Nursing Errors?

The quantitative research study conducted with the intent to analyze the competence and knowledgebase of nursing professionals in executing nasogastric (NG) intubation to patients in the clinical setting.  The study also evaluated the efficiency of nurses in maintaining nasogastric tube following its insertion to the patients requiring enteral feeding or aspiration. The randomized study limited to the timeframe of three weeks and attempted to include 40 registered nurses working in the intensive care unit of Bankstown Hospital for obtaining their responses in terms of questionnaire disseminated to evaluate the degree of competence among nursing professionals in context to administering nasogastric tube insertion to the patients’ population. The research questionnaire encapsulated in sealed envelopes and distributed to the lockers of registered nurses for processing and retrieved within the stipulated timeframe for analysis. The responses in the questionnaire statistically analyzed and confirmed that majority of the research participants confident in administering nasogastric tube (NGT) to the patients requiring enteral feeding. Furthermore, the study subjects displayed the experience and potential in terms of aspirating and flushing the NGT. The nursing professionals also shared their willingness in attending educational sessions to further improve their efficiency and skills in context to nasogastric intubation for enteral purposes.

Keywords: Nasogastric, NGT, Nurses, questionnaire, enteral, flushing, feeding, aspiration           

Clinical Study Report

The NGT insertion executed with the intent of accessing the stomach to drain its content, decompress the gastric region or perform gastric sampling while creating a passage through the gastrointestinal tract. This intubation indeed proceeded to initiate enteral feeding in cases of gastrointestinal morbidities including small bowel obstruction, postoperative ileus, and gastric paralysis (Guenter & Silkroski, 2001, p. 155). Furthermore, failure to thrive, intestinal malabsorption and feeding aversion include some of the clinical comorbidities warranting insertion of nasogastric tube as evidenced by the clinical literature. The other requirement of NGT insertion relates to gastric lavage in cases of drug intoxication or traumatic conditions. The NG intubation is a well known clinical intervention employed in cases of gastrointestinal abnormalities for preventing aspiration of contents and vomiting following the enteral feeding. The nasogastric intubation is advantageous in the assessment of gastrointestinal hemorrhage in context to devising therapeutic or surgical interventions following the nasogastric evaluation. However, the contraindications regarding NGT insertion require careful assessment in context to patient’s clinical complexity to avoid potential complications following the nasogastric intervention. These contraindications include coagulopathy, nasal obstruction, esophageal stenosis and patient’s reluctance in undergoing nasogastric intervention following the clinical requirement (Kirby & Dudrick, 1994, p. 90). The complications following the insertion of NGT include clogging, nasal trauma, aspiration, pneumothorax, otitis media, gastrointestinal hemorrhage, reflux esophagitis, otitis media and tube dislodgement as evidenced by the clinical literature. The nursing professionals require in depth knowledge of the NG intubation and probable complications in efficiently administering feed or medication to the respective patients. Furthermore, the necessary precautions including utilization of gloves, masks and gown warranted in context to avoiding contact with the body fluids of patients or handling traumatic conditions during NG intubation. The clinical study conducted with the intent to analyze the competence of registered nurse professionals in terms of administering nasogastric tube and rendering its maintenance to ascertain error free provision of feeding or medication to the required patients’ population.

Clinical Study Report

The basic equipments necessary to execute insertion of nasogastric tube include adhesive tape, lubricant, and syringe for catheter tip irrigation, nasogastric tube, drainage device, purified water, pH indicator strips, emesis basin and personal protective equipment (Kowalak, 2009, p. 659-660). The nursing professionals expected to gain expertise and competence for ensuring adequate placement of the NG tube prior to initiation of feeding or medication administration following the instructions by the physician. It’s highly necessary for the qualified nurses to carefully analyze the physician’s orders and descriptive protocol in context to the medical necessity to efficiently administer nasogastric tube to the target population (Rosdahl & Kowalski, 2003, p. 351). Indeed, effective communication between the nurses and patients required to retain confidentiality and avoid deviation from safety protocols while rendering nasogastric intubation. The clinical literature reveals diarrhea and abdominal distension as some of the most common symptoms experienced by patients undergoing enteral feeding through nasogastric tube (Bullock et al, p. 424). The qualified registered nurses require attaining expertise and knowledge in context to managing these common symptoms following the NG intubation. Baillie (2014:p.491) discusses the clinical protocol for administering nasogastric tube to the required candidates. Indeed, the nasogastric intubation requires execution with the approval of patient’s consulting physician in accordance with the clinical rationale described in the medical report. Indeed, the outcomes of the nasogastric intubation require careful monitoring to evaluate the successful administration of NG tube by the rendering nurse professional (Altman, 2010, p. 707). The research study conducted by Lee & Mason (2013) evaluated the knowledge and competence of medical undergraduates in terms of inserting NG tubes to the patients. The results of the study indicated the lack of confidence and knowledge among doctors in context to enteral feeding by the nasogastric tube, thereby warranting the need for conducting training sessions and workshops for the physicians to disseminate information regarding NG insertion in accordance with the clinical scenarios. Indeed, the physicians’ awareness in context to the technicalities of NGT insertion is highly required to avoid misplacement of the tube into respiratory tract resulting in life threatening morbidities including pneumothorax, pulmonary hemorrhage and aspiration pneumonia. Fitzpatrick & Wallace (2012, p. 151) describe errors reported in context to inappropriate placement of NG tube, as evidenced by research studies. The clinical studies reveal the reported cases of intestinal malabsorption following erroneous placement of NG tube in patient’s duodenum resulting in abnormal weight gain and diarrhea. Indeed, the monitoring of nasogastric intubation between intervals of feeding and medication administration warranted to rule out complications in context to tubal administration. Hopp & Rittenmeyer (p. 274) emphasize the need for radiographic validation to ensure proper placement of nasogastric tube. Contrarily, the induction of positional change of NG tube warranted to ascertain appropriate tubal placement for avoiding any possibility of clogging or aspiration pneumonia. The lab analysis of the tubal aspirate in terms of consistency and color also provides some clue about the probable misplacement requiring immediate medical intervention. Mills (2006, p. 179) describes the requirement of NG tube insertion for administering medications during the postoperative period. The clinical literature recommends placing the patients in low Fowler’s position for inserting NG tube during the postoperative care. Tollefson (2004, p. 117) describes the procedure for NG tube insertion and psychomotor skills warranted by the healthcare professionals to ensure safe and uncomplicated intubation to the required patients. The clinical studies reveal the short-term requirement of nasogastric tube for enteral feeding in the clinical setting (Fabbro et al, 2010, p. 262). Indeed, frequent malposition of the NG tubes result in feeding mismanagement and adverse influence on the social functioning of the treated population. Therefore, careful administration of NG tube is imperative in avoiding potential complications arising due to tubal mismanagement by the nursing professionals. Furthermore, the adequate looping of the taped bridle around the nasogastric tube assists in tubal feeding and generating confidence in nurses in context to reducing the probability of feeding inadequacy due to inappropriate intubation. The quantitative research study conducted by Indiana University School of Nursing (2008) evaluated the competence of nursing professionals in terms of assessment of methods employed for nasogastric intubation to the patients’ population. The study revealed the practice of NEX (Nose-Ear-Xiphoid) method by several nursing professionals for NG intubation. However, few nurses utilized protocol related to pH testing and aspiration of gastric contents in context to evidence based practice to ensure appropriate placement of tubes to the target patients. Indeed, the necessity of conducting regular training sessions and educational seminars regularly emphasized by the clinical studies to ascertain proper positioning of NG tubes with the intent to avoid potential feeding complications following the tubal misplacement. The most important drawback of NEX tubal insertion includes dropping the lower end of the tube in patient’s esophagus with inappropriate frequency. This indeed, increases the scope of tubal misplacement leading to gastrointestinal complications. The literature review reveals the requirement of NG intubation in context to enteral feeding pertaining to the span of not more than six weeks duration. However, the utilization of evidence based approaches and methods for tubal insertion and feeding highly warranted by the nursing professionals to facilitate the intubation process and reduce the probability of tubal misplacement and its potential gastrointestinal complications resulting in life threatening morbidities among the patients population.

Literature Review

The study utilized a sample size of 40 registered nurses pertaining to intensive care unit for conducting the survey in terms of the research questionnaire requiring processing by the selected nurses within a timeframe of three weeks duration. The inclusion criteria of the research study followed the convention of contact the registered nursing professionals with exposure to nasogastric intubation services in the hospital setting. However, the non-registered professionals, retired nurses and interns were excluded from the research study.

Only 31 registered nursing professionals were able to accomplish the survey questions in accordance with the provided instructions. Four of the registered nursing professionals excluded from the overall analysis because of their inability to process the research questionnaire in entirety. Indeed, three nurses did not receive the survey questionnaire due to their prescheduled vacation. Two of the nursing participants did not display interest in the survey and therefore, quitted and did not accomplish the provided questionnaire. The prior approval from ethics committee of the hospital obtained in context to initiating the study and informed consent forms provided to each participant for their approval with written commitment to retain confidentiality during and after the study duration.

The recruitment of the nursing professionals executed through disseminating the following questionnaire in the sealed envelopes and the findings committed for publication in peer reviewed journal while retaining confidentiality of the nurses’ personal information, as committed in the informed consent form.

How confident are you in inserting a Nasogastric tube?

How comfortable are you in aspirating a nasogastric tube?

How comfortable are you in feeding a patient via a nasogastric tube?

How confident are you in flushing a nasogastric tube?

How confident are you in positioning a patient for tube insertion?

How well do you understand the common methods of checking NGT placement?

How confident are you in checking for tube placement?

How confident are you in accurately measuring the tube for insertion depth?

How confident are you in supervising a colleague with the procedure of inserting a NGT?

Would you like obtaining more training on this subject?

The results obtained on a grade of 1 – 10 in terms of responses by the registered nursing professionals.

Variables

Grades

Never Done

Marginal

Average

Confident

V. Confident

How confident are you in inserting a Nasogastric tube

         2 (6.4%)

   5 (16.12%)

13 (41.93%)

6 (19.35%)

5 (16.12)

How comfortable are you in aspirating a nasogastric tube

0 (0%)

5 (16.12%)

8 (25.8%)

7 (22.5%)

11 (35.48%)

How comfortable are you in feeding a patient via a nasogastric tube

0 (0%)

2 (6.4%)

10 (32.2%)

9 (29%)

10 (32.2%)

How confident are you in flushing a nasogastric tube

            0 (0%)

1 (3.22%)

12 (38.70%)

7 (22.5%)

     11 (35.48%)

How confident are you in positioning a patient for tube insertion

            0 (0%)

3 (9.67%)

8 (25.8%)

8 (25.8%)

12 (38.70%)

How well do you understand the common methods of checking NGT placement

            1 (3.22%)

       6 (19.35%)

  14 (45.16%)

  5 (16.12%)

     5 (16.12%)

How confident are you in checking for tube placement

            5 (16.12%)

        7 (22.5%)

  12 (38.70%)

  4 (12.90%)

      3 (9.67%)

How confident are you in accurately measuring the tube for insertion depth

            3 (9.67%)

       5 (16.12%)

       9 (29%)

       9 (29%)

      5 (16.12%)

How confident are you in supervising a colleague with the procedure of inserting a NGT

            10 (32.2%)

      4 (12.90%)

    6 (19.35%)

    7 (22.5%)

     4 (12.90%)

Would you like obtaining more training on this subject

No

I Don’t mind

Yes

Certainly

I am trained

           0 (0%)

     11 (35.48%)

    10 (32.2%)

 10 (32.2%)

    1 (3.22%)

 

The study results indicate that most of the registered nursing professionals obtained an average score in almost entire study variables. More than nineteen percent of nursing professionals could insert NG tube confidently; however, almost forty-two percent scored average in terms of inserting nasogastric tube to the patients’ population. This indicates that greater percentage of nursing professionals capable in terms of executing NG tube placement policy and procedures, as evidenced by the clinical literature (Alpers et al, 2008, p. 352). Indeed, more than thirty-five percent of the nursing professionals displayed considerable confidence in terms of their comfort in aspirating nasogastric tube in various clinical scenarios. This indicates that these nursing professionals are proficient in context to aspirating the gastric contents to evaluate the residual feeding volume, delayed stomach emptying and patterns of gastric intolerance in terms of managing the enteral nutrition (Smeltzer et al, 2007, p. 566).

More than thirty-eight percent of registered nurses displayed confidence in positioning the patient for tube insertion. This indicates that these professionals are completely aware of the protocols of NG tube insertion in accordance with the documentation in evidence based clinical literature. Indeed, the correct positioning of the patient for NG tube insertion determined in context to assessing the clinical condition and selecting the precise distance of the enteral tube for evaluating its appropriate position following the successful insertion (Mallett et al, 2013, p. 1966). The appropriate positioning of the NG tube is of paramount importance to avoid any inadvertent insertion to brain or lungs, thereby leading to serious clinical complications. In fact, most of the nursing professionals exhibited confidence and comfort in feeding the patients through nasogastric tube. This indicates that nursing professionals are well aware of the entire feeding requirements through nasogastric intubation in context to the evidence based literature. Guenter  Silkroski (2001, p. 156) reveal the paediatric indications for nasogastric feeding including infantile diarrheal syndrome, increased feeding time and malnourishment.

The study results indicate that more than thirty-five percent of the registered nurses displayed confidence in terms of their potential in flushing the nasogastric tube. This clearly indicates that majority of the nurses are well aware of the technicalities and complications associated with nasogastric tubal flushing. Indeed, the practice of appropriate techniques for nasogastric tubal flushing highly warranted in avoiding fatalities associated with misplacement or inappropriate flushing of the nasogastric tube. Boyd (2013) describes the events of patients deaths associated with inappropriate flushing of nasogastric tubes prior to the confirmation of their initial placement leading to pulmonary trauma and consequent deaths of the treated patients. The results of the research survey reveal that more than sixteen percent of the study participants showed considerable confidence in practicing common methods of checking NGT placement in patients. However, more than forty-five percent of nurses stood average in their knowledge for evaluating the NGT placement. Allbee et al (2011, p. 501) reveal the prevalent techniques including hand aspiration, evaluation through stethoscope and injection of air through NG tube for confirming its appropriate placement inside patient’s stomach. Indeed, more than thirty-eight percent of the study participants scored average in terms of their confidence in evaluating the NG tubal placement. These findings indicate that the study participants display awareness in context to the tubal placement methodology; however, they still require further training to increase their confidence levels in terms of placing the NG tube to the respective patients for proactively avoiding potential complications related to the malposition of the NG tube due to errors in its placement.

The study survey indicates that more than twenty nine percent of the study subjects confident in measuring the tube in terms of its depth of insertion. The clinical literature reveals the importance of determining the depth of NG tubal invasion with respect to the associated risk potential. Indeed, the standard procedure for determining NG tubal length in context to its placement includes the measurement from the ear until its tip placed inferiorly to the xiphoid process (Beebe & Myers, 2010, p. 451). In fact, more than 12.90% nurses showed the potential for training and supervising their colleagues in the insertion of nasogastric tube. However, more than 32.2% professionals shared their willingness in obtaining further training to enhance their skills and expertise in nasogastric tubal insertion.

The discussion of the study findings clearly reveals the importance of the relevant expertise, competence and skills among registered nursing professionals in inserting the nasogastric tube to the eligible patients. Indeed, the conditions of gastric inflation, gastric distension, gastritis and gastroesophageal reflux disease increase the probability of aspiration, vomiting and ventilatory compromise that require careful monitoring by the nursing professionals while inserting the NG tube in different clinical scenarios. The nasogastric intubation proves to be the method of choice for aspiring or feeding the patients experiencing intestinal insufficiency or drug intoxication. Furthermore, the nursing professionals bear the professional and moral responsibility to understand the potential contraindications and complications in context to NGT insertion to render quality of care while administering feed or medication through NG intubation. The clinical literature reveals that patients with potential esophageal stenosis or varices not subjected to receive nasogastric intubation. Additionally, patients predisposed to basilar skull fractures also should not receive NG intubation for feeding or medication. The application of lidocaine and nasal decongestant warranted prior to NGT insertion to facilitate the process and nursing professionals require in depth understanding in terms of administering these pre-medications to facilitate the NG tubal administration. Nursing professionals require considering the stiffness of NG tubes while inserting them inside the eligible candidates. Indeed, the stiff tubes can easily penetrate the gastrointestinal tract and reduce the risk of gastric or esophageal injury or misplacement into pulmonary location as evidenced by the clinical literature. The guiding principles of NG tubal insertion warrant the utilization of guide wire and radiologic intervention to ascertain the appropriate positioning of NG tube for avoiding potential complications following the malposition due to inappropriate insertion. Furthermore, the utilization of appropriate sterilization techniques and surgical equipments warranted to avoid the probability of occurrence of infectious manifestations following the tubal insertion. The measurement of the NG tube in relation to the length of intubation assists in proper placement following its systematic insertion. The patients require positioning in high fowler state in accordance with the physician’s instructions prior to administering the NG tube following the medical necessity. The lubrication of the NG tube with anaesthetic gel required to induce local analgesia for reducing the pain experienced during the intubation process. The tube facilitated through patient’s wider nostril and directed to esophagus until it reaches finally to the stomach. The tube is fixated while decompressing the gastric contents prior to initiating feeding or medication. The tube requires regular maintenance by the nursing professionals in terms of flushing with air or saline in timely intervals to avoid obstruction or clogging. The validation of appropriate positioning of NG tube executed with the application of additional tests including whoosh test, chest radiograph and pH analysis. Furthermore, the nursing professionals require evaluating NG tube periodically following the initial placement and particularly prior to each feeding, and in cases of triggering of coughing and vomiting for checking secondary infection following the insertion. The dislodgement of the NG tube requires immediate attention by the nursing staff for appropriate remedial action in context to avoiding trauma and discomfort to the patient. Indeed, the qualified nursing professionals require competence and knowledge in context to NG tubal insertion and maintenance in relation to the medical necessities requiring NG intervention to facilitate patient’s medication or feeding.

Conclusion

The study concluded with the findings indicating that most of the study subjects evaluated during the research survey displayed average scores in all variables accessed to evaluate their efficiency and knowledge in administering and maintaining the NG tube in context to patient’s medical necessities. This certainly indicates the need to conduct prospective educational campaigns and seminars with the intent of further educating the nursing professionals regarding potential complications and traumatic conditions following the NG tubal insertion. The skills and competence level of more than one-third of the nursing professionals remained below average in accordance with the findings of the study. This indeed, warrants further investigation through prospective multicentre research studies of longer duration and increased sample size to determine the exact knowledge gaps and deficit in potential and competence among registered nurses in terms of inserting and maintaining nasogastric tubes to the required patients’ population. The research survey further reveals that only 6.4% of the study candidates never had the change to insert NG tube to patients. This indicates that almost all of the research participants have experience to variable extents in context to nasogastric tubal placement. Furthermore, the findings of the study prove that all research participants had the opportunity to aspirate and flush the nasogastric tube during their professional tenure. This proves that all of the nursing professionals are proficient in aspirating NG tubes to variable proportion. Indeed, most of the study subject showed confidence e in terms of aspirating NG tube to the eligible patients. This indicates that the prospective training programs require more emphasis on the insertion and management of NG tubes rather than mere aspiration principles. The research survey concluded that 96.78 % of the nursing professions shown their willingness to attend the training program for enhancing their skills and expertise in NG intubation and management process. This further indicates the scope of conducting prospective interactive sessions and training programs for the nursing professionals in the wider context of enhancing their potential and quality of care while imparting NG tubes to the patients’ population. The study concluded with the finding that 12.90% of the research participants pertain to the section of senior nurses capable to supervise and impart training sessions to the junior nursing professionals. Indeed, the quantitative research study explored the competence level of nursing professionals in terms of insertion and management of NG tubes and retrieved the findings indicating wide range of awareness among registered nurses regarding administering the NG tubes to eligible candidates in context to their medical necessities. However, potential gaps in terms of study variables obtained indicating the lack of confidence between certain group of nurses in context to NG intubation and gaps in knowledge also explored in nursing groups with respect to accurately placing and positioning NG tube. Nurses also require training sessions to improve their skills and enhance knowledge regarding NG tubal feeding to the patients’ population. The research survey remained limited to a single clinical setting and explored the knowledgebase of very limited number of registered nurses. Therefore, the results of the research study are still debatable and the wider perspective of knowledge gaps between the nursing professionals in terms of NGT handling yet to be identified while conducting cross border studies across various hospital settings through disseminating research questionnaires and initiating face to face interactive sessions as well with the nursing professionals. The multiple findings through interview sessions and research questionnaires will assist the researchers in identifying the focus of the prospective skill enhancing training sessions for the nurses with the intent to enhance their knowledge and expertise in context to handle NG tubes and their complications within the patients’ population. Most importantly, the senior nurses associated with the bigger surgical facilities across the globe require prospective assessment to determine their knowledgebase and precisely evaluate their potential in terms of identifying the areas of improvement in NG intubation. Indeed, the precision in nasogastric intubation will enhance the quality of care to the patients and assist in avoiding misplacement and malpositioning of the NG tubes due to errors in placement. Addressing these core issues in context to NG intubation by nurses will undoubtedly enhance the error free administration of NG feed and drugs while avoiding potential complications and injuries to the patients following the intubation.

References

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Tollefson, J. (2004). Clinical Psychomotor Skills: Assessment Tools for Nursing Students. Australia: Thomson.

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