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Feeding Tube Placements: Dietitian training and the Procedure
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Transcript of Feeding Tube Placements: Dietitian training and the Procedure
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FEEDING TUBE PLACEMENTS:
DIETITIAN TRAINING AND THE PROCEDURE
Lisa Molnar, RD, LD, CNSCHennepin County Medical Center
(HCMC)
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OBJECTIVES After this presentation the attendee should
be able to Develop training for dietitians to place feeding
tubes at their facility Understand the procedure of feeding tube
placement at the bedside.
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DIETITIAN FEEDING TUBE PLACEMENTS AT HCMC Started in June of 2011 Primary placer in the MICU, SICU, BURN, and PICU,
Monday – Friday 8am-4pm Each floor has own rules for nursing placement
Back up placer in all other areas of the hospital during same hours Float Pool RN is primary contact 24/7 on floors
After hours/weekend/holiday if available, but not staffed 5 Dietitians
2 Full Time 3 Part Time (0.6, 0.5, and 0.7)
Use the Cortrak® Monitor Avg. 50-60 patients/placements per month Currently, no change in staffing or work loads
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FEEDING TUBE DATAAPRIL-DECEMBER 2012, N=489
Average length of time from order placement to response: 5 ½ hours Delayed 2/2 other procedures, weekend/night
orders, hemodynamic instability of patient Average Length of time of feeding tube
placement: 23 minutes Actual placement time (not including set
up/clean up) 85% Small Bowel placement 78% Nasal Bridle use Average number of X-rays per feeding tube
placement: 1.15 Reglan use: 38% of placements
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FEEDING TUBE PLACEMENT COMPETENCY AT HCMC
Review Hospital Policies Feeding Tube Placement and Enteral Feeding
Review Readings Mosby’s Nursing Skills Guidelines for the Provision and Assessment of Nutrition Support Therapy in
the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) American Dietetic Association’s Evidenced Analysis Library, Critical Illness
topics: gastric vs small bowel feeding tube placement; Monitoring criteria in critical care: gastric residual volume, patient positioning, promotility agents
Nutrition Critical Care Clinical Practice Guidelines. Strategies to Optimize Delivery and Minimize Risk of EN.
View videos on feeding tube placement Corpak® Video Cortrak® Video
Observe feeding tube placement in Fluoroscopy x 1-2 Review directions for use of the Cortrak® device and observe RD/RN
place gastric and small bowel feeding tubes using Cortrak® until comfortable with the procedure
On the job training with trained RD/ICU RN with successful placement of at least 3 in small bowel
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TRAINING WITH CORPAK® MEDSYSTEMS Cortrak® sent out a nurse to assist with
Training for 1 week after complete non-hands on portion of competency
Completed slide show education with the nurse from Cortrak®
Hands on training – placed as many feeding tubes as ordered during that week in SICU and MICU with observation of Cortrak® nurse Minimum for 3 successfully before deemed
“competent” After “competent”, must complete 1 feeding
tube placement successfully every 3 months to maintain competency
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TRAINING NEW DIETITIANS Same competency form New dietitian will shadow competent dietitian
placing feeding tubes until comfortable to start placing on own
New dietitian will place at least 3 post pyloric feeding tubes successfully with observation until dietitian is comfortable.
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CHECK LIST BEFORE STARTING Check physician order
Nasal vs Oral Placement Gastric vs post-pyloric
Communicate with primary RN Timing Sedation needed Pro-kinetic agent (ie Reglan)
Explain procedure to the patient/family
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FEEDING TUBE PLACEMENT – SET UP Obtain Supplies
Feeding tube 10 Fr in adults (43 in or 55 in) 8 Fr in peds (36 in)
Cortrak® Monitor 10 mL saline flush 60 mL luer or eccentric tip syringe Lubrication Stethoscope Nasal Bridle or Tape
AMT Bridle® NGT tape Paper Tape, Silk Tape (to patient or ETT) Twill Tape
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CORTRAK® MONITOR
Monitor
Place over Zyphoid Process
Feeding tube wire connects to monitor
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USING THE CORTRAK® GRID
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GETTING STARTED Place Cortrak® monitor device over Zyphoid
Process, the device should be level Enter via nare or mouth depending on order Once feeding tube advanced to 5-10 cm, turn
Cortrak® monitor on Watch monitor as advance feeding tube
Feeding tube should go straight down to cross section
If deviates left or right prior to cross section, possible lung placement
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POSSIBLE LUNG PLACEMENTS- PULL BACK
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PLACEMENT
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GETTING TO THE STOMACH Most adults GE junction is at 50 cm, can
measure if peds or abnormal sized adult Auditory confirmation by pushing air through 60
mL syringe and listening with a stethoscope Advance feeding tube to desired final location Ok to push (give length) through the stomach. If having trouble
Pull NGT Fill stomach with air Pull out stylet a few inches and try to advance Turn the tube as advancing Go slower
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GASTRIC PLACEMENT
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GETTING POST PYLORIC The longest portion of the feeding tube
placement Do not advance in length, put pressure on
the tube only, small intestine will pull it in Tips to improve advancement
“Floppy tip” – pulling out the stylet Flush with saline or air Reglan use (IV 10 mg works in minutes) Turn the tube while putting on pressure Reposition the patient Pull back/out NGT
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POST-PYLORIC PLACEMENT
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EXAMPLE AT HCMC:LIGAMENT OF TREITZ
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EXAMPLE AT HCMC: DUODENAL PLACEMENT
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CORTRAK/FLUOROSCOPY COMPARISON
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SECURE THE FEEDING TUBE
Nasal Bridle
NGT Tape
Twill Tape