Verifying NG tube placement in children
We want to clarify some information in your recent survey report “20 Questions: Evidence-based Practice or Sacred Cow?” (August 2015). Statement 5, which says that pH testing of gastric aspirate is a reliable way to establish correct placement of a gastric feeding tube, is identified as “false” by the authors. We feel the correct response is “probably true,” particularly in the case of pediatric patients.1
I chair the New Opportunities for Verification of Enteral Tube Location (NOVEL) project sponsored by A.S.P.E.N. The referenced 2014 press release by A.S.P.E.N. is about a recently completed 1-day point prevalence study on NG tube use authored by our workgroup.2 In that study, we document the wide diversity of methods used to verify NG tube placement. In a prior review article also cited in your references, we explore the use of pH measurement in pediatric practice and the existing evidence to support use of this method of NG tube placement verification.3 Neither of these references suggest that pH testing isn't reliable.
While we don't disagree with the statement that radiographs are the most reliable method to verify NG tube placement, we don't agree that this method is or should be widely used in pediatrics due to concerns about radiation exposure and its cumulative effect on the future health of the children we serve.
We wish to convey to your readers that, at this time, in pediatric patients pH measurement is the best practice we have to verify NG tube placement when combined with other measures, such as confirmation of tube length and skilled nursing assessment of the child. For more information about the NOVEL project, please check out this link: www.nutritioncare.org/novel/.
—BETH LYMAN, MSN, RN, CNSC, CHILDREN'S MERCY KANSAS CITY, NOVEL PROJECT CHAIR REPRESENTING A.S.P.E.N.
PEGGI GUENTER, PHD, RN, FAAN, DIRECTOR OF CLINICAL PRACTICE, QUALITY AND ADVOCACY AT A.S.P.E.N.
LADONNA NORTHINGTON, DNS, RN, UNIVERSITY OF MISSISSIPPI SCHOOL OF NURSING, REPRESENTING THE SOCIETY OF PEDIATRIC NURSING
CAROL KEMPER, PHD, RN, CPHQ, CHILDREN'S MERCY KANSAS CITY, REPRESENTING CHILD HEALTH PATIENT SAFETY ORGANIZATION PATIENT SAFETY TEAM
SHARON IRVING, PHD, CRPN, FCCM, CHILDREN'S HOSPITAL OF PHILADELPHIA, REPRESENTING AMERICAN ASSOCIATION OF CRITICAL-CARE NURSES
KERRY WILDER, MBA, BSN, RN, CHILDREN'S HEALTH, DALLAS, TEX., REPRESENTING NATIONAL ASSOCIATION OF NEONATAL NURSES
LORI DUESING, MSN, RN, CNPN-AC, CHILDREN'S HOSPITAL OF WISCONSIN, REPRESENTING NORTH AMERICAN SOCIETY FOR PEDIATRIC GASTROENTEROLOGY HEPATOLOGY AND NUTRITION
JANE ANNE YAWORSKI, MSN, RN, CNS, CHILDREN'S HOSPITAL OF PITTSBURGH, REPRESENTING A.S.P.E.N.
GINA REMPEL, MD, FRCPC, FAAP, CHILDREN'S HOSPITAL WINNIPEG, REPRESENTING A.S.P.E.N.
WEDNESDAY MARIE A. SEVILLA, MD, MPH, UT LE BONHEUR CHILDREN'S HOSPITAL, REPRESENTING A.S.P.E.N.
DEAHNA VISSCHER, REPRESENTING PARENTS WHO HAVE LOST A CHILD AS A RESULT OF NG TUBE MISPLACEMENT
1. Gilbertson HR, Rogers EJ, Ukoumunne OC. Determination of a practical pH cutoff level for reliable confirmation of nasogastric tube placement. JPEN J Parenter Enteral Nutr. 2011;35(4):540–544.
Lyman B, Kemper C, Northington L, et al. Use of temporary enteral access devices in hospitalized neonatal and pediatric patients in the United States. JPEN J Parenter Enteral Nutr. [e-pub Jan. 7, 2015]
3. Irving SY, Lyman B, Northington L, Bartlett JA, Kemper C; Novel Project Work Group. Nasogastric tube placement and verification in children: review of the current literature. Crit Care Nurse. 2014;34(3):67–78.
Julie Miller, BSN, RN, CCRN, replies:
Thank you for your response to our article and the additional information on gastric pH testing. In our presentation of the information on pH testing for gastric tube verification, we should have specified that this applies to adult patients only. Your additional information will help nurses differentiate the care of adult and pediatric patients. We appreciate the dialogue this article is providing about best practices for all patients.
Appreciating a nurse who went the extra mile
Kudos for the insightful and well-written Sharing article, “NP to the Rescue” (August 2015),* in which an employee health NP encourages a reluctant surgeon who'd suffered a sharps injury to accept postexposure prophylaxis (PEP). Fortunately, the NP reached out while the window for PEP was still open, giving the surgeon the chance to make a more informed choice about antiretroviral therapy. Besides carefully explaining the risks and benefits of PEP, the NP went the extra mile by calling an infectious-disease colleague for urgent clinical intervention.
As a school nurse, I review bloodborne pathogens and personal protection equipment (PPE) each year with all of my staff. As I review PPE and hand hygiene again this autumn, I'll think about this article.
—DIANE LYNCH, MSN, RN
Avoid PCA by proxy
“Sidestep the Perils of PCA in Post-op Patients” (Controlling Pain, April 2015)* is very informative for nurses working with post-op patients receiving patient-controlled analgesia (PCA).
We too had an unfortunate incident in the administration of PCA on the med-surg unit where I work. Even though the nursing staff had taught the family members not to administer PCA by proxy, they did so. The PCA was discontinued, naloxone was administered, and the patient recovered without complications. Nurses asked the family members why they'd pushed the PCA activation button for the patient. They said that they thought she was hurting “more than she let on.”
PCA by proxy is very dangerous. The nursing staff must safeguard patients during PCA by regularly assessing their sedation level. Two nurses should independently double-check the prescriber's order, patient identification, drug and concentration, PCA pump settings, and line attachment before use, every shift, and with any programming change.1
I suggest that the nursing staff give printed educational material to patients and their significant others and have them sign it to acknowledge their understanding of PCA. Nurses must continue to verbally reinforce PCA instructions with the patient and family while PCA is in use.
—CAROL L. SELLERS, BSN, RN, CMSRN
Institute for Safe Medication Practices. Part II. How to prevent errors—safety issues with patient-controlled analgesia. Acute Care ISMP Medication Alert! 2003. www.ismp.org/newsletters/acutecare/articles/20030724.asp.
Hooray for mentors
I enjoyed reading “Mentoring RNs Pursuing BSN Degrees: A Leadership Journey” (Learning Curve, July 2015).* I'm a strong advocate for mentoring and mentorship programs because they help to increase clinical knowledge and skills, promote job satisfaction, and advance professional development.1
I found a mentor in my first nursing manager 10 years ago when I was a new graduate nurse. She was inspiring, motivational, and encouraging. She had leadership skills that I found myself wanting to replicate in my life. Mentorship is an excellent way to develop staff members' professionalism and keep the nursing profession growing. I think more mentoring programs should be available to all nurses.
—MEGAN BLAIRE, BSN, RN
1. Thomka LA. Mentoring and its impact on intellectual capital: through the eyes of the mentee. Nurs Adm Q. 2007;31(1):22–26.
* Individual subscribers can access articles free online at www.nursing2015.com.