UBC Theses and Dissertations

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UBC Theses and Dissertations

The effect of the patient’s level of consciousness and the degree of nasogastric tube flexibility on… Heaslip, Jane Elizabeth 1982

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0 THE EFFECT OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND THE DEGREE OF NASOGASTRIC TUBE FLEXIBILITY ON THE EASE OF INSERTION OF THE TUBE IN PATIENTS WITH AN ENDOTRACHEAL TUBE IN PLACE by JANE ELIZABETH HEASLIP B.A., The U n i v e r s i t y o f Manitoba, 1977 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES (School of Nursing) We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA March 1982 © Jane E l i z a b e t h H e a s l i p , 19 82 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the requirements f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head o f my department o r by h i s o r her r e p r e s e n t a t i v e s . I t i s understood t h a t c o p y i n g or p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Department of Nursing The U n i v e r s i t y o f B r i t i s h Columbia 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 Date 16th A p r i l , 1982 ABSTRACT The E f f e c t of the P a t i e n t ' s L e v e l of Consciousness and the Degree of N a s o g a s t r i c Tube F l e x i b i l i t y on the Ease of I n s e r t i o n Of the Tube i n P a t i e n t s With an End o t r a c h e a l Tube i n Place Jane E. H e a s l i p The purpose of t h i s study was to examine the e f f e c t t h a t the p a t i e n t ' s l e v e l of consciousness and the degree of n a s o g a s t r i c tube f l e x i b i l i t y would have on the ease of i n s e r t i o n of the tube i n p a t i e n t s with an en d o t r a c h e a l tube i n p l a c e . The s t a t i s t i c a l hypotheses t e s t e d were: 1. The Degree of n a s o g a s t r i c tube f l e x i b i l i t y w i l l not i n f l u e n c e the ease with which the tube i s i n s e r t e d . 2. The l e v e l of consciousness of the p a t i e n t w i l l not i n f l u e n c e the ease with which the n a s o g a s t r i c tube i s i n s e r t e d . 3. There w i l l be no i n t e r a c t i o n between the degree of f l e x i b i l i t y of the n a s o g a s t r i c tube to be i n s e r t e d and the l e v e l o f consciousness o f the p a t i e n t i n whom the tube i s p l a c e d . The sample from whom data was c o l l e c t e d f o r the study c o n s i s t e d of 121 p a t i e n t s admitted to the r e s p i r a t o r y i n t e n s i v e c a r e u n i t of a l a r g e t e a c h i n g h o s p i t a l who r e q u i r e d e n d otracheal i n t u b a t i o n and subsequent placement of a n a s o g a s t r i c tube. The number of attempts per p a t i e n t f o r s u c c e s s f u l placement of each tube were recorded over a fo u r month p e r i o d and the data analysed u s i n g a 2 X 3 f a c t o r i a l d e s i g n . The two independent v a r i a b l e s were degree of n a s o g a s t r i c tube f l e x i b i l i t y w ith two l e v e l s : f l e x i b l e and r i g i d , and l e v e l of consciousness w i t h three l e v e l s : c o n s c i o u s , obtunded and unconscious. The data c o l l e c t e d from the study i n d i c a t e t h a t the degree of n a s o g a s t r i c tube f l e x i b i l i t y s i g n i f i c a n t l y a f f e c t s the ease wi t h which a tube can be i n s e r t e d i n an i n t u b a t e d p a t i e n t ( c v = . 0 5 ) the r i g i d tube r e q u i r i n g a s t a t i s t i c a l l y fewer number of attempts than the f l e x i b l e tube. The d i f f e r e n c e among l e v e l s of p a t i e n t consciousness were not found t o be s t a t i s t i c a l l y s i g n i f i c a n t i n t h i s i n v e s t i g a t i o n but the i n t e r a c t i o n between the degree of tube f l e x i b i l i t y and l e v e l o f p a t i e n t consciousness r e v e a l e d s t a t i s t i c a l s i g n i f i c a n c e . T h e s i s Chairman TABLE OF CONTENTS Page CHAPTER ONE : THE PROBLEM AND PURPOSES 1 I n t r o d u c t i o n 1 S t a t e m e n t o f t h e P r o b l e m 4 P u r p o s e s o f t h e S t u d y 4 D e f i n i t i o n o f Terms 5 CHAPTER TWO: REVIEW OF THE LITERATURE 7 I n t r o d u c t i o n 7 H i g h l i g h t s o f t h e H i s t o r i c a l D e v e l o p m e n t o f t h e 8 N a s o g a s t r i c Tube Methods o f I n s e r t i n g N a s o g a s t r i c Tubes 18 CHAPTER THREE: METHODOLOGY 28 P r e l i m i n a r y E x p e r i m e n t 28 R e s e a r c h D e s i g n 28 P o p u l a t i o n and Sample 30 D a t a C o l l e c t i o n Method 30 Method o f S c o r i n g t h e Number o f I n s e r t i o n s 31 E t h i c s and Human R i g h t s 31 D a t a A n a l y s i s 32 CHAPTER FOUR: THE FINDINGS 34 D e s c r i p t i v e S t a t i s t i c s 35 I n f e r e n t i a l S t a t i s t i c s 35 P o s t Hoc A n a l y s e s and A d d i t i o n a l O b s e r v a t i o n s 38 CHAPTER F I V E : SUMMARY, RECOMMENDATIONS, IMPLICATIONS AND CONCLUSIONS.. 42 Summary 4 2 I m p l i c a t i o n s 45 Recommendations C o n c l u s i o n s 46 BIBLIOGRAPHY 4 9 APPENDICES 56 One: F o r c e s n R e q u i r e d t o D e f l e c t NGT a t 0 C and 18 C Two: C o n s e n t Form T h r e e : I n s e r t i o n T e c h n i q u e F o u r : D a t a C o l l e c t i o n S h e e t iv. LIST OF TABLES Page 1. Number of Attempts Required f o r S u c c e s s f u l N a s o g a s t r i c Tube I n s e r t i o n i n P a t i e n t s w i t h Three D i f f e r e n t L e v e l s of Consciousness u s i n g F l e x i b l e and R i g i d N a s o g a s t r i c Tubes 36 2. Mean N a s o g a s t r i c Tube I n s e r t i o n Attempts 37 3. ANOVA Summary Table. 39 4. t - T e s t Comparing Mean I n s e r t i o n attempts of Unconscious P a t i e n t s 39 5. Forces Required t o D e f l e c t N a s o g a s t r i c Tube ' at 0 C and 18°C 57 v LIST OF FIGURES Page 1. Graphic r e p r e s e n t a t i o n o f the mean number of i n s e r t i o n s r e q u i r e d f o r s u c c e s s f u l n a s o g a s t r i c i n t u b a t i o n i n p a t i e n t s w i t h t h r e e d i f f e r e n t l e v e l s o f consciousness 37 2. I l l u s t r a t i o n of f o r c e s r e q u i r e d t o d e f l e c t N a s o g a s t r i c Tubing a t 0°C and 18°C 57 v i ACKNOWLEDGEMENTS The author g r a t e f u l l y acknowledges the c o n t r i b u t i o n s made by many i n the p r e p a r a t i o n of t h i s t h e s i s . P a r t i c u l a r thanks are give n t o the Committee members, Ms. Sue Rothwell and P r o f e s s o r Harold R a t z l a f f f o r t h e i r s u s t a i n e d support, encouragement, enthusiasm, and guidance. Thanks are extended as w e l l to Mr. Bob Bruce f o r h i s i n s t r u c t i o n i n computer programming, to Mr. Mike P o s n i k o f f f o r h i s s u p e r v i s i o n of the p h y s i c s experiments, and to Barbara Moore of F i l t n e s s and Cameron who typed the manuscript. A p p r e c i a t i o n t o the Nursing Research Committee, the Head Nurse, and the Med i c a l D i r e c t o r o f the I n t e n s i v e Care U n i t i s g r a t e f u l l y extended f o r t h e i r p e r m i s s i o n to use the u n i t to c a r r y out the r e s e a r c h programme. Without the c o o p e r a t i o n of the nurses working i n the u n i t t h i s r e s e a r c h c o u l d never have been c a r r i e d out and s p e c i a l thanks are extended to them f o r t h e i r f a i t h f u l l n e s s i n r e c o r d i n g data and adhering t o the r e s e a r c h p r o t o c o l w h i l e meeting the demands of t h e i r busy u n i t . v i i 1 CHAPTER ONE THE PROBLEM I n t r o d u c t i o n The ease w i t h which a n a s o g a s t r i c tube i s i n s e r t e d may w e l l be r e l a t e d t o such f a c t o r s as the degree of a n x i e t y on the p a r t of the nurse, the l e v e l o f the nurse's knowledge c o n c e r n i n g the anatomy of the nasopharynx, esophagus, and stomach, the degree of p a t i e n t c o o p e r a t i o n d u r i n g the procedure, and the m a n a g e a b i l i t y of the tube i t s e l f . * ' A r e c e n t a r t i c l e suggests t h a t a nurse's l e v e l of a n x i e t y c o n c e r n i n g n a s o g a s t r i c i n t u b a t i o n w i l l decrease as she becomes more aware of the anatomic and 2 p h y s i o l o g i c p r i n c i p l e s t h a t govern placement of the tube. Procedures t h a t are based upon these f i n d i n g s 3 have r e c e n t l y been d e l i n e a t e d . M a n a g e a b i l i t y of the tube to ^ C e c i l i a Volden, J a c q u e l y n Grinde, and David C a r l , " N a s o g a s t r i c I n t u b a t i o n , " N u r s i n g 8 0 . 1 0 (September 1 9 8 0 ) : 1 4 - 1 7 . 2 Barbara A, Griggs and Mary C. Hoppe, " N a s o g a s t r i c Tube Feeding," American J o u r n a l of N u r s i n g 79 (March 1 9 7 9 ) : 4 8 1 - 4 8 5 . 3 See Barbara A. Griggs and Mary C. Hoppe, " N a s o g a s t r i c Tube Feeding," American J o u r n a l of N u r s i n g 7 9 (March 1 9 7 9 ) : 4 8 1 - 4 8 5 ; Edwina A. McConnell, " A l l About G a s t r o i n t e s t i n a l I n t u b a t i o n , " N u r s i n g 7 5 5(September 1 9 7 5 ) : 3 1 - 3 6 ; and C e c i l i a Volden, J a c q u e l y n Grlnde, and David C a r l , "Taking the Trauma Out of N a s o g a s t r i c I n t u b a t i o n , " Nursing 8Oio(September 1 9 8 0 ) : 1 4 - 1 7 . 2 be . i n s e r t e d has been d i s c u s s e d i n r e l a t i o n to a n a e s t h e t i s e d p a t i e n t s w i t h e n d o t r a c h e a l tubes i n 4 p l a c e . Volden e t a l recommend t h a t the n a s o g a s t r i c tube be p l a c e d on i c e b e f o r e i n s e r t i o n i n o r d e r to prevent c o i l i n g of the tube i n the back of the t h r o a t , but t h i s s u g g e s t i o n was made with o u t b e n e f i t o f a c o n t r o l l e d c l i n i c a l t r i a l . 5 The approaches most f r e q u e n t l y used by nurses t o s o l v e problems a r e t r i a l and e r r o r , r e l i a n c e on p a s t e x p e r i e n c e , g "common sense", " f a i t h " , and custom. A l l these methods have been used i n d e c i d i n g how b e s t to i n s e r t a n a s o g a s t r i c tube. The r a t i o n a l e f o r i n s e r t i n g a tube t h a t has been c o o l e d b e f o r e "*See David A. Chadwick, "The I n s e r t i o n of N a s o g a s t r i c Tubes i n t h e A n a e s t h e t i s e d P a t i e n t , " A n a e s t h e s i a 28 (1973):341-342; Liew Pak Chin, "A Method of P a s s i n g N a s o - g a s t r i c Tube During A n a e s t h e s i a i n the Newborn," A n a e s t h e s i a 27 (October 1972):458; A.R. Hunter, "The I n s e r t i o n of N a s o g a s t r i c Tubes i n the A n a e s t h e t i s e d P a t i e n t , " A n a e s t h e s i a 28 (1973):708-709; R.K. Mirakhur, "Simple and R e l i a b l e Method of I n s e r t i n g a Naso-g a s t r i c Tube During A n a e s t h e s i a , " B r i t i s h J o u r n a l of A n a e s t h e s i a 45 (1973):1062; K i e - C h u l Ohn,and Wen-Hsien Wu, "A New Method f o r N a s o g a s t r i c Tube I n s e r t i o n , " A n a e s t h e s i o l o g y 51 (1979') : 568; Akitomo Matsuki and Elemer K. Zsigmond, "Simple and R e l i a b l e Method of I n s e r t i n g a N a s o g a s t r i c Tube During A n a e s t h e s i a , " B r i t i s h J o u r n a l of A n a e s t h e s i a 26 (1972):610; Donald A. Mundy, "Another Technique f o r I n s e r t i o n of N a s o g a s t r i c Tubes," A n a e s t h e s i o l o g y 50 (1979):374; E. Robinson J r . , e t a l , "Feeding Tube I n t r o d u c t i o n — A n E a s i e r Way," C r i t i c a l Care Medicine 7 (August 1 9 7 9 ) : 3 4 9 ; A.K. Saha, "The I n s e r t i o n of N a s o g a s t r i c Tubes i n the A n a e s t h e t i s e d P a t i e n t , " A n a e s t h e s i a 29 ( 1 9 7 4 ) : 3 6 7 ; Robert M. Smith, "Simple and Safe Method f o r I n s e r t i n g a N a s o g a s t r i c Tube," B r i t i s h J o u r n a l of A n a e s t h e s i a 4 5 (1973):1168; and R.W. V i r t u e , "Simple and R e l i a b l e Method of I n s e r t i n g a N a s o g a s t r i c Tube During A n a e s t h e s i a , " B r i t i s h J o u r n a l of A n a e s t h e s i a 45 (1973):234. ^ C e c i l i a Volden, J a c q u e l y n Grinde and C a r l , David, " N a s o g a s t r i c I n t u b a t i o n , " N u r s i n g 8QlO(September 1980) :14. 6 Thelma J . W e l l s , " C l i n i c a l N u r s i n g : C u r i o u s e r and C u r i o u s e r , " The American J o u r n a l of Nursinc?9(October 1 9 7 9 ) : . 1757-1760. 3 i n s e r t i o n to promote r i g i d i t y o r s t o r e d a t room temperature to ensure f l e x i b i l i t y i s the s a m e — " t h i s i s the way i t has always been done" or "I b e l i e v e t h i s method works b e s t " . When one method f a i l s a second i s adopted, and when success i s f i n a l l y achieved i t i s more o f t e n than not a t t r i b u t e d t o " l u c k " . In the case of a p a t i e n t with an e n d o t r a c h e a l tube i n p l a c e the nurse i s most l i k e l y to use one of the a l t e r n a t i v e s j u s t d e s c r i b e d i n p l a c i n g a n a s o g a s t r i c tube d e s p i t e some evidence t h a t i n t h i s p a t i e n t a t l e a s t t h e r e i s an advantage i n i n s e r t i n g a more r i g i d tube. I t seems a l o g i c a l c o n s i d e r a t i o n t h a t a s t i f f e n e d tube might c o n t r i b u t e t o the ease of i n s e r t i o n i f one's a t t e n t i o n i s g i v e n f o r a moment to the nature of the .tube i t s e l f . Most n a s o g a s t r i c tubes now i n use both f o r f e e d i n g and drainage are made of p l a s t i c . The assembly of polymeric chains i s h e l d together by a number of d i f f e r e n t f o r c e s and, when heated, these chains move apart s u f f i c i e n t l y t o permit them to s l i d e over one another but r e t a i n t h e i r 7 cohesiveness because of the f o r c e s s t i l l o p e r a t i n g . T h i s means t h a t the type of p l a s t i c from which most n a s o g a s t r i c tubes are made, p o l y v i n y l c h l o r i d e , i s s o f t e r and l e s s e a s i l y d i r e c t e d when at room temperature than when c o l d . T h i s s o f t n e s s i s an advantage i n terms of p a t i e n t comfort and s a f e t y because i t w i l l cause l e s s oropharyngeal d i s c o m f o r t than a harder m a t e r i a l , but i t i s a disadvantage r e g a r d i n g i n s e r t i o n because i t prevents the tube from being e a s i l y d i r e c t e d . 7 . W i l l i a m L. Masterson and E m i l J . S l o w i n s k i , Chemical  P r i n c i p l e s (Philadelphia/Toronto/London: W.B. Saunders Company, 1976), p.327. 4 Statement of the Problem L i t e r a t u r e review has shown t h a t quantitative , o b j e c t i v e o measures have not as y e t been used to examine the f a c t o r s t h a t i n f l u e n c e the ease with which a n a s o g a s t r i c tube can be i n t r o d u c e d . Since the r e c e n t l i t e r a t u r e c l aims t h a t the l e v e l o f consciousness of the p a t i e n t , the presence or absence of an en d o t r a c h e a l tube, and the degree of n a s o g a s t r i c tube f l e x i b i l i t y a l l i n f l u e n c e the ease w i t h which t h a t tube can be i n s e r t e d , a c o n t r o l l e d study t o examine these f a c t o r s would be h e l p f u l . Such a study would be e s p e c i a l l y s i g n i f i c a n t i f i t s implementation c o u l d encourage problem s o l v i n g techniques t h a t would r e p l a c e what Thelma Wells c a l l s the methods of r e l i a n c e on p a s t experience alone, common sense, f a i t h , and/or custom. Purpose of the Study The purpose of t h i s study was to examine the e f f e c t s t h a t two degrees of f l e x i b i l i t y of the n a s o g a s t r i c tube and l e v e l of p a t i e n t consciousness have on the ease of i n s e r t i o n of a naso-g a s t r i c tube i n p a t i e n t s w i t h an endotracheal tube i n p l a c e . The s t a t i s t i c a l hypotheses to be t e s t e d were: 1. The degree of tube f l e x i b i l i t y w i l l not i n f l u e n c e the ease w i t h which the n a s o g a s t r i c tube i s i n s e r t e d . 2. The l e v e l of consciousness of the p a t i e n t w i l l not i n f l u e n c e the ease with which the n a s t o g a s t r i c tube i s i n s e r t e d . 3. There w i l l be no i n t e r a c t i o n between the degree of f l e x i b i l i t y o f the n a s o g a s t r i c tube to be i n s e r t e d and the l e v e l o f consciousness of the p a t i e n t i n whom 5 t h e t u b e i s p l a c e d . The o b j e c t i v e o f t h e s t u d y was t o f o r m a l l y t e s t what n u r s e s have come t o b e l i e v e t h r o u g h t r i a l and e r r o r o r p a s t e x p e r i e n c e , b u t what h a s n o t a s y e t b e e n v a l i d a t e d ( i . e . , t h a t t h e r e i s a d i f f e r e n c e i n t h e e a s e o f i n s e r t i o n o f a n a s o g a s t r i c t u b e i n t h e p a t i e n t who has an e n d o t r a c h e a l t u b e i n p l a c e t h a t i s d e p e n d e n t u p o n . t h e d e g r e e o f f l e x i b i l i t y o f t h e t u b e i n s e r t e d and t h e l e v e l o f c o n s c i o u s n e s s o f t h e p a t i e n t ) . The a i m . o f t h e i n v e s t i g a t i o n was t o p r o v i d e a more s c i e n t i f i c b a s e upon w h i c h t h e c l i n i c a l d e c i s i o n c o u l d be made c o n c e r n i n g t h e p l a c e m e n t o f n a s o g a s t r i c t u b e s i n i n t u b a t e d p a t i e n t s w i t h v a r y i n g l e v e l s o f c o n s c i o u s n e s s . D e f i n i t i o n s o f t h e Terms N a s o g a s t r i c Tube R R A r g y l e S a l e m Sump Tube. T h i s i s a d o u b l e lumen -tube made o f t h e r m o s e n s i t i v e p o l y v i n y l c h l o r i d e w h i c h i n c r e a s e s i n f l e x i b i l i t y a t n o r m a l body t e m p e r a t u r e . One lumen s e r v e s f o r s u c t i o n d r a i n a g e o r f e e d i n g w h i l e t h e o t h e r p r o v i d e s an a i r v e n t t o b r e a k t h e vacuum when t h e stomach has been e v a c u a t e d o f a c c u m u l a t e d l i q u i d , a i r and s m a l l p a r t i c u l a t e m a t t e r . A number 14 t u b e i s 4.7 mm i n d i a m e t e r and 122 cm i n l e n g t h . A number 18 t u b e i s 6.0 mm i n d i a m e t e r and 122 cm i n l e n g t h . The t u b e h a s a n R R X - r a y opaque S e n t i n e l L i n e and S e n t i n e l Eye w h i c h p e r m i t e x a c t l o c a t i o n o f t h e t u b e and d r a i n a g e eyes.-D e g r e e o f Tube S t i f f n e s s 1. F l e x i b l e : t u b e i n i t s n a t u r a l p l i a b l e s t a t e a t room 6 temperature. 2. R i g i d : tube i n the s t i f f e n e d s t a t e as produced by a ten minute immersion i n an i c e bath. L e v e l of Consciousness 1. Conscious: the p a t i e n t i s a l e r t and o r i e n t e d t o person and p l a c e , has a gag r e f l e x p r e s e n t and i s able to swallow and to cooperate w i t h the•nurse d u r i n g the i n s e r t i o n of the" naso-g a s t r i c tube. 2. Obtunded: the p a t i e n t i s n e u r o l o g i c a l l y impaired e i t h e r because of h i s p h y s i c a l c o n d i t i o n or the a d m i n i s t r a t i o n of s e d a t i v e s and/or a n a l g e s i c s so t h a t he i s unable to a c t i v e l y cooperate w i t h the i n s e r t i o n of h i s n a s o g a s t r i c tube; there are gag and swallow r e f l e x e s p r e s e n t . 3. Unconscious: the p a t i e n t i s i n a p p r o p r i a t e l y r e s p o n s i v e or nonresponsive to p a i n f u l s t i m u l i and has no gag or swallow r e f l e x due e i t h e r to p h y s i c a l c o n d i t i o n or a d m i n i s t r a t i o n of a n a e s t h e s i a . Endotracheal Tube Portex s o f t c u f f e d e n d o t r a c h e a l tube. Ease of I n s e r t i o n Measure-The number of attempts necessary f o r s u c c e s s f u l placement of the n a s o g a s t r i c tube i n the stomach as evidenced by a s p i r a t i o n of g a s t r i c f l u i d w ith a s y r i n g e . Any " p u l l back" of the tube determines the p o i n t a t which second and subsequent attempts are to be counted. 7 CHAPTER TWO REVIEW OF THE LITERATURE -Introduction The nurse new to the t y p i c a l m e d i c a l - s u r g i c a l r e s p i r a t o r y i n t e n s i v e care u n i t i s o f t e n overwhelmed by the number of tubes and c a t h e t e r s emanating from any g i v e n p a t i e n t . There are tubes coming from below the dura t h a t a t t a c h t o tr a n s d u c e r s to r e c o r d i n t r a c r a n i a l p r e s s u r e . Swan-Ganz c a t h e t e r s i n s e r t e d i n j u g u l a r v e i n s r e c o r d pulmonary a r t e r y p r e s s u r e s . S i l a s t i c t u b i n g i n the s u b c l a v i a n v e i n p r o v i d e s an avenue f o r h y p e r a l i m e n t a t i o n of the s e r i o u s l y i l l . F i n e wires i n t r o d u c e d through the femoral v e i n a c t as a temporary pacemaker f o r the f a i l i n g h e a r t and the humble j e l c o i n the p e r i p h e r a l v e i n p r o v i d e s a rou t e f o r the a d m i n i s t r a t i o n o f medications and f l u i d . Blood d r a i n s s l o w l y through a chest tube t o a b o t t l e on the f l o o r w h i l e s a l i n e i r r i -gates an abdominal wound through a sump tube. Suprapubic, u r e -t e r a l and u r e t h r a l c a t h e t e r s d r a i n u r i n e i n t o bags. R e c t a l tubes d r a i n l i q u i d s t o o l from n o n f u n c t i o n i n g bowel. E n d o t r a c h e a l , n a s o t r a c h e a l , and tracheostomy tubes p r o v i d e p a t i e n t connections t o v e n t i l a t o r s w h i l e l a r g e bore c a t h e t e r s p l a c e d i n femoral a r t e r i e s and v e i n s a t t a c h p a t i e n t s to hemo d i a l y s i s machines. The number of tubes and c a t h e t e r s used to t r e a t , diagnose and monitor any g i v e n p a t i e n t depends upon h i s p a r t i c u l a r needs. I t i s the purpose of t h i s chapter t o d i s c u s s h i g h l i g h t s of the h i s t o r i c a l development of the use of tubes and c a t h e t e r s 8 i n the p r o v i s i o n o f p a t i e n t c a r e . Emphasis w i l l be p l a c e d on the h i s t o r i c a l development of the use of the n a s o g a s t r i c tube and d i s -c u s s i o n w i l l i n c l u d e s p e c i f i c r e f e r e n c e t o methods d e v i s e d to overcome d i f f i c u l t i e s encountered i n n a s o g a s t r i c i n t u b a t i o n . Highlights of the Historical Development of the Nasogastric Tube The e a r l y tubes and c a t h e t e r s r e f l e c t e d the p r i m i t i v e l e v e l of technology a v a i l a b l e to the a n c i e n t p r a c t i t i o n e r . Thus, the f i r s t u r e t h r a l c a t h e t e r s , venous drainage systems, and t r a c h e o s -g tomy tubes o f 3,0 00 years B.C. were made of hollow reeds. As knowledge of metals became a v a i l a b l e these tubes began t o be fas h i o n e d o f g o l d , i r o n , l e a d and bronze. By 1036 the r i g i d metal u r e t h r a l c a t h e t e r had been r e p l a c e d by a more f l e x i b l e one made of s i l v e r , by the 16th century the venous reeds r e p l a c e d by s i l v e r a r t e r i a l tubes, and by 1869 tracheostomy tubes made 9 of cane were r e p l a c e d w i t h those made of s i l v e r . In the e a r l y 19th century f o l l o w i n g the d i s c o v e r y o f rubber .and w i t h advancement i n manufacturing methods the f i r s t rubber u r e t h r a l c a t h e t e r was i n t r o d u c e d i n France."^ Twenty years l a t e r , i n 18 80, the f i r s t rubber e n d o t r a c h e a l tube was described.''" 1 In the 20th g F i e l d i n g H. G a r r i s o n , An I n t r o d u c t i o n t o the H i s t o r y of  Medicine, ( P h i l a d e l p h i a and London: W.B. Saunders Company, 1929), p.55, and M. Jastrow, J r . , "The Medicine o f the Babylonians and A s s y r i a n s , " Lancet 2 (1913):1137. 9 See F. Adams, The Extant Works of Aretaeus, the Cappo- doc i a n (London, 1956), p.346; Andreas L i b a v i u s , Syntagma Arcanorum  et Commentationum Chymicorum, ( F r a n k f u r t , 1613), p.34 and F r e i d r i c h Trendelenburg, " B e i t r a g e Zur Den Operationen An Den Luftwegen. 2. Tamponnade der Trachea," A r c h i v e n f u r K l i n i s h e C h i r u r g i e 12 (1871) 121:133. " ^ G a r r i s o n , p.380. ''"''"William MacEweri, " C l i n i c a l Observations on the I n t r o d u c t i o n of T r a c h e a l Tubes by the Mouth Instead of Performing Tracheotomy or Laryngotomy," B r i t i s h M e d i c a l J o u r n a l 2 ( J u l y 24, 1880):122-124. 9 century w i t h the advent of the p l a s t i c s i n d u s t r y , the tubes of reed and cane t h a t had been r e p l a c e d by tubes of metal and then of rubber were r e p l a c e d once again by a new m a t e r i a l . Double lumen c a t h e t e r s s t i f f enough to t r a n s m i t i n t r a c a r d i a c p r e s s u r e s 12 and y e t not i n j u r e the h e a r t were inv e n t e d . S i l a s t i c u r e t h r a l c a t h e t e r s thought t o harbour fewer b a c t e r i a than the rubber 13 c a t h e t e r s were now a v a i l a b l e . S o f t c u f f e d e n d o t r a c h e a l and tracheostomy tubes were i n t r o d u c e d i n the hope t h a t tubes of these new m a t e r i a l s would l e s s e n the p o s s i b i l i t y of t r a c h e a l 14 e r o s i o n . Although the discovery and use of new m a t e r i a l s accompanied by advances i n technology has r e s u l t e d i n improved tubes and c a t h e t e r s f o r p a t i e n t c a r e , these f a c t o r s alone are not enough t o e x p l a i n the appearance of these d e v i c e s throughout m e d i c a l h i s t o r y . I t i s hoped t h a t a more d e t a i l e d account of the h i s t o r y of the n a s o g a s t r i c tube w i l l demonstrate the p a r t i n d i v i d u a l i m a g i n a t i o n has p l a y e d i n the e v o l u t i o n of any g i v e n tube or c a t h e t e r . 12 A. Cournand, R.A. B l o o m f i e l d , and H.D. Lauson, "Double Lumen Cat h e t e r f o r Intravenous and I n t r a c a r d i a c Blood Sampling and P r e s s u r e T r a c i n g , " Proceedings o f the S o c i e t y o f B i o l o g y  and Medicine 60 (1945):73. 13 S a l l y Thomas, "Passing Tubes and C a t h e t e r s , " Nursing M i r r o r , 1 4 8 (March 29 ,.1979) : 33 . 14 John L. S t a u f f e r , D a n i e l E. Olson, and Thomas L. P e t t y , "Complications and Consequences of Endotracheal I n t u b a t i o n and Tracheotomy," The American J o u r n a l of Medicine 70, (January, 1981):65. 10 Even p r i o r t o the use of the p r i m i t i v e stomach tube, v a r i o u s p r a c t i c e s were i n d u l g e d i n by the Romans to induce vomi t i n g a t the completion, o f a banquet i n order t o prevent the a f t e r e f f e c t s of an overloaded stomach as w e l l as to g i v e p l a c e again f o r another meal. At times emetics were employed but these seemed too u n c e r t a i n i n t h e i r r e s u l t s and i t was soon r e a l i z e d t h a t i t was onl y necessary to apply the f i n g e r 15 to the t h r o a t t o accomplish the same r e s u l t . I t was o n l y a matter o f time b e f o r e the pinna or "vomiting f e a t h e r " was employed as a s u b s t i t u t e f o r the f i n g e r i n order t o g i v e a 16 sense o f refinement to the procedure. The pinna, b e f o r e u s i n g , was o f t e n dipped i n t o some nauseating mixture to 17 i n c r e a s e i t s e f f e c t i v e n e s s . I t was O r i b a s i u s , w r i t i n g i n the f o u r t h century, however, who gave us what i s probably the 18 f i r s t d e s c r i p t i o n of a stomach tube. T h i s was an instrument made of s o f t l e a t h e r f i l l e d w i t h wool i n the lower p o r t i o n and hollow i n the upper p a r t so t h a t the f i n g e r c o u l d be i n t r o d u c e d i n t o i t . I t was the l e n g t h o f s i x t e e n f i n g e r s so t h a t i t would reach a t l e a s t i n t o the esophogus and perhaps even i n t o the stomach. The stomach contents o b v i o u s l y d i d not escape through 15 Ralph H. Major, " H i s t o r y o f the Stomach Tube," Annals  of M e d i c a l H i s t o r y 6, (1934):500. 16 J u l i u s Friedenwald and Samuel Mo r r i s o n , "The H i s t o r y of the Development of the Stomach Tube wi t h Some Notes on the Duodenal Tube," B u l l e t i n of the I n s t i t u t e of the H i s t o r y of  Medicine 4, (June 1936):426. 17 Suetonius, H i s t o r y o f Twelve Caesars, ed. J.H. F r a s e r , t r a n s . Philamon H o l l a n d (London), p.46. 18 O r i b a s i u s , C o l l e c t i o n Medicale, ed. Daremberg (Erlangen, 1612), Book 8, Chapter 6. t h e lumen o f t h e sound and t h e i n s t r u m e n t was p r o b a b l y w i t h d r a w n when t h e p a t i e n t began t o v o m i t . I n s t r u m e n t s o f t h i s t y p e , known as l o r a v o m i t o r i a , were o f t e n u s e d i n t h e t r e a t m e n t o f 19 p o i s o n i n g and p r o v e d q u i t e e f f e c t i v e . The f u r t h e r d e v e l o p m e n t s o f t h i s i n s t r u m e n t a r e d e s c r i b e d 20 i n many o f t h e works o f t h e a n c i e n t p h y s i c i a n s . The u s e s f o r t h e i n s t r u m e n t i n c r e a s e d so t h a t t h e y were no l o n g e r c o n f i n e d t o e m p t y i n g t h e s tomach b u t a l s o i n c l u d e d f o r c i n g f o o d down i n t o t h e s tomach and e x t r a c t i n g f o r e i g n b o d i e s f r o m t h e e s o p h a g u s . T h e s e t u b e s were h o l l o w and were made o f l e a d , c o p p e r , o r s i l v e r . They o f t e n had s m a l l sponges t i e d t o t h e d i s t a l end t o make i t p o s s i b l e t o remove f o r e i g n b o d i e s s u c h as f i s h b o n e s . An a d v a n c e i n t h e u s e o f t h e s tomach t u b e was made i n 159 8 by Hieronymus C a p i v a c c e u s when he d e v i s e d a n . i n s t r u m e n t . . . 21 f o r a r t i f i c i a l f e e d i n g . He a t t a c h e d an a n i m a l b l a d d e r t o t h e 19 See S c r i b o n i u s L a r g u s , De C o m p o s i t i o n e Medicamentorum L i b e r , ( B a s l e , C r a t a n d r u m , 1529), C o m p o s i t i o CLXXX, p.128; D. H i e r o n M e r c u r i a l i s F a r o l i v i e n s i s , T r a c t a t u s V a r i i ( L u g d u n i , P i l l e h a t t e , 1523), p.47; and J . A r c u l a n e u s , P a r t i c u l a r u m Morborum, ( V e n i c e , 1557), p.68. 20 See T. W i l l i s , P h a r m a c e u t i c e R a t i o n a l i s (London: D r i n g , H a r p e r and L e i g h , 1679), p.23; G u i l h e l m i F a b r i c i i H i l d a n i , O p e r a Quae E x t a n t Omnia, ( F r a n c o f u r t i , 1682), C e n t u r i a P r i m a O b s e r v a t i o XXXVI, p.31; and S c h u l t e s , L ' A r c e n a l de C h i r u r g i e , ( L y o n : C e l l i e r , 1674), p.23. 21 H i e r o n y m u s C a p i v a c c e u s , M e d i c a l P r a c t i c e , ( V e n i c e , 159 8) L i b . l , Cap.53. proximal end o f a hollow metal tube and expressed f l u i d through i t i n t o the stomach of a p a t i e n t s u f f e r i n g from t e t a n u s . In 1670 F a b r i c i u s ab Aquapendente d e s c r i b e d a curved tube made of s i l v e r and covered w i t h sheep i n t e s t i n e which he i n t r o d u c e d through the nose and i n t o the stomach f o r the purpose of 22 f e e d i n g . He f e l t h i s tube was a b l e to pass more e a s i l y i n t o the stomach when covered w i t h the sheep i n t e s t i n e which acted as a l u b r i c a n t . In 1744 the use of the stomach tube was extended to i n c l u d e the a d m i n i s t r a t i o n of a n t i d o t e s to poisons i n p a t i e n t s unconscious or obtunded and unable t o swallow. F o r t y - s i x y ears l a t e r the f i r s t long term use of a stomach tube was d e s c r i b e d 23 by John Hunter i n the management of a p a t i e n t w i t h b u l b a r p a l s y . The instrument used was made of a f r e s h e e l s k i n drawn over a probang and t i e d a t the d i s t a l end over a sponge and a t the proximal end j u s t below a s m a l l l o n g i t u d i n a l s l i t through which a bladder and a wooden pipe were i n t r o d u c e d to a d m i n i s t e r wine, eggs, m i l k , sugar, and medications twice d a i l y . The p a t i e n t improved over the next seventeen days w i t h t h i s treatment and r e q u i r e d no f u r t h e r care once he was able to swallow. In 179 7 Alexander Monro p o i n t e d out t h a t the stomach tube when atta c h e d to a s y r i n g e c o u l d be used f o r the a s p i r a t i o n of stomach contents i n cases of p o i s o n i n g and f o r the a d m i n i s t r a t i o n 22 F a b r i c i u s ab Aquapendente, Oeuvres C h i r u r g i c a l e s , (Lyon: H i g u e t a i n and B a r b i e r , 1670), p.594. 23 John Hunter, T r a n s a c t i o n of a S o c i e t y f o r the Improvement  of M e d i c a l and C h i r u r g i c a l Knowledge, (London: S t . Paul's Churchyard, 1793), p.182. 24 o f f o o d i n p a t i e n t s w i t h d y s p h a g i a . The stomach t u b e was i n t r o d u c e d i n t o F r a n c e by R e n a u l t and was u s e d by him and by 25 D u p u y t r e n i n t h e t r e a t m e n t o f p o i s o n i n g . I t was i n t r o d u c e d i n A m e r i c a by P h i l i p P h y s i c k who had s t u d i e d i n E d i n b u r g h u n d e r J o h n H u n t e r and who was f a m i l i a r w i t h t h e u s e o f t h e stomach t u b e i n France. A h e a t e d d i s c u s s i o n a r o s e i n t h e l i t e r a t u r e i n c o n n e c t i o n w i t h t h e u s e o f t h e stomach t u b e i n t h e p o i s o n e d p a t i e n t . T h i s d i s c u s s i o n a l s o c o n c e r n e d t h e i n v e n t i o n o f t h e f i r s t s t o m a c h pump, b u t i t i s d i f f i c u l t t o e s t a b l i s h who 27 a c t u a l l y i n v e n t e d i t . I t r e m a i n e d f o r L e f e v r e i n 1842, C a n s t a t t i n 1843, and K u s s m a u l i n 1869 t o u r g e t h e u s e o f t h e stomach t u b e i n 24 A l e x a n d e r Munro, J r . , " D i s p u t a t i o M e d i c a I n a u g u r a l i s de D y s p h a g i a " , (Ph.D. d i s s e r t a t i o n , The U n i v e r s i t y o f E d i n b u r g h , 1797), p.78. 25 F. C a d e t , " S e c o u r s a A d m i n i s t r e r Dans L e s Empoisonnements D ' a p r e s l a Methode de M. D u y p t r e n , " B u l l , de Pharm. 2 ( F e b . , 1810):62. 26 P.S. P h y s i c k , " A c c o u n t o f t h e New Mode o f E x t r a c t i n g P o i s o n o u s S u b s t a n c e s f r o m t h e Stomach," E c l e c t i c R e p e r t o r y  and A n a l y t i c a l Review 3 (1812):11. 27 See E. J u k e s , "New Means o f E x t r a c t i n g Opium f r o m t h e Stomach," London M e d i c a l and P h y s i c a l J o u r n a l 48 (1822):218; F. Bush, "On t h e Common S y r i n g e w i t h a F l e x i b l e Tube, As A p p l i c a b l e t o t h e Removal o f Opium and O t h e r P o i s o n s f r o m t h e Stomach," London M e d i c a l and P h y s i c a l J o u r n a l 48 (1822):218; D. E v a n s , T r a n s a c t i o n s o f t h e A s s o c i a t e d A p o t h e c a r i e s and  S u r g e o n - A p o t h e c a r i e s o f E n g l a n d and Wales 1 (1823) :208; and J . Reed, " S i r A s t l e y C o o p e r ' s A d d r e s s , " L a n c e t 1 (1823):276. d i f f e r e n t c l i n i c a l s e t t i n g s . ' ' 0 L e f e v r e recommended i t s use i n the treatment of p a t i e n t s w i t h l i f e t h r e a t e n i n g v o m i t i n g , C a n s t a t t i n the treatment of g a s t r i c d i l a t a t i o n , and Kussmaul as a method both f o r d i a g n o s i s and treatment of d i s e a s e s of the stomach. In 1871 Leube e s t a b l i s h e d the concept of the " t e s t meal" w h i l e u s i n g the stomach tube i n s t u d i e s concerned w i t h 29 g a s t r i c m o t i l i t y a f t e r the i n g e s t i o n of c e r t a i n foods. By t h i s time then, the stomach tube was an instrument whose v a l u e had been r e c o g n i z e d both f o r d i a g n o s i s and t h e r a p e u t i c s and p h y s i c i a n s began to look more c l o s e l y a t the p r o p e r t i e s of the tube i t s e l f . Jurgensen wrote the f i r s t a r t i c l e recommending the use o f a s o f t rubber tube, e x p l a i n i n g i t s method of i n t r o d u c t i o n , d e s c r i b i n g the p o s i t i o n the p a t i e n t should take d u r i n g tube i n s e r t i o n , and a d v i s i n g the reader of the type of s u c t i o n t o be a p p l i e d . ^ Jurgensen's tube ended i n a p e r f o r a t e d 2 8 See A r n o l d I. Walder, "A H i s t o r i c a l Review of the N a s o g a s t r i c Tube," S u r g i c a l H i s t o r y 51 (March, 1962):411; A. Kussmaul, "Ueber D i a Behandlung der Magenerweiterung Durch Eine Neue Methoda, M i t t e l s t der Magenpumpe," Deutch Arch, f .  K l i n . Med 6 (1869):455; and C. C a n s t a t t , " S p e c i e l l e P a t h o l , und Therapie," E rlangen 4 (1843):382. 29W.O. Leube, "Die Magensonde," Erlangen (1879):28. "^T. Jurgensen, Deutsch Arch, f . K l i n . Med. (1870):239. i v o r y b a l l and was guided by means of a wire s t y l e t . In 1874 and 1875 Ewald and Oser independently i n t r o d u c e d a s o f t rubber 31 tube which c o u l d be i n s e r t e d without the a i d of a s t y l e t . In an emergency s i t u a t i o n i n which a s t i f f tube was not a v a i l a b l e Ewald improvised a tube made from rubber gas t u b i n g i n which he cut o f f the sharp end and cut out two e y e l e t s . He o i l e d the tube and succeeded i n p a s s i n g i t i n t o the stomach w i t h l i t t l e d i f f i c u l t y . Oser f e l t he was a b l e to pass h i s rubber tube because he f i r s t sought the p a t i e n t ' s c o o p e r a t i o n d u r i n g the procedure. The need f o r a s s u r i n g p a t i e n t c o o p e r a t i o n d u r i n g n a s o g a s t r i c i n t u b a t i o n through both t e a c h i n g and the p r o v i s i o n of support has been s t r e s s e d by s e v e r a l c l i n i c i a n s s i n c e Oser made h i s important o b s e r v a t i o n . McConnell recommends t h a t a l l p a t i e n t s , even those who may appear to be unconscious, r e c e i v e 32 an e x p l a n a t i o n of the procedure b e f o r e i t i s begun. She suggests t h a t an e x p l a n a t i o n should i n c l u d e i n f o r m a t i o n about the purpose of the n a s o g a s t r i c tube f o r the p a r t i c u l a r p a t i e n t , what he can expect both d u r i n g and a f t e r the i n s e r t i o n , and what he can do to make the passage of the tube as atraumatic as p o s s i b l e . McConnell emphasizes the p o i n t t h a t although a l l t h i s i n f o r m a t i o n i s necessary f o r every p a t i e n t the manner i n which i t i s presented w i l l depend upon the needs of the i n d i v i d u a l p a t i e n t and can be determined by a s k i n g the p a t i e n t both what he wishes to know and what he a l r e a d y knows. Griggs and Hoppe i n 31 David C h a r l e s Schechter and Henry Swan, "L e v i n and h i s Tube," S u r g i c a l H i s t o r y 51 (1962):417 32 Edwina A. McConnell, " A l l About G a s t r o i n t e s t i n a l I n t u b a t i o n , " Nursing 75 5 (September,' .197-5),.: 31. t h e i r review o f n a s o g a s t r i c tube feeding,. p o i n t out t h a t a l l p a t i e n t s undergoing g a s t r i c i n t u b a t i o n r e q u i r e support, encouragement, and reassurance d u r i n g the procedure but are not . . 33 s p e c i f i c as to how t h i s should be gi v e n . Thomas, however, recommends a " f i r m but sympathetic approach" coupled w i t h "a s k i l l a c q u i r e d w i t h the conf i d e n c e o f experience" i n order t o calm the f e a r surrounding the procedure which she f e e l s a l l 34 p a t i e n t s have. The need f o r adequate e x p l a n a t i o n o f the procedure as w e l l as the p r o v i s i o n o f emotional support d u r i n g n a s o g a s t r i c tube i n s e r t i o n i s a l s o s t r e s s e d by Volden, e t a l . These authors suggest t h a t i t i s o f t e n a d v i s a b l e to have an a s s i s t a n t d u r i n g the procedure who w i l l p r o v i d e emotional 35 support by h o l d i n g the p a t i e n t ' s hand d u r i n g i n t u b a t i o n . Although no recommendations s p e c i f i c t o the p a r t i c u l a r needs f o r i n f o r m a t i o n and support o f the p a t i e n t r e q u i r i n g n a s o g a s t r i c i n t u b a t i o n i n a c r i t i c a l care u n i t have been made i t i s c l e a r t h a t i n p r i n c i p l e the suggestions made b y the authors p r e v i o u s l y mentioned should be a p p l i e d . In the c r i t i c a l c a r e environment there are times when r e s t o r a t i v e treatments designed to be su p p o r t i v e are c a r r i e d out i n a h u r r i e d manner. The h u r r i e d a c t i v i t y o f the h e a l t h team pushes i t i n t o a g o a l d i r e c t e d framework and t h i s i s l i k e l y t o convey t o the p a t i e n t a f e e l i n g of a n x i e t y o r sense of urgency. In her d i s c u s s i o n of the 33 . Barbara A. Griggs and Mary C. Hoppe, "N a s o g a s t r i c Tube Feeding," American J o u r n a l of Nursing 79 (March, 1979) : 485 . 34 S a l l y Thomas, "Passing Tubes and C a t h e t e r s , " Nursing M i r r o r , 148 (March 29, 1979):32. 35 C e c i l i a Volden, Jacquelyn G n n e , and David C a r l , "Taking the Trauma out of N a s o g a s t r i c I n t u b a t i o n , " Nursing 80 10 (September, 1980):16. 17 p s y c h o l o g i c a l e q u i l i b r i u m of the p a t i e n t i n the c r i t i c a l care environment Roberts says t h a t the primary s t a b i l i z i n g f o r c e 3 6 i s the nurse. She s t r e s s e s the need f o r adequate e x p l a n a t i o n of a l l equipment and procedures used f o r the p r o v i s i o n o f p a t i e n t care and emphasizes the t e a c h i n g , s u p p o r t i v e , r e a s s u r i n g r o l e o f nurses i n the i n t e n s i v e care u n i t . The l e v e l o f consciousness of any gi v e n p a t i e n t w i l l c e r t a i n l y d i c t a t e the type of e x p l a n a t i o n and support necessary a t the time o f n a s o g a s t r i c i n t u b a t i o n but as Oser, McConnell, Griggs and Hoppe, Thomas, and Volden e t a l have p o i n t e d out, some e x p l a n a t i o n and support are necessary i f i n t u b a t i o n i s to be c a r r i e d out w i t h the c o o p e r a t i o n of the p a t i e n t . The advantages o f the rubber tube were i t s f l e x i b i l i t y and the f a c t t h a t i t c o u l d e a s i l y be made radiopaque. However, pure n a t u r a l l a t e x absorbs c o n s i d e r a b l e water and p i c k s up an unpleasant odor and s t a i n , both of which are d i f f i c u l t to remove. For these reasons many m a t e r i a l s and a l t e r a t i o n s i n des i g n have been used i n an e f f o r t t o f u r t h e r improve upon the stomach tube. The tubes now i n use are made of p o l y v i n y l r e s i n s softened w i t h p l a s t i c i z e r s and made radiopaque by the a d d i t i o n of p l a t i n u m c h l o r i d e . The tubes are non - t o x i c , n o n - r e a c t i v e to body t i s s u e s , odor and t a s t e f r e e , and thermosenstive a t normal body temperature. They s t i l l , however, pose c e r t a i n problems r e g a r d i n g i n s e r t i o n and much of the r e c e n t l i t e r a t u r e concerning the stomach tube addresses t h i s i s s u e . 3 6 ' Sharon L. Roberts, " P s y c h o l o g i c a l E q u i l i b r i u m , " i n AACN'S C l i n i c a l Reference f o r C r i t i c a l Care Nursing,eds. Marguerite Rogers Kinney, C y n t h i a Boyd Deer, Donna Rogers Pocka and Dorothy M. Nagelhaut Voorman. (New York: McGraw-Hill Book Company, 1981) p.341. 18 Methods of I n s e r t i n g N a s o g a s t r i c Tubes Methods of i n s e r t i n g n a s o g a s t r i c tubes are d e s c r i b e d i n 3.7 both the medical and n u r s i n g l i t e r a t u r e . ' I t i s d i f f i c u l t t o e s t a b l i s h p r e c i s e l y when nurses began to i n s e r t n a s o g a s t r i c tubes but i t i s u n l i k e l y t h a t t h i s o c c u r r e d much bef o r e the l a t e t h i r t i e s as i t i s a t t h i s time when the procedure i s f i r s t d e s c r i b e d i n the n u r s i n g procedure manuals i n t h i s c i t y . I t i s c e r t a i n l y t r u e , however, t h a t procedures found i n p o l i c y manuals have g e n e r a l l y been e s t a b l i s h e d i n p r a c t i c e f o r some p e r i o d of time so t h i s date must be taken o n l y as a rough g u i d e l i n e f o r the acceptance o f n a s o g a s t r i c i n s e r t i o n as a n u r s i n g procedure. At the moment both d o c t o r s and nurses i n s e r t stomach tubes i n s i t u a t i o n s t h a t vary from h o s p i t a l t o h o s p i t a l and from ward to ward i n the same h o s p i t a l . That a l l who i n s e r t these tubes do a t times experience d i f f i c u l t y w i t h the procedure i s evidenced by the number of a r t i c l e s t h a t has appeared with suggestions 3 8 f o r overcoming i n s e r t i o n problems. ~"'See A. Tucker and J e n n i f e r Lewis, "Procedures i n P r a c t i c e : P a s s i n g a N a s o g a s t r i c Tube," B r i t i s h M e d i c a l J o u r n a l 281 (October 25, 1980):1128-1129; Lawrence T i n c k l e r , " N a s o g a s t r i c Tube Management," B r i t i s h J o u r n a l o f Surgery 59 (August, 1972):637-641; Edwina A. McConnell, " A l l About G a s t r o i n t e s t i n a l I n t u b a t i o n , " Nursing 75 (September, 1975):31-37; and Volden e t a l . , "Taking the Trauma out of N a s o g a s t r i c I n t u b a t i o n , " Nursing 80 10 (September, 1980):14-17. 38 See E a r l P. Robinson J r . and Paul M. Cox, J r . , "Feeding Tube I n t r o d u c t i o n — A n E a s i e r Way," C r i t i c a l Care Medicine 7 (1979): 349-350; Robert M. Smith, "Simple and Safe Method f o r I n s e r t i n g a N a s o g a s t r i c Tube," B r i t i s h J o u r n a l o f Ana e s t h e s i a 45 (1973):1168; Ki e - C h u l Ohn and Wen-Hsien Wu, "A New Method f o r N a s o g a s t r i c Tube I n s e r t i o n , " A n e s t h e s i o l o g y 51 (1979):568; and Barbara A. Griggs and Mary C. Hoppe, "Update: N a s o g a s t r i c Tube Feeding," American J o u r n a l of Nursing 79 (March, 1979):481-485. 19 The major problem areas t h a t have been i d e n t i f i e d are those t h a t r e l a t e to the experience of the person attempting to i n s e r t the n a s o g a s t r i c tube with the procedure, those t h a t r e l a t e to the anatomical and p h y s i o l o g i c a l knowledge base of the person i n s e r t i n g the tube, those t h a t r e l a t e to a n x i e t y on the p a r t of the p a t i e n t r e g a r d i n g the procedure, those t h a t r e l a t e to a l t e r a t i o n s i n the anatomy of the mouth, nose, esophagus or stomach as a r e s u l t of immaturity, aging, i n j u r y , or the presence of other f o r e i g n bodies i n the nasopharyngeal c a v i t y , those t h a t r e s u l t from p h y s i o l o g i c a l changes due to a l t e r a t i o n s i n the p a t i e n t ' s l e v e l of consciousness, those t h a t r e l a t e to the nature of the i n s e r t i o n as a b l i n d procedure, and f i n a l l y , 39 those t h a t r e l a t e to the nature of the tube to be i n s e r t e d . "See S a l l y Thomas, "Passing Tubes and C a t h e t e r s , " Nursing M i r r o r 148 (March 29,1979): 32-34; M a r j o r i e L. Beck, "Three More G a s t r o i n t e s t i n a l T e s t s — A n d How to Help Your P a t i e n t Through Each," Nursing 81 n , (May ,19 81) : 5-6 ; M a r j o r i e L. Beck, "Three Common G a s t r o i n t e s t i n a l T e s t s — A n d How to Help Your P a t i e n t Through Each," Nursing 81 11 (April, 1981): 34-35; Liew Pak Chi n , "A Method of P a s s i n g N a s o g a s t r i c Tube During A n a e s t h e s i a i n the Newborn," A n a e s t h e s i a 27 (October, 1972):458; S a l l y N e t h e r c o t t , " C l e a r i n g A Pathway," Nursing M i r r o r 150 ( A p r i l 24, 1980):25-27; John D. B u l l o c k , "A Convenient Method f o r I n s e r t i n g Small Feeding Tubes," Gut 10 (1969):599-600; A s h i q H. T a h i r and John A d r i a n i , "A Method of I n s e r t i n g a N a s o g a s t r i c Tube i n the A n a e s t h e t i s e d or Comatose P a t i e n t , " A n a e s t h e s i a And A n a l g e s i a 50 (March, A p r i l , 1971):179-180; R.H. Mirakhur, "Simple and R e l i a b l e Method of I n s e r t i n g a N a s o g a s t r i c Tube During A n a e s t h e s i a , " B r i t i s h . J o u r n a l of A n a e s t h e s i a 45 (1973):1062; A.K. Saha, "The I n s e r t i o n of N a s o g a s t r i c Tubes i n A n a e s t h e t i s e d P a t i e n t s , " A n a e s t h e s i a 29 (1974):367; and C. Van Der Weyden, " I n s e r t i o n of N a s o g a s t r i c Tubes," B r i t i s h J o u r n a l of A n a e s t h e s i a 51 (1979):73. 20 V a r i o u s a u t h o r s have a d d r e s s e d one o r a n o t h e r o f t h e s e i s s u e s . Thomas, f o r e xample, s t r e s s e s t h e i m p o r t a n c e o f e x p e r i e n c e w i t h t h e p r o c e d u r e as a p o s i t i v e f a c t o r i n a t t a i n i n g 40 s u c c e s s f u l n a s o g a s t r i c i n t u b a t i o n . V o l d e n e t a l . , on t h e o t h e r hand, s t a t e t h a t e x p e r i e n c e i s n o t l i k e l y t o l e s s e n t h e 41 a n x i e t y e x p e r i e n c e d by t h e n u r s e f o r any p a r t i c u l a r i n s e r t i o n . These a u t h o r s , as w e l l as o t h e r s , s t r e s s t h e i m p o r t a n c e o f a c a l m , c o o p e r a t i v e p a t i e n t and a sound knowledge b a s e o f t h e i n v o l v e d anatomy and p h y s i o l o g y i n e n s u r i n g s u c c e s s f u l t u b e 42 p l a c e m e n t . A d v i c e b a s e d upon t h e p r o v i s i o n o f an a n a t o m i c a l b a s i s a s a r a t i o n a l e i n g u i d i n g i n s e r t i o n o f a n a s o g a s t r i c t u b e i s , however, c o n f l i c t i n g a t t i m e s . M c C o n n e l a d v i s e s h y p e r -e x t e n s i o n o f t h e n e ck d u r i n g t h e p r o c e d u r e as t h e b e s t 43 a n a t o m i c a l p o s i t i o n w h i l e Thomas and P e r s o n s recommend f l e x i o n . 40 S a l l y Thomas, " P a s s i n g Tubes and C a t h e t e r s , " N u r s i n g  M i r r o r 148 (March 29 , 1979) :32. 41 . . C e c i l i a V o l d e n , J a c q u e l y n G r i n d e , and D a v i d C a r l , " T a k i n g t h e Trauma o u t o f N a s o g a s t r i c I n t u b a t i o n , " N u r s i n g 80 10 (September, 1980) :14. 42 See C a r o l P e r s o n s , "Why R i s k TPN when Tube F e e d i n g W i l l Do?" RN 44 ( J a n u a r y , -1981) :35-41: Edwina M c C o n n e l l , " A l l A b o u t G a s t r o i n t e s t i n a l I n t u b a t i o n , " N u r s i n g 75 5 (September, 1 9 7 5 ) : 31-37; M a r j o r i e Beck, "Th r e e Common G a s t r o i n t e s t i n a l T e s t s — A n d . How t o H e l p Y o u r P a t i e n t T h r o u g h E a c h , " N u r s i n g 81 11:34-3 5; and B a r b a r a G r i g g s and M a r c h C. Hoppe, "Update: N a s o g a s t r i c Tube F e e d i n g , " A m e r i c a n J o u r n a l o f N u r s i n g 79 (March, 1979):481-485. 43 See M c C o n n e l l , p.32; Thomas, p.32; and P e r s o n s , p.37. Tucker and Lewis o f f e r h e l p f u l " t r o u b l e s h o o t i n g " t i p s f o r naso-g a s t r i c i n s e r t i o n based on problems t h a t a r i s e as a r e s u l t of • . . 44 anatomical v a r i a t i o n s t h a t are found from p a t i e n t t o p a t i e n t . Two i n f o r m a t i v e s t u d i e s based upon anatomical r e l a t i o n s h i p s t h a t i n f l u e n c e the proper placement of the n a s o g a s t r i c tube have been r e p o r t e d . Ziemer a n d . C a r r o l l arranged to be presen t a t i n f a n t a u t o p s i e s i n order to v e r i f y tube placement accomplished by a c o n v e n t i o n a l measurement taken from the t i p of the i n f a n t ' s nose t o the lobe o f the ear to the x i p h o i d p r o c e s s , a measurement 45 i n common c l i n i c a l use. Based on t h e i r f i n d i n g s a t autopsy they recommend t h a t a b e t t e r and more acc u r a t e measurement i s one taken from the t i p of the nose t o the lobe of the ear to a p o i n t midway between the x i p h o i d process and the u m b i l i c u s . Robert Hanson i n h i s study sought to f i n d the bes t measurement f o r placement of the n a s o g a s t r i c tube i n the fundus of 46 the a d u l t stomach. His study was conducted u s i n g 99 cadavers and 5 normal a d u l t v o l u n t e e r s . With the s u b j e c t s i n the supine p o s i t i o n v a r i o u s e x t e r n a l measurements used i n c l i n i c a l p r a c t i c e were made and compared, to measurements t h a t would be r e q u i r e d to secure proper placement i n the. cadaver and i n the normal l i v i n g a d u l t . He found t h a t the b e s t measurement i n use i n c l i n i c a l p r a c t i c e was t h a t made from the t i p of the nose t o the t i p of the 44 A. Tucker and J e n n i f e r Lewis, "Passing A N a s o g a s t r i c Tube," B r i t i s h M e d i c a l J o u r n a l 281 (October 25, 1980):1129. 45 Mary Ziemer and Jane Schupay C a r r o l l , " I n f a n t Gavage Reconsidered," American J o u r n a l of Nursing 78 (September, 1978) : 1543-1544. 46 Robert L. Hanson, "New Approach t o Measuring A d u l t Naso-g a s t r i c Tubes f o r I n s e r t i o n , " American J o u r n a l of Nursing 80 (J u l y , 1980):1334-1335. 22 ear lobe to the t i p of the x i p h o i d , but t h a t t h i s measurement would ensure proper placement i n o n l y 72% of the s u b j e c t s i n h i s sample. He went on t o develop a formula u s i n g t h i s c l i n i c a l measurement t h a t would secure proper placement of the n a s o g a s t r i c tube i n 91% of h i s sample. T h i s formula makes use of the NEX (Nose, ear and NEXcm-50cm xiphoid), and i s expressed as: 2 + 5 0 = the l e n g t h of tube n e c e s s a r y f o r a c c u r a t e placement. Those who most f r e q u e n t l y and most p r a c t i c a l l y approach the problems t h a t a r i s e i n r e g a r d to i n t r o d u c t i o n of a n a s o g a s t r i c tube and a l t e r e d l e v e l of c o n s c i o u s n e s s are the a n a e s t h e t i s t s . T h e i r problem i s compounded by the f a c t t h a t the a l t e r a t i o n i n consciousness i s drug induced and r e q u i r e s the presence of an e n d o t r a c h e a l tube which a l t e r s the normal anatomy of the r e g i o n concerned i n order to accomplish v e n t i l a t i o n of the p a t i e n t . S e v e r a l of the authors suggest i n s e r t i n g a second e n d o t r a c h e a l tube, e i t h e r c u t or uncut, i n t o the esophagus and d i r e c t i n g the n a s o g a s t r i c tube through t h i s tube. Once placement of the n a s o g a s t r i c tube i n the stomach i s assured the second e n d o t r a c h e a l 47 tube i s removed. Baraka, however, recommends t h a t a r e c t a l "'See A.R. Hunter, "The I n s e r t i o n of N a s o g a s t r i c Tubes i n the A n a e s t h e t i s e d P a t i e n t , " A n a e s t h e s i a 28 (1973):708; David H. Sprague and Steven R. C a r t e r , "An A l t e r n a t i v e Method f o r N a s o g a s t r i c Tube I n s e r t i o n , " A n a e s t h e s i o l o g y 53 (1980):436; A s h i q H. T a h i r and John A d r i a n i , . "A Method of I n s e r t i n g a N a s o g a s t r i c Tube i n the A n a e s t h e t i s e d or Comatose P a t i e n t , " A n a e s t h e s i a and A n a l g e s i a 50 ( M a r c h - A p r i l , 1971):179; David D. Cohen, "A Method o f I n s e r t i n g a N a s o g a s t r i c Tube i n the A n a e s t h e t i s e d or Comatose P a t i e n t , " A n a e s t h e s i a and A n a l g e s i a 50 (November-December, 1971):1010; R.H. Mirakhur, "Simple and R e l i a b l e Method of I n s e r t i n g a N a s o g a s t r i c Tube During A n a e s t h e s i a , " B r i t i s h J o u r n a l of A n a e s t h e s i a 45 (1974):1062; Robert W. V i r t u e , "Simple and R e l i a b l e Method of I n s e r t i n g a N a s o g a s t r i c Tube During A n a e s t h e s i a , " B r i t i s h J o u r n a l of A n a e s t h e s i a 45 (1973):234; David A. Chadwick, "The I n s e r t i o n of N a s o g a s t r i c Tubes i n the Anaesthe-t i s e d P a t i e n t , " A n a e s t h e s i a 28 (1973):341. tube r a t h e r than an e n d o t r a c h e a l tube be used f o r t h i s procedure. He t h i n k s t h a t the f i r m but f l e x i b l e w a l l of the r e c t a l tube, i t s g r e a t e r l e n g t h , and i t s smooth t e r m i n a l o u t l e t are more s u i t a b l e f o r b l i n d nasoesophageal i n t u b a t i o n . The methods thus f a r d e s c r i b e d r e q u i r e the i n s e r t i o n of tubes with diameters s i g n i f i c a n t l y l a r g e r than the diameter of the n a s o g a s t r i c tube i t s e l f . The use of these l a r g e tubes can r e s u l t i n trauma to the nose and the use of l a r g e tubes e i t h e r n a s a l l y or o r a l l y i n a conscious or semiconscious p a t i e n t i s d i f f i c u l t and p a i n f u l even with t o p i c a l a n a e s t h e s i a . Robinson and Cox d e s c r i b e a method f o r the i n s e r t i o n of p e d i a t r i c f e e d i n g tubes which does not r e q u i r e the use of a tube of l a r g e r 49 diameter. They suggest threading, the f e e d i n g tube w i t h a s t r a i g h t s t a i n l e s s s t e e l guide w i r e . When the tube i s i n the stomach the guide wire i s removed and the tube l e f t i n p l a c e . This method i s s i m i l a r t o t h a t d e s c r i b e d by Matsuke and Zsigmond. During a n a e s t h e s i a they use a w e l l l u b r i c a t e d g u i t a r s t r i n g to thread the n a s o g a s t r i c tube b e f o r e i n s e r t i o n and they r e p o r t good R.B. Kamal, "Use of M a g i l l Tube f o r P a s s i n g N a s o g a s t r i c Tube i n A n a e s t h e t i s e d or Comatose P a t i e n t s , " A n a e s t h e s i a and  A n a l g e s i a 54 (January-February, 1974):156. 48 Annis Baraka, "Simple Method of I n s e r t i n g a N a s o g a s t r i c Tube f o r A n a e s t h e s i a , " A n a e s t h e s i a and A n a l g e s i a 55 (March-A p r i l , 1975):304. 4 9 E a r l P. Robinson and Paul M. Cox, "Feeding Tube I n t r o d u c t i o n — A n E a s i e r Way," C r i t i c a l Care Medicine 7 (1979):349 50 r e s u l t s with t h i s method i n both a d u l t s and c h i l d r e n . Other methods r e p o r t e d i n the a n a e s t h e t i c l i t e r a t u r e to a i d i n the i n s e r t i o n of n a s o g a s t r i c placement i n the unconscious p a t i e n t do not r e l y on the degree of tube r i g i d i t y as the most i n f l u e n t i a l f a c t o r i n tube placement. Liew Pak Chin, f o r example, suggests t h a t packing the mouth wi t h gauze around an u n c u f f e d endotracheal tube i n the i n f a n t w i l l p r o v i d e 51 a " t u n n e l " through which a n a s o g a s t r i c tube w i l l e a s i l y pass. 52 Smith recommends an even more novel approach. He recommends h o l d i n g the d i s t a l end of the n a s o g a s t r i c tube i n the mouth and blowing r e p e a t e d l y on i t u n t i l i t reaches the stomach. T h i s a c t i o n , he says, d i s t e n d s the esophagus ahead of the tube and p r o v i d e s f o r immediate r e c o g n i t i o n of o b s t r u c t i o n or k i n k i n g of 53 the tube. Another i n t e r e s t i n g manoeuvre i s d e s c r i b e d by Mundy. He passes a tap-water c o o l e d , w e l l l u b r i c a t e d n a s o g a s t r i c tube i n t o the p o s t e r i o r pharynx and then g r i p s the a l a e of the t h y r o i d c a r t i l a g e between the thumb and index f i n g e r s and l i f t s i t a n t e r i o r l y . T h i s opens the esophagus which i s u s u a l l y c o l l a p s e d due to g r a v i t y and the n a s o g a s t r i c tube then passes through 50 Akitoma Matsuki and Elemer K. Zsigmond, "Simple and R e l i a b l e Method of I n s e r t i n g a N a s o g a s t r i c Tube During A n a e s t h e s i a , " B r i t i s h J o u r n a l of A n a e s t h e s i a 44 (1972):234. ^ L i e w Pak Chin, "A Method of P a s s i n g N a s o g a s t r i c Tube During A n a e s t h e s i a i n the Newborn," An a e s t h e s i a 27 (October 1972) 458. 52 Robert Smith, "Simple and Safe Method f o r I n s e r t i n g a N a s o g a s t r i c Tube," B r i t i s h J o u r n a l of A n a e s t h e s i a 45 (1973):1168. 53 Donald A. Mundy, "Another Technique f o r I n s e r t i o n of N a s o g a s t r i c Tubes," A n a e s t h e s i o l o g y 50 (1979):374. the esophagus i n t o the stomach. One must monitor the p a t i e n t c a r e f u l l y d u r i n g t h i s procedure as v i g o r o u s m a n i p u l a t i o n of the t h y r o i d c a r t i l a g e may a c t i v a t e the c a r o t i d sinus r e f l e x c a using changes i n h e a r t r a t e and b l o o d p r e s s u r e . The e x t r a o r d i n a r y methods used to f a c i l i t a t e n a s o g a s t r i c tube i n s e r t i o n are most o f t e n used i n h i g h l y s p e c i a l i z e d areas of the h o s p i t a l where the necessary equipment and personnel f a m i l i a r w i t h i t s use are r e a d i l y a v a i l a b l e . The most common method used by nurses and d o c t o r s i n the h o s p i t a l wards to f a c i l i t a t e n a s o g a s t r i c i n t u b a t i o n i s the c o o l i n g of the n a s o g a s t r i c tube b e f o r e i n s e r t i o n . T h i s a c t i o n i s w i d e l y recommended i n the l i t e r a t u r e , p a r t i c u l a r l y when p a t i e n t s are unconscious or obtunded. and unable.to cooperate d u r i n g the 54 procedure. While i t i s u s u a l l y t r u e t h a t n a s o g a s t r i c i n t u b a t i o n i s an u n e v e n t f u l procedure, c e r t a i n c o m p l i c a t i o n s can occur. These i n c l u d e e r o s i o n of n a s a l c a r t i l a g e , s i n u s i t i s , esophageal s t r i c t u r e , i n a d v e r t a n t c a n u l a t i o n of the t r a c h e o b r o n c h i a l t r e e w i t h or without l a r y n g e a l o b s t r u c t i o n , o t i t i s media, ru p t u r e of esophageal v a r i c e s , r u p t u r e of the esophagus or stomach, i n a b i l i t y 55 . . to remove the tube, and r e f l u x e sophagxtis. In a d d i t i o n , 54 See Thomas, p.33; Beck, p.5; N e t h e r c o t t , p.26; Volden e t a l , p.15; Persons, p.37; McConnell, p.34; and Tucker and Lewis, p.1130. 55 See J.S. Chaffee, "Complications of G a s t r o i n t e s t i n a l I n t u b a t i o n , " Annals of Surgery 130 (1949);113-123; J.M. F a r r i s and G.K. Smith, "An E v a l u a t i o n of Temporary Gastrostomy—A S u b s t i t u t e f o r N a s o g a s t r i c S u c t i o n , " Annals of Surgery 144 (1956): 475-486; G.N. Grant, D.W. E l l i o t t , and P.L. F r e d e r i c k , " P o s t o p e r a t i v e Decompression by Temporary Gastrostomy or N a s o g a s t r i c Tube: An O b j e c t i v e Comparison," A r c h i v e s of Surgery 85 (1962): 844-851. 26 t h e r e h a v e b e e n r e p o r t s o f i n t r a c r a n i a l p e n e t r a t i o n by a n a s o g a s t r i c t u b e b o t h i n t h e p r e s e n c e and a b s e n c e o f e x i s t i n g 5 6 c r a n i a l t r a u m a . F o r t h i s r e a s o n c e r t a i n a u t h o r s a d v i s e p a s s a g e o f t h e n a s o g a s t r i c t u b e u n d e r d i r e c t v i s i o n no m a t t e r 57 what m a n i p u l a t i o n s a r e u s e d . O t h e r s recommend X - r a y o f t h e abdomen f o r t u b e p o s i t i o n a t l e a s t i n t h e c a s e o f t h e 5 8 c r i t i c a l l y i l l o r u n c o n s c i o u s p a t i e n t . T h i s h i s t o r i c a l l y o r i e n t e d r e v i e w o f t h e l i t e r a t u r e h a s a t t e m p t e d t o d e m o n s t r a t e t h a t t h e u s e o f new m a t e r i a l s a c c o m p a n i e d by a d v a n c e s i n t e c h n o l o g y and i n d i v i d u a l i m a g i n a t i o n has r e s u l t e d i n i mprovements i n t u b e s and c a t h e t e r s t h a t have been u s e d f o r c e n t u r i e s . I t has b e en shown as w e l l t h a t p r o b l e m s e n c o u n t e r e d i n t u b e i n s e r t i o n may e x i s t d e s p i t e t h e u s e o f t h e b e s t m a t e r i a l s t e c h n o l o g y c a n o f f e r . I t i s t h e p u r p o s e o f t h i s t h e s i s t o a d d r e s s t h e q u e s t i o n o f w h e t h e r o r n o t t h e and R.C. Hanselman, R.C. Meyer, " C o m p l i c a t i o n s o f G a s t r o i n t e s t i n a l I n t u b a t i o n , " S u r g e r y , G y n e c o l o g y and O b s t e t r i c s 114 (1962): 207-222. 5 ^ S e e R o n a l d F. Young, "CSF R h i n o r r h e a F o l l o w i n g N a s o g a s t r i c I n t u b a t i o n , " The J o u r n a l o f Trauma 19 ( O c t o b e r , 1979):789-790; J o h n D. F r e m s t a d and S t e p h e n H. M a r t i n , " L e t h a l C o m p l i c a t i o n f r o m I n s e r t i o n o f N a s o g a s t r i c Tube a f t e r S e v e r e B a s i l a r S k u l l F r a c t u r e , " The J o u r n a l o f Trauma 18 (December, 1978):820-822; J a y A. G r e g o r y , P a u l T. T u r n e r , and A r d e n F. R e y n o l d s , "A C o m p l i c a t i o n o f N a s o g a s t r i c I n t u b a t i o n : I n t r a c r a n i a l P e n e t r a t i o n , " The J o u r n a l o f  Trauma 18 (December, 197.8) : 823-824; and B e r n a r d o B o r o v i t c h , J a c o b B r a u n , T u v i Y o s e f o v i t c h , J o s e p h N. G u i l b u r d , J a n G r u s h k i e w i c z and E l i P e y s e r , " I n t r a c r a n i a l P e n e t r a t i o n o f N a s o g a s t r i c Tube," N e u r o s u r g e r y 8 ( F e b r u a r y , 1981):245-247. 57 See A.K. Saha, "The I n s e r t i o n o f N a s o g a s t r i c Tubes i n t h e A n a e s t h e t i s e d P a t i e n t , " A n a e s t h e s i a 29 (1974):367; and C. Van Der Weyden, " I n s e r t i o n o f N a s o g a s t r i c T u b e s , " B r i t i s h J o u r n a l o f  A n a e s t h e s i a 51 (1979):73. P a u l D. L a r s e n , " K n o t t e d N a s o g a s t r i c T u b i n g , " J o u r n a l o f  t h e A m e r i c a n M e d i c a l A s s o c i a t i o n 238 ( J u l y 18, 1977):211. degree of n a s o g a s t r i c tube f l e x i b i l i t y and the p a t i e n t ' s l e v e l of consciousness have b e a r i n g on the ease of i n s e r t i o n of the n a s o g a s t r i c tube. The next chapters w i l l d e s c r i b e the methodology employed t o answer t h i s q u e s t i o n , the f i n d i n g s t h a t r e s u l t e d from implemention of the study, and the recommendations and i m p l i c a t i o n s t h a t arose as a r e s u l t of those f i n d i n g s . 28 CHAPTER THREE METHODOLOGY An e x p e r i m e n t a l a p p r o a c h was s e l e c t e d f o r t h i s study-as r e v i e w o f t h e l i t e r a t u r e d e m o n s t r a t e d t h a t f a c t o r s w h i c h a f f e c t t h e e a s e w i t h w h i c h a n a s o g a s t r i c t u b e c a n be i n s e r t e d h ave been f a i r l y w e l l d e f i n e d . The d a t a f r o m t h e e x p e r i m e n t were c o l l e c t e d and r e c o r d e d by t h e n u r s e s i n v o l v e d i n t h e s t u d y and a n a l y s e d u s i n g a 2 X 3 f a c t o r i a l d e s i g n . P r e l i m i n a r y E x p e r i m e n t Use o f t h e n a s o g a s t r i c t u b e i n t h e u n i t i n w h i c h t h e s t u d y was c a r r i e d o u t was p e r f o r m e d w i t h a t u b e a t room t e m p e r a t u r e o r one w h i c h had been immersed i n a t e n m i n u t e i c e b a t h . S o p h i s t i c a t e d measurements t o d e t e r m i n e t h e optimum d e g r e e o f s t i f f n e s s f o r i n s e r t i o n o f a n a s o g a s t r i c t u b e were b e y o n d t h e s c o p e o f t h i s s t u d y . However, an e x p e r i m e n t was p e r f o r m e d t o d e t e r m i n e t h e e f f e c t o f a t e n m i n u t e i c e b a t h i m m e r s i o n on t h e n a s o g a s t r i c t u b e and measurements were t a k e n w h i c h d e m o n s t r a t e d a t h r e e f o l d d i f f e r e n c e between t h e f o r c e r e q u i r e d t o bend a 59 f l e x i b l e and a r i g i d t u b e . R e s e a r c h D e s i g n T h i s i n v e s t i g a t i o n u s e d a 2 X 3 f a c t o r i a l d e s i g n i n v o l v i n g 59 . . . . The e x p e r i m e n t i s d e s c r i b e d i n A p p e n d i x One. 29 a f i x e d - m o d e l a n a l y s i s o f v a r i a n c e . Such a d e s i g n was c o n s i d e r e d a p p r o p r i a t e f o r t h i s s t u d y w h i c h had two i n d e p e n d e n t v a r i a b l e s , d e g r e e o f n a s o g a s t r i c t u b e f l e x i b i l i t y and l e v e l o f p a t i e n t c o n s c i o u s n e s s , w i t h two and t h r e e l e v e l s r e s p e c t i v e l y . One o f t h e v a r i a b l e s , d e g r e e o f n a s o g a s t r i c t u b e f l e x i b i l i t y , was m a n i p u l a t e d by t h e e x p e r i m e n t e r w h i l e t h e o t h e r , l e v e l o f p a t i e n t c o n s c i o u s n e s s , was d e p e n d e n t upon t h e p h y s i c a l s t a t u s o f any g i v e n p a t i e n t . A s s i g n m e n t o f s u b j e c t s t o t h i s l a t t e r v a r i a b l e was c o n s i d e r e d t o be random as r e v i e w o f u n i t s t a t i s t i c s r e g a r d i n g p a t i e n t s ' l e v e l o f c o n s c i o u s n e s s on a d m i s s i o n t o t h e u n i t showed v e r y l i t t l e week t o week v a r i a t i o n . Schema o f 2 X 3 F a c t o r i a l D e s i g n F a c t o r A a-1 F a c t o r B 30 P o p u l a t i o n and Sample The p o p u l a t i o n from which the study sample was drawn were those p a t i e n t s admitted to an I n t e n s i v e R e s p i r a t o r y Care U n i t of a 9 40 bed t e r t i a r y care t e a c h i n g h o s p i t a l who r e q u i r e both en d o t r a c h e a l and n a s o g a s t r i c i n t u b a t i o n . The sample f o r the study c o n s i s t e d of 121 p a t i e n t s r e q u i r i n g o r a l e n d o t r a c h e a l placement and subsequent n a s o g a s t r i c tube i n t u b a t i o n admitted to the I n t e n s i v e R e s p i r a t o r y Care U n i t over a p e r i o d of s i x t e e n weeks. C r i t e r i a f o r e x c l u s i o n from the study were c o n t r a i n d i c a t i o n . f o r n a s o g a s t r i c i n t u b a t i o n as determined by the a d m i t t i n g r e s i d e n t and presence of a tracheostomy or n a s o t r a c h e a l tube as opposed to an o r a l e n d o tracheal tube. Data C o l l e c t i o n Method In order to conduct the study i n the I n t e n s i v e Care U n i t a p p r o v a l from both the Nursing Research Committee at the h o s p i t a l and the E t h i c s Committee at the U n i v e r s i t y of B r i t i s h Columbia was sought and o b t a i n e d . Consent forms were signed by 6 0 the u n i t nurses i n d i c a t i n g t h e i r w i l l i n g n e s s to p a r t i c i p a t e . The u n i t nurses attended an i n s e r v i c e t r a i n i n g s e s s i o n conducted to e x p l a i n the r e s e a r c h p r o p o s a l and to s t a n d a r d i z e the technique by which n a s o g a s t r i c tubes would be i n s e r t e d d u r i n g 61 the study. The technique used was compatible w i t h t h a t a l r e a d y i n use i n the u n i t a t the time of the study. Systematic 60, Appendix Two. 61 Appendix Three. randomization of the degree of n a s o g a s t r i c tube f l e x i b i l i t y was assured by a s s i g n i n g r i g i d tubes to odd study weeks and f l e x i b l e tubes to even weeks. The l e v e l of consciousness of each p a t i e n t was assessed by the nurse i n s e r t i n g the n a s o g a s t r i c tube immediately p r i o r t o the procedure. Data was c o l l e c t e d on a data c o l l e c t i o n sheet.by the nurse i n s e r t i n g the n a s o g a s t r i c 6 2 tube immediately f o l l o w i n g the procedure. Method of S c o r i n g the Number of I n s e r t i o n s Any continuous forward movement of the n a s o g a s t r i c tube r e s u l t i n g i n stomach placement, as evidenced by a s p i r a t i o n of g a s t r i c contents was c o n s i d e r e d a s u c c e s s f u l i n s e r t i o n and was g i v e n a score of one. Any " p u l l back" on the tube, t h a t i s , i n t e r r u p t i o n of the forward movement, determined the p o i n t a t which second and subsequent attempts were counted. Each attempt (forward movement) was g i v e n a score of one. T h i s meant, f o r example, t h a t should a nurse be r e q u i r e d to p u l l back t h r e e times on the n a s o g a s t r i c tube b e f o r e a steady forward motion r e s u l t e d i n proper p o s i t i o n i n g of the tube, the number of attempts or score f o r t h i s i n s e r t i o n would be f o u r . The score ob t a i n e d , t h e r e f o r e , was c o n s i d e r e d t o have an u n d e r l y i n g r a t i o s c a l e , making par a m e t r i c s t a t i s t i c s a p p r o p r i a t e f o r data a n a l y s i s E t h i c s and Human Rights Preceeding implementation of t h i s study approval was sought and obtained from both the h o s p i t a l and u n i v e r s i t y e t h i c s Appendix Four. c o m m i t t e e s . P e r m i s s i o n f o r i m p l e m e n t a t i o n o f t h e s t u d y was a l s o o b t a i n e d f r o m t h e M e d i c a l D i r e c t o r and Head N u r s e o f t h e I n t e n s i v e C a r e U n i t who were r e s p o n s i b l e f o r t h e w e l f a r e o f t h e p a t i e n t s u n d e r t h e i r c a r e . P a t i e n t c o n s e n t was c o n s i d e r e d t o be u n n e c e s s a r y as i n s e r t i o n o f a n a s o g a s t r i c t u b e i n t h e p a t i e n t who had an e n d o t r a c h e a l t u b e i n p l a c e was a r o u t i n e p r o c e d u r e c o n d u c t e d t o e n s u r e p r o t e c t i o n o f t h e a i r w a y i n t h e f a c e o f p o s s i b l e g a s t r i c a s p i r a t i o n and b o t h f l e x i b l e and r i g i d t u b e s were b e i n g r a n d o m l y u s e d i n t h e u n i t f o r i n s e r t i o n i n t h e p a t i e n t . P e r m i s s i o n o f n u r s e s t o p a r t i c i p a t e i n t h e s t u d y was o b t a i n e d as e a c h n u r s e was r e q u i r e d t o u s e b o t h r i g i d and f l e x i b l e t u b e s and i t was n o t known i f a l l n u r s e s w o u l d i n i t i a l l y be w i l l i n g t o do t h i s . N u r s e s were a d v i s e d t h a t i f i n : t h e i r j u d g e -ment one o f t h e o t h e r t y p e o f t u b e was c l i n i c a l l y i n d i c a t e d i n a p a r t i c u l a r p a t i e n t t h e n t h e y s h o u l d p r o c e e d a s t h e y t h o u g h t p r o p e r and t h e i n s e r t i o n w o u l d be e x c l u d e d f r o m t h e s t u d y . D a t a A n a l y s i s D e s c r i p t i v e S t a t i s t i c s The number o f a t t e m p t s r e q u i r e d f o r s u c c e s s f u l n a s o g a s t r i c t u b e p l a c e m e n t i n t h r e e g r o u p s o f p a t i e n t s w i t h v a r y i n g l e v e l s o f c o n s c i o u s n e s s were r e c o r d e d and d i s p l a y e d i n g r a p h i c f o r m . The means and s t a n d a r d s d e v i a t i o n s o f t h e s i x g r o u p s o f s u b j e c t s were c a l c u l a t e d and d i s p l a y e d i n t a b l e f o r m . A g r a p h o f t h e means f r o m a l l g r o u p s was a l s o c o n s t r u c t e d i n o r d e r t o d e m o n s t r a t e t h e n a t u r e o f t h e i n t e r a c t i o n t h a t e x i s t e d between t h e t h r e e l e v e l s o f p a t i e n t c o n s c i o u s n e s s and t h e d e g r e e o f n a s o g a s t r i c t u b e f l e x i b i l i t y . I n f e r e n t i a l S t a t i s t i c s An a n a l y s i s of v a r i a n c e (ANOVA) was used t o analyse the d i f f e r e n c e i n ease of i n s e r t i o n of the n a s o g a s t r i c tube among the d i f f e r e n t groups of p a t i e n t s . An F t e s t was used t o t e s t f o r s i g n i f i c a n t d i f f e r e n c e s between the groups. I t was decided t h a t the n u l l h y p o thesis would be r e j e c t e d a t the .05 l e v e l o f s i g n i f i c a n c e . Hypothesis t e s t i n g based on the F d i s t r i b u t i o n as the t h e o r e t i c a l model i n v o l v e d the assumptions of n o r m a l i t y , randomness, h o m o s c e d a s t i c i t y , independence, and a d d i t i v i t y . A summary t a b l e was used t o r e p o r t the ANOVA r e s u l t s . F i n a l l y , a pooled v a r i a n c e estimate t - t e s t was performed on the data from the two groups of unconscious p a t i e n t s and the r e s u l t s r e p o r t e d i n t a b l e form. 34 CHAPTER FOUR THE FINDINGS The data were analysed u s i n g the A n a l y s i s o f V a r i a n c e (ANOVA) procedure found i n the S t a t i s t i c a l Package f o r the S o c i a l S c i e n c e s , V e r s i o n 8.00 a t the U n i v e r s i t y of B r i t i s h Columbia Computing Centre. The purpose o f the a n a l y s i s was to t e s t three hypotheses: 1. There w i l l be no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n the mean number of attempts r e q u i r e d t o i n s e r t a n a s o g a s t r i c tube i n an i n t u b a t e d p a t i e n t when a f l e x i b l e tube i s compared with a r i g i d tube a t the a'= .05 l e v e l of s t a t i s t i c a l s i g n i f i c a n c e . 2. There w i l l be no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e i n the mean number of attempts r e q u i r e d to i n s e r t a n a s o g a s t r i c tube i n the i n t u b a t e d p a t i e n t when t h r e e l e v e l s o f consciousness are compared a t the a=.05 l e v e l of s t a t i s t i c a l s i g n i f i c a n c e . 3. There w i l l be no s t a t i s t i c a l l y s i g n i f i c a n t i n t e r a c t i o n between the degree of n a s o g a s t r i c tube f l e x i b i l i t y and p a t i e n t l e v e l o f consciousness when these d i f f e r e n t treatments are compared a t the a=.05 l e v e l of s t a t i s t i c a l s i g n i f i c a n c e . 35 D e s c r i p t i v e D a t a The t o t a l number o f p a t i e n t s i n t h e s t u d y was 121. F o r t y - t w o p a t i e n t s were c o n s c i o u s a t t h e t i m e o f n a s o g a s t r i c t u b e i n s e r t i o n , f o r t y - t w o were o b t u n d e d , and t h i r t y - s e v e n were u n c o n s c i o u s . S i x t y - o n e p a t i e n t s - w e r e i n t u b a t e d , u s i n g f l e x i b l e t u b e s and s i x t y u s i n g r i g i d t u b e s . The number o f a t t e m p t s r e q u i r e d u s i n g f l e x i b l e and r i g i d t u b e s i n t h e t h r e e d i f f e r e n t g r o u p s o f p a t i e n t s i s d i s p l a y e d i n g r a p h i c f o r m i n T a b l e 1. The mean number o f attempts and t h e s t a n d a r d d e v i a t i o n s f o r t h e s i x d i f f e r e n t g r o u p s o f p a t i e n t s a r e r e p o r t e d i n T a b l e 2. A g r a p h i c r e p r e s e n t a t i o n o f t h e means i s r e p r e s e n t e d i n F i g u r e 1. D u r i n g t h e s i x t e e n week s t u d y p e r i o d f o u r p a t i e n t s a d m i t t e d t o t h e u n i t were e x c l u d e d f r o m t h e s t u d y . One p a t i e n t had a p l a t e l e t c o u n t o f f o u r h u n d r e d and n a s o g a s t r i c i n t u b a t i o n was n o t p e r f o r m e d b e c a u s e o f t h e p o s s i b i l i t y o f h e m o r r h a g i n g as a r e s u l t o f t h e t r a u m a . One p a t i e n t was a d m i t t e d f o r m u l t i - s y s t e m f a i l u r e f o l l o w i n g e s o p h a g e c t o m y and h i s n a s o g a s t r i c t u b e had been i n s e r t e d p r i o r t o s u r g e r y . One p a t i e n t r e q u i r e d t r a c h e o s t o m y and t h e l a s t had a n a s o t r a c h e a l t u b e i n p l a c e . I n f e r e n t i a l D a t a I n a n a l y s i n g t h e d a t a f r o m t h i s s t u d y t h e l e t t e r A was a s s i g n e d t o main e f f e c t one ( t h e e f f e c t o f t u b e f l e x i b i l i t y on t h e e a s e o f i n s e r t i o n o f n a s o g a s t r i c t u b e s i n i n t u b a t e d p a t i e n t s ) , and t h e l e t t e r B t o main e f f e c t two ( t h e e f f e c t - . . o f l e v e l o f p a t i e n t c o n s c i o u s n e s s on t h e e a s e o f i n s e r t i o n o f n a s o g a s t r i c t u b e s i n i n t u b a t e d p a t i e n t s ) . The i n t e r a c t i o n e f f e c t ( t h a t between l e v e l o f p a t i e n t c o n s c i o u s n e s s and t h e d e g r e e o f n a s o g a s t r i c t u b e f l e x i b i l i t y ) was d e s i g n a t e d AB. The l e v e l o f 36 TABLE 1 Number o f a t t e m p t s R e q u i r e d f o r S u c c e s s f u l N a s o g a s t r i c Tube I n s e r t i o n i n P a t i e n t s w i t h T h r e e D i f f e r e n t L e v e l s o f C o n s c i o u s n e s s U s i n g F l e x i b l e and R i g i d N a s o g a s t r i c T u b e s . 1 2 3 4 5 6 7 8 9 1 0 1 2 3 4 5 6 7 8 9 1 0 1 2 3 4 5 6 7 8 9 1 0 number of attempts number of attempts number of attempts R i g i d Tubas 1 2 3 4 5 6 7 8 9 1 0 1 2 3 4 5 6 7 8 9 1 0 1 2 3 4 5 6 7 8 9 1 0 number of attempts number of attempts number of attempts Table 2 Mean N a s o g a s t r i c Tube I n s e r t i o n Attempts • Tube Type S t a t e of P a t i e n t F l e x i b l e R i g i d N Conscious X S 3.600 1.353 2.591 1.593 42 Obtunded X S 3.238 1.480 2.571 1.805 42 Unconscious X S 4. 800 2.745 1.588 1.064 37 N 61 60 121 F i g u r e 1 Graphic r e p r e s e n t a t i o n of the mean number of i n s e r t i o n s r e q u i r e d f o r s u c c e s s f u l n a s o g a s t r i c i n t u b a t i o n i n p a t i e n t s with r r three d i f f e r e n t l e v e l s o f consciousness. f l e x i b l e tube r i g i d tube c O A K i«u'% ebtundfei uniotJScuju.4 Level of consciousness 38 s t a t i s t i c a l s i g n i f i c a n c e o r a l p h a , f o r t h i s e x p e r i m e n t , was s e t a t .05. The summary t a b l e f o r t h e a n a l y s i s i s f o u n d i n T a b l e 2. B a s e d on t h e e x p e r i m e n t a l f i n d i n g s t h e n u l l h y p o t h e s i s f o r F a c t o r B was a c c e p t e d and t h e n u l l h y p o t h e s e s f o r F a c t o r A and t h e i n t e r a c t i o n AB were r e j e c t e d . An a d d i t i o n a l s t a t i s t i c , a p o o l e d v a r i a n c e e s t i m a t e , was employed t o examine f u r t h e r t h e u n c o n s c i o u s g r o u p o f p a t i e n t s as t h e mean number o f i n s e r t i o n s i n t h e two s u b g r o u p s o b v i o u s l y v a r i e d . The t v a l u e w h i c h r e s u l t e d f r o m t h i s c a l c u l a t i o n was s i g n i f i c a n t b e y o n d t h e .01 l e v e l o f s i g n i f i c a n c e and t h e n u l l h y p o t h e s i s i n t h i s c a s e was r e j e c t e d as w e l l . ( T a b l e 3) A n a l y s i s o f t h e d a t a , i n l i g h t o f a l l s t a t i s t i c a l t e s t s p e r f o r m e d , l e d t o t h e c o n c l u s i o n t h a t t h e v a r i a t i o n p r e s e n t i n t h e g r o u p s o f c o n s c i o u s and o b t u n d e d p a t i e n t s was most l i k e l y due t o c h a n c e w h i l e t h e v a r i a t i o n i n t h e u n c o n s c i o u s p a t i e n t s r e p r e s e n t e d t h e s i g n i f i c a n t d e g r e e t o w h i c h t h e d e g r e e o f f l e x i b i l i t y o f t h e n a s o g a s t r i c t u b e i n f l u e n c e d t h e e a s e w i t h w h i c h t h i s t u b e c o u l d be i n s e r t e d i n t h e s e p a t i e n t s . Use o f a r i g i d t u b e i n t h e u n c o n s c i o u s p a t i e n t s s i g n i f i c a n t l y r e d u c e d t h e number o f a t t e m p t s r e q u i r e d f o r s u c c e s s f u l i n s e r t i o n . P o s t Hoc A n a l y s e s and A d d i t i o n a l O b s e r v a t i o n s I n r e c o r d i n g t h e d a t a f o r t h e s t u d y t h e n u r s e s were a s k e d t o r e p o r t t h e i r e x p e r i e n c e s w i t h t h e p r o c e d u r e i n t e r m s o f number o f n a s o g a s t r i c t u b e i n s e r t i o n s t h e y p e r f o r m e d p e r month, t h e i r l e v e l o f a n x i e t y r e g a r d i n g a p a r t i c u l a r i n s e r t i o n , t h e i r c o n f i d e n c e i n o b t a i n i n g s u c c e s s f u l p l a c e m e n t o f t h e t u b e , t h e Table 3 ANOVA of the E f f e c t of the P a t i e n t ' s L e v e l of Consciousn and Degree o f N a s o g a s t r i c Tube F l e x i b i l i t y on the Ease of I n s e r t i o n . Source SS df MS F R a t i o P r o b a b i l i t y A 79.755 1 79.755 25.592 0.001 B 1.734 2 0.867 0.278 0.758 AB 38.217 2 19.108 6.132 0.003 E r r o r 358.389 115 3.116 T o t a l 478.095 120 .— Table 4 t-TEST Comparing Mean I n s e r t i o n Attempts on Two Unconscious P a t i e n t s . Group Number . of .'cases Mean Value df P r o b a b i l i t y 1 20 4.800 4.53 35 0.000 2 17 1.588 Group 1 - f l e x i b l e n a s o g a s t r i c tube. Group 2 - r i g i d n a s o g a s t r i c tube. 40 method they were taught to i n s e r t n a s o g a s t r i c tubes, and whether or not they had a p e r s o n a l p r e f e r e n c e f o r the type of tube used. They were a l s o asked t o r e c o r d the presence of s i d e e f f e c t s induced by the i n s e r t i o n of the n a s o g a s t r i c tube. A l l nurses had a t l e a s t two years of work experience p r i o r to employment i n the u n i t and l e n g t h of time working i n the u n i t ranged from t h r e e weeks to elev e n y e a r s . No nurse r e p o r t e d i n s e r t i n g fewer than two n a s o g a s t r i c tubes per month and one nurse r e p o r t e d i n s e r t i n g an average of s i x . The mean number of monthly i n s e r t i o n s was 4.23. I t was concluded t h a t a l l nurses were experienced w i t h the procedure. Although two nurses r e p o r t e d a h i g h l e v e l of a n x i e t y d u r i n g some i n s e r t i o n s the number of attempts necessary i n these cases to secure s u c c e s s f u l n a s o g a s t r i c tube placement d i d not seem to vary s i g n i f i c a n t l y from the mean number of attempts r e q u i r e d f o r s u c c e s s f u l i n s e r t i o n s performed by nurses r e p o r t i n g low or moderate l e v e l s of a n x i e t y . The mean number of attempts r e q u i r e d f o r s u c c e s s f u l n a s o g a s t r i c i n t u b a t i o n , by nurses who had been taught t o i n s e r t t h e i r tubes u s i n g e i t h e r r i g i d or f l e x i b l e tubes was very s i m i l a r . ( a mean of 3.2 f o r the former and 3.4 f o r the l a t t e r ) . I t was not p o s s i b l e t o determine whether p r e f e r e n c e f o r a f l e x i b l e or r i g i d tube had any b e a r i n g on s u c c e s s f u l n a s o g a s t r i c i n t u b a t i o n because of the l a r g e number of nurses who r e p o r t e d t h a t i t would depend upon the circumstances but then d i d not e l a b o r a t e on those circumstances. There were no s i g n i f i c a n t s i d e e f f e c t s noted i n t h i s study t h a t c o u l d be a t t r i b u t e d t o the degree of n a s o g a s t r i c tube 41 f l e x i b i l i t y except f o r s u b j e c t i v e complaints of d i s c o m f o r t from p a t i e n t s who were c o n s c i o u s . There were a g r e a t e r number of complaints o f d i s c o m f o r t from those who were i n t u b a t e d u s i n g r i g i d tubes. These complaints s t r e s s e d the uncomfortable f e e l i n g of c o l d n e s s o f the tube, and were expressed i n the form of e x p l e t i v e s . P a t i e n t s who had subdural screws i n p l a c e a t the time of n a s o g a s t r i c i n t u b a t i o n experienced a r i s e i n i n t r a c r a n i a l p r e s s u r e (ICP) d u r i n g the procedure r e g a r d l e s s of the type of tube used. The s i z e of n a s o g a s t r i c tube used i n 119 i n s e r t i o n s was a number 18. Two p a t i e n t s , one a s i x t e e n y e a r - o l d boy and the other a 72 year o l d 40kg woman were i n t u b a t e d with #14 Salem Sumps. I t would appear t h a t the l a r g e s t tube p o s s i b l e i s used f o r n a s o g a s t r i c i n s e r t i o n i n t h i s u n i t and t h i s probably r e f l e c t s the f a c t t h a t the tubes are i n i t i a l l y used f o r drainage which can o n l y be s u c c e s s f u l l y accomplished through a wide bore t u b i n g . The mean s i z e of o r a l e n d o t r a c h i a l tube used f o r p a t i e n t s i n the study was a number 7 f o r women and a number 8 f o r men. 42 CHAPTER FIVE SUMMARY, RECOMMENDATIONS, IMPLICATIONS AND CONCLUSIONS Summary The purpose o f t h i s study was to examine the e f f e c t s t h a t the degree of f l e x i b i l i t y o f the n a s o g a s t r i c tube and the p a t i e n t ' s l e v e l o f consciousness would have on the ease of i n s e r t i o n of the tube i n p a t i e n t s w i t h an en d o t r a c h e a l tube i n p l a c e . The u l t i m a t e aim o f the i n v e s t i g a t i o n was the p r o v i s i o n of a more s c i e n t i f i c base upon which c l i n i c a l d e c i s i o n s c o u l d be made about how best to i n s e r t a n a s o g a s t r i c tube i n i n t u b a t e d p a t i e n t s . In order to ensure t h a t the study f i n d i n g s would be g e n e r a l i z a b l e , procedures used i n the study were those commonly i n use i n c l i n i c a l p r a c t i c e . Thus, the number of attempts r e q u i r e d f o r s u c c e s s f u l n a s o g a s t r i c tube placement i n the stomach c o n s t i t u t e d the d e f i n i t i o n of ease o f i n s e r t i o n and the number of tube " p u l l back manoeuvres", the p o i n t a t which subsequent i n s e r t i o n s must be counted. In the same manner the degree of tube f l e x i b i l i t y was desig n a t e d r i g i d or f l e x i b l e depending upon whether or not the tube was a t room temperature or submerged i n an i c e bath. In p r a c t i c e these tubes were r e f e r r e d to as "warm" and " c o l d " . The sample from whom the study data was c o l l e c t e d c o n s i s t e d o f 121 p a t i e n t s admitted t o an eleve n bed r e s p i r a t o r y 43 m e d i c a l - s u r g i c a l i n t e n s i v e c a r e u n i t i n a l a r g e t e a c h i n g h o s p i t a l who r e q u i r e d e n d o t r a c h e a l i n t u b a t i o n and s u b s e q u e n t p l a c e m e n t o f a n a s o g a s t r i c t u b e . The number o f a t t e m p t s r e q u i r e d f o r s u c c e s s f u l n a s o g a s t r i c p l a c e m e n t was r e c o r d e d o v e r a f o u r month p e r i o d and t h e d a t a a n a l y s e d by computer u s i n g a 2 X 3 f a c t o r i a l d e s i g n . The two i n d e p e n d e n t v a r i a b l e s were d e g r e e o f t u b e f l e x i b i l i t y and l e v e l o f c o n s c i o u s n e s s . The two l e v e l s o f f l e x i b i l i t y were f l e x i b l e and r i g i d . T h r e e l e v e l s o f c o n s c i o u s n e s s were:.. c o n s c i o u s , o b t u n d e d and u n c o n s c i o u s . The d a t a showed t h a t t h e d e g r e e o f t u b e s t i f f n e s s s i g n i f i c a n t l y a f f e c t e d t h e e a s e w i t h w h i c h a n a s o g a s t r i c t u b e c o u l d be i n s e r t e d i n an i n t u b a t e d p a t i e n t (p=.001); t h e r i g i d t u b e r e q u i r e d a s t a t i s t i c a l l y s i g n i f i c a n t l y f e w e r number o f a t t e m p t s f o r s u c c e s s f u l p l a c e m e n t t h a n t h e f l e x i b l e t u b e . The d i f f e r e n c e s i n l e v e l s o f c o n s c i o u s n e s s were n o t f o u n d t o be s t a t i s t i c a l l y s i g n i f i c a n t i n t h e i r e f f e c t on e a s e o f i n s e r t i o n i n t h i s s t u d y . The i n t e r a c t i o n between t h e d e g r e e o f t u b e s t i f f n e s s and l e v e l o f c o n s c i o u s n e s s , however, was s t a t i s t i c a l l y s i g n i f i c a n t . The d i f f e r e n c e i n t h e means i n t h e u n c o n s c i o u s g r o u p o f p a t i e n t s seemed p a r t i c u l a r l y d r a m a t i c and a p o o l e d v a r i a n c e e s t i m a t e t - t e s t p e r f o r m e d on t h e s e two g r o u p s y i e l d e d a t v a l u e o f 4.53 and a p r o b a b i l i t y l e s s t h a n .001. I t was t h e r e f o r e c o n c l u d e d t h a t t h e v a r i a t i o n f o u n d i n t h e c o n s c i o u s and o b t u n d e d g r o u p s o f p a t i e n t s r e s u l t e d more l i k e l y f r o m c h a n c e t h a n f r o m t h e t y p e o f n a s o g a s t r i c t u b e u s e d f o r i n t u b a t i o n . The v a r i a t i o n p r o d u c e d i n t h e two g r o u p s o f u n c o n s c i o u s p a t i e n t s by t h e t y p e o f t u b e u s e d was so g r e a t t h a t i t was h i g h l y u n l i k e l y t h a t c h a n c e a l o n e c o u l d be r e s p o n s i b l e f o r t h e v a r i a t i o n n o t e d . 44 The experimental f i n d i n g t h a t the use of a r i g i d tube i n n a s o g a s t r i c i n t u b a t i o n of the unconscious p a t i e n t w i t h an e n d o t r a c h e a l tube i n p l a c e does p o s i t i v e l y i n f l u e n c e the .ease wi t h which the n a s o g a s t r i c tube i s i n t r o d u c e d supports i n p r i n c i p l e those manouvres recommended by Hunter, Sprague and C a r t e r , T a h i r , Cohen, A d r i a n i , Baraka, Robinson and Cox, Matsuki, and Zsigmond. In the unconscious p a t i e n t n e i t h e r the v o l u n t a r y , pharyngeal, nor esophageal stages of swallowing are p r e s e n t and the p e r i s t a l t i c movements i n i t i a t e d d u r i n g these v a r i o u s stages t h a t c o u l d be expected to a i d i n n a s o g a s t r i c tube i n s e r t i o n , are t h e r e f o r e , absent. The conscious p a t i e n t , however, i s a b l e to a c t i v e l y p a r t i c i p a t e i n the a c t of d e g l u t i t i o n w h i l e secondary p e r i s t a l t i c a c t i o n , a t l e a s t , i s p r e s e n t i n the p a t i e n t who i s obtunded. Both the r e s u l t s o f t h i s study and the l a r g e number of an e c d o t a l r e p o r t s recommending the use of r i g i d n a s o g a s t r i c tubes i n unconscious p a t i e n t s would seem t o i n d i c a t e t h a t the d i f f i c u l t i e s encountered i n the n a s o g a s t r i c i n t u b a t i o n of t h i s group o f p a t i e n t s due i n p a r t to the i n a b i l i t y t o swallow, can be somewhat overcome by u s i n g a r i g i d tube. In t h i s study the b e l i e f h e l d i n c l i n i c a l p r a c t i c e and expressed by authors such as Thomas, Griggs and Hoppe, and N e t h e r c o t t t h a t l e v e l of consciousness i n i t s e l f i n f l u e n c e s the ease w i t h which a n a s o g a s t r i c tube can be i n s e r t e d was not supported. T h i s i s probably an i n d i c a t i o n of the i n f l u e n c e t h a t i n d i v i d u a l p a t i e n t c h a r a c t e r i s t i c s have upon the ease of i n s e r t i o n of any g i v e n n a s o g a s t r i c tube. An unconscious i n t u b a t e d p a t i e n t unable t o swallow, f o r i n s t a n c e , may be e a s i e r to i n t u b a t e w i t h a n a s o g a s t r i c tube than a conscious p a t i e n t who i s a b l e to swallow 45 but whose a n x i e t y d u r i n g the procedure a d v e r s e l y a f f e c t s the extent o f h i s c o o p e r a t i o n , d e s p i t e adequate e x p l a n a t i o n and support by the nurse. Recommendations and I m p l i c a t i o n s I m p l i c a t i o n s f o r c l i n i c a l p r a c t i c e which arose from t h i s study are l i m i t e d by the f a c t t h a t t h e r e have been no other c o n t r o l l e d c l i n i c a l t r i a l s concerned w i t h t h i s p a r t i c u l a r problem and t h a t data has not y e t been p u b l i s h e d t h a t would i n d i c a t e a t e x a c t l y which degree of f l e x i b i l i t y a n a s o g a s t r i c tube can be most e a s i l y d i r e c t e d and s t i l l f u l f i l l c r i t e r i a f o r s a f e t y and comfort. Notwithstanding these c a u t i o n s , the f o l l o w i n g recommendations are made: 1. Where the c l i n i c i a n i s knowledgeable about the technique of n a s o g a s t r i c i n t u b a t i o n and i s experienced i n i t s a p p l i c a t i o n , the use of a r i g i d n a s o g a s t r i c tube reduces the number of attempts necessary f o r s u c c e s s f u l tube placement i n the unconscious p a t i e n t with an end o t r a c h e a l tube and should be used i n t h i s p a t i e n t . 2. Although t h e r e was no s i g n i f i c a n t d i f f e r e n c e between u s i n g a f l e x i b l e or r i g i d tube i n the conscious or obtunded p a t i e n t there were more s u b j e c t i v e complaints o f d i s c o m f o r t u s i n g the r i g i d tube i n conscious p a t i e n t s and i t i s advised t h a t i n t h i s group of p a t i e n t s the i n i t i a l i n s e r t i o n attempt be made with a f l e x i b l e tube. I m p l i c a t i o n s f o r f u r t h e r r e s e a r c h which can be made as a r e s u l t o f t h i s study a re: 1. The study should be r e p l i c a t e d t o ensure co n f i d e n c e i n 46 the f i n d i n g s . 2. P a t i e n t s w i t h tracheostomies and n a s o t r a c h e a l tubes were not i n c l u d e d i n t h i s study. F u r t h e r i n f o r m a t i o n about the e f f e c t a l t e r e d t r a c h e a l and/or oesophageal anatomy has on the ease of n a s o g a s t r i c tube i n s e r t i o n might be gained by i n c l u d i n g these p a t i e n t s i n the study. 3. There were no s i g n i f i c a n t s i d e e f f e c t s noted i n t h i s study t h a t c o u l d be a t t r i b u t e d to the degree of n a s o g a s t r i c tube f l e x i b i l i t y except f o r the s u b j e c t i v e c o m p l a i n t s : 6 f d i s c o m f o r t from those i n the conscious group. D i r e c t v i s u a l techniques were not employed to assess nasopharyngeal or esophageal damage and a p p l i c a t i o n of these techniques i n subsequent i n v e s t i g a t i o n s may very w e l l i n c r e a s e . o u r knowledge about s i d e e f f e c t s o c c u r r i n g as a r e s u l t of n a s o g a s t r i c i n t u b a t i o n with both f l e x i b l e and r i g i d tubes. 4. A l l 22 p a t i e n t s who had subdural screws i n p l a c e a t the time of n a s o g a s t r i c i n t u b a t i o n experienced a r i s e i n i n t r a c r a n i a l p r e s s u r e (TCP) d u r i n g the procedure r e g a r d l e s s of the degree of tube f l e x i b i l i t y . I t would be i n t e r e s t i n g t o repeat the study i n t h i s group of p a t i e n t s to see i f the degree and d u r a t i o n of ICP r i s e i s a f f e c t e d by the degree o f n a s o g a s t r i c tube f l e x i b i l i t y i n p a t i e n t s w i t h v a r y i n g l e v e l s of consciousness. C o n c l u s i o n s In order t o seek more i n f o r m a t i o n concerning h i s own body and to t r e a t or diagnose the maladies t h a t sometimes a f f l i c t i t , man has f o r c e n t u r i e s i n s e r t e d tubes and c a t h e t e r s i n t o the body's numerous o r i f i c e s . The tubes used i n t h i s e x p l o r a t i o n have i n c r e a s e d i n s o p h i s t i c a t i o n w i t h advances i n s c i e n t i f i c knowledge and technology. I n i t i a l attempts made to ease the manner i n which these tubes have been i n t r o d u c e d were focussed upon m a n i p u l a t i o n o f the m a t e r i a l s used and experimentation with new and d i f f e r e n t m a t e r i a l s as these became a v a i l a b l e . I t has been the purpose o f t h i s study t o apply quantitative measurements to two methods of n a s o g a s t r i c tube i n s e r t i o n i n common c l i n i c a l use i n an e f f o r t to determine the e f f e c t each has on the ease w i t h which those tubes can be i n s e r t e d i n p a t i e n t s w i t h v a r y i n g l e v e l s of cons c i o u s n e s s . The r e s u l t s have shown t h a t w h i l e use of a r i g i d tube i n the unconscious p a t i e n t s i g n i f i c a n t l y a f f e c t s the ease with which a n a s o g a s t r i c tube can be i n s e r t e d i n t h a t fewer attempts are necessary to secure placement w i t h t h i s type of tube than with a f l e x i b l e tube, t h e r e has been no evidence t o show t h a t d i f f e r e n t l e v e l s of consciousness have any o v e r a l l e f f e c t t h a t c o u l d be c o n s i d e r e d s i g n i f i c a n t on the ease w i t h which a tube can be i n t r o d u c e d . 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An a e s t h e s i a 27 (October 1972): 458. 51 Conway, K e v i n . "A Method o f I n s e r t i n g a N a s o g a s t r i c Tube i n t h e A n a e s t h e t i s e d o r Comatose P a t i e n t . " A n a e s t h e s i a and  A n a l g e s i a 50 (November-December 1971):1010-1011. D a v i s , L a r r y E . , and Hofmann, W i l l i a m . "A Long Term N a s o g a s t r i c F e e d i n g Tube Made f r o m M o d i f i e d P e n r o s e T u b i n g . " J o u r n a l o f t h e A m e r i c a n M e d i c a l A s s o c i a t i o n 209 ( A u g u s t 1969):685-686. Deane, R o b e r t S., Morgan, J o h n G., and S h i n o z a k i , Tamotsu. " N a s o g a s t r i c W i t h N a s o t r a c h e a l Tube." The New E n g l a n d  J o u r n a l o f M e d i c i n e 287 (November 23, 1972):1103. D e t t a l , M e r v y n . " S u c c e s s f u l Use o f t h e M i l l e r - A b b o t t Tube." The C a n a d i a n J o u r n a l o f S u r g e r y 10 ( A p r i l , 1967):245-256. D e n n i s , C l a r e n c e . 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Hassan,M.A.-,- and H o b s l e y , M. " P o s i t i o n i n g o f N a s o g a s t r i c T u b e s W i t h o u t F l u o r o s c o p y . " The B r i t i s h S o c i e t y o f  G a s t r o e n t e r o l o g y 9 (1968):728. Hodge, J o s e p h . "New, Improved N a s o g a s t r i c D u o d e n a l M e r c u r y T i p Sump Tube f o r u s e i n t h e Management o f I n t e s t i n a l O b s t r u c t i o n . " The A m e r i c a n J o u r n a l o f S u r g e r y 140 (September 1980):475-476. H u n t e r , A.R. "The I n s e r t i o n o f N a s o g a s t r i c Tubes i n t h e A n a e s t h e t i s e d P a t i e n t . " A n a e s t h e s i a 28 (1973):708-709. H u n t e r , J o h n . "A C a s e o f P a r a l y s i s o f D e g l u t i o n , C u r e d by an A r t i f i c i a l Mode o f C o n v e y i n g F o o d and M e d i c i n e s i n t o t h e Stomach." T r a n s a c t i o n s o f a S o c i e t y f o r t h e  Improvement o f M e d i c a l and C h i r u r g i c a l Knowledge (1793) : 182-189. 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" A l l A b o u t G a s t r o i n t e s t i n a l I n t u b a t i o n . " N u r s i n g 75 (September 1975):31-37. 53 McGuirt, W. F r e d e r i c k and S t r o u t , John J . "Securing of Intermediate D u r a t i o n Feeding Tubes." The Laryngoscope 90 (1980):2046-2048. Major, Ralph H. " H i s t o r y of the Stomach Tube." Annals of  M e d i c a l H i s t o r y 6 (1934) .-500-509. Matsuki, Akitomo and Zsigmond, Elemer K. "Simple and R e l i a b l e Method of I n s e r t i n g a N a s o g a s t r i c Tube During A n a e s t h e s i a . " B r i t i s h J o u r n a l of A n a e s t h e s i a (1972):610. Matthew, Henry, Macintosh, T. F., Tompsett, S. L., and Cameron, Jean C. " G a s t r i c A s p i r a t i o n and Lavage i n Acute P o i s o n i n g . " B r i t i s h M e d i c a l J o u r n a l (May 1966) : 1333-1336. Mirakhur, R. K. "Simple and R e l i a b l e Method of I n s e r t i n g a N a s o g a s t r i c Tube During A n a e s t h e s i a . " B r i t i s h J o u r n a l  of A n a e s t h e s i a 45 (1973):1062. Mundy, Donald A. "Another Technique f o r I n s e r t i o n of N a s o g a s t r i c Tubes." A n a e s t h e s i o l o g y 50 (1979):374. Nelson, R i c h a r d L. and Nyhus, L l o y d M. "A New Long I n t e s t i n a l Tube." Surgery, Gynecology and O b s t e t r i c s 149 (October 1979):581-582. N e t h e r c o t t , S a l l y . " C l e a r i n g a Pathway." Nursing M i r r o r 150 ( A p r i l 1980):25-27. Ohn, K i e - C h u l and Wu, Wen-Hsien. "A New Method f o r N a s o g a s t r i c Tube I n s e r t i o n . " A n a e s t h e s i o l o g y 51 (1979):568. Persons, C a r o l . "Why Risk TPN When Tube Feeding W i l l Do?" RN 44 (February 1981):35-41. P e t e r s , J . L., V a l l i s , C, and F o r r e s t e r , P. " I n s e r t i n g Narrow-Bore N a s o g a s t r i c Tubes." Lancet (October 28, 1978):944. Pope, C h a r l e s E. "Esophageal P h y s i o l o g y . " M e d i c a l C l i n i c s  of North America 58 (November 1974):1181-1199. Ravdin, I.S. "The Modern Role of the Esophagoscope i n Surgery." Surgery 51 (March 1962):420-422. Robinson, E a r l P., and Cox, Paul M. "Feeding Tube I n t r o d u c t i o n — An E a s i e r Way." C r i t i c a l Care Medicine 7 (1979):349. Sader, A l b e r t A. "New Way to S t a b i l i z e N a s o g a s t r i c Tubes." American J o u r n a l of Surgery 130 (1975):102. Saha, A. K. "The I n s e r t i o n of N a s o g a s t r i c Tubes i n the A n a e s t h e t i s e d P a t i e n t . " A n a e s t h e s i a 29 (1974):367. S c h e c h t e r , D a v i d C h a r l e s and Swan, H e n r y . " L e v i n and H i s Tube." S u r g e r y 51 (March 1962):415-419. S m i t h , R o b e r t M. " S i m p l e and S a f e Method f o r I n s e r t i n g a N a s o g a s t r i c Tube." B r i t i s h J o u r n a l o f A n a e s t h e s i a 45 (1973):1168. S p r a g u e , D a v i d H., and C a r t e r , S t e v e n R. "An A l t e r n a t e Method f o r N a s o g a s t r i c Tube I n s e r t i o n . " A n a e s t h e s i o l o g y 53 ( 1 980):436. S t a u f f e r , J o h n L., O l s o n , D a n i e l E . , and P e t t y , Thomas L. " C o m p l i c a t i o n s and C o n s e q u e n c e s o f E n d o t r a c h e a l I n t u b a t i o n and T r a c h e o t o m y . " The A m e r i c a n J o u r n a l o f  M e d i c i n e 70 ( J a n u a r y 1981):65-76. T a h i r , A s h i q and A d r i a n i , J o h n . "The I n s e r t i o n o f a N a s o g a s t r i c Tube i n t h e A n a e s t h e t i s e d o r Comatose P a t i e n t . " A n a e s t h e s i a and A n a l g e s i a 50 ( M a r c h - A p r i l 1973):179-180. T a n n e r , C h r i s t i n e and P a d r i c k , K a r e n . " R e s e a r c h U t i l i z a t i o n Q & A F o c u s on AACN 8 (October/November 1981):33-34. Thomas, S a l l y , " P a s s i n g Tubes and C a t h e t e r s . " N u r s i n g M i r r o r 148 (March 1979) :.32-33. 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" I n s e r t i o n o f N a s o g a s t r i c T u b e s . " B r i t i s h  J o u r n a l o f A n a e s t h e s i a 51 (1979):73. Van E s s , L e s t e r J . "Use o f a C o l o r Coded G a s t r i c Tube." I n t e r n a t i o n a l S u r g e r y 62 ( A ugust 1977):418-419. V i r t u e , R o b e r t W. " S i m p l e and R e l i a b l e Method o f I n s e r t i n g a N a s o g a s t r i c . T u b e D u r i n g A n a e s t h e s i a . " B r i t i s h J o u r n a l o f A n a e s t h e s i a 45 (1973):234. Volden, C e c i l i a , Grinde, Jacquelyn, and C a r l , David. "Taking the Trauma out of N a s o g a s t r i c I n t u b a t i o n . " Nursing 80 10 (September 1980):14-17. Walder, A r n o l d I. "A H i s t o r i c a l - Review of the N a s o g a s t r i c Tube." Surgery 51 (March 1962):407-413. W e l l s , Thelma J . " C l i n i c a l N ursing: C u r i o u s e r and C u r i o u s e r . " American J o u r n a l of Nursing79(October 1979) : 1757-1760. Young, Ronald F. " C e r e b r o s p i n a l F l u i d Rhinorrhea F o l l o w i n g N a s o g a s t r i c I n t u b a t i o n . " The J o u r n a l of Trauma 19 (October 1979):789-791. Ziemer, Mary and C a r r o l l Jane Schupay. " I n f a n t Gavage Reconsidered. " American J o u r n a l of Nursing 7^(September 1978):1543-1544. APPENDIX ONE 57 Experiment t o Determine an E f f e c t o f C o o l i n g on a D e f l e c t i o n of N a s o g a s t r i c Tube Obj e c t i v e : To measure and compare the f o r c e s r e q u i r e d to d e f l e c t a l u b r i c a t e d p o l y v i n y l c h l o r i d e n a s o g a s t r i c tube a t room temperature and 0°C. TABLE 5 Forces r e q u i r e d to d e f l e c t l u b r i c a t e d PVC N a s o g a s t r i c t u b i n g a t 0 C and 18 C. FIGURE II Data tubing temperature force to deflect tubing from 0-20cm force to deflect tubing from 20-50cm 18°C 1.0. Newtons 2.0 Newtons (room temperature) 0°C 3.0 Newtons 5.0 Newtons (ice water bath) N a s o g a s t r i c tube d e f l e c t i o n The above results are averages of 80 t r i a l s for each conditon. C o n c l u s i o n : The f o r c e r e q u i r e d to d e f l e c t l u b r i c a t e d p o l y v i n y l -c h l o r i d e n a s o g a s t r i c t u b i n g a t 0°C i s g r e a t e r than the f o r c e r e q u i r e d a t room temperature or 18°C. The r e s u l t s o b t a i n e d i n t h i s experiment i n d i c a t e t h a t the f o r c e s r e q u i r e d to d e f l e c t the t u b i n g a t 0°C are about t h r e e times as g r e a t as the f o r c e s r e q u i r e d to d e f l e c t the t u b i n g a t 18°C. APPENDIX TWO 5 9 Nurse's I n f o r m a t i o n and Consent Form Mr ./Miss/Mrs ./Ms ._ My name i s Jane H e a s l i p . I am a student i n the graduate programme i n n u r s i n g a t the U n i v e r s i t y of B r i t i s h Columbia. I am i n t e r e s t e d i n s t u d y i n g how nurses can more e a s i l y i n t r o d u c e n a s o g a s t r i c tubes i n i n t u b a t e d p a t i e n t s . Although the b a s i c procedure f o r p l a c i n g the tube i s w e l l understood, nurses have not y e t been a b l e t o document whether or not changes i n the degree of f l e x i b i l i t y of the tube have any b e a r i n g on the ease with.which.the tube i s i n s e r t e d . In o r d e r to d i s c o v e r i f t h e r e i s an e f f e c t from the degree of tube f l e x i b i l i t y on the ease of i n s e r t i o n of the n a s o g a s t r i c tube, I would l i k e t o ask you to p a r t i c i p a t e i n a study to be implemented i n the ICU t h a t would r e q u i r e you t o use a n a s o g a s t r i c tube t h a t has been submerged i n an i c e bath f o r ten minutes t o ensure r i g i d i t y , and one t h a t has been s t o r e d a t room temperature to ensure f l e x i b i l i t y on a l t e r n a t e weeks. I would a l s o ask your p e r m i s s i o n as p a r t of the study to c o l l e c t some data c o n c e r n i n g your p r o f e s s i o n a l e x p e r i e n c e w i t h the procedure and your o p i n i o n s about i t . Should you a t any time f e e l t h a t i n the i n t e r e s t s of the p a t i e n t the r e s e a r c h p r o t o c o l should be abandoned, you are f r e e t o do so. You are a t a l l times encouraged to f o l l o w your c l i n i c a l judgement and no c r i t i c i s m w i l l be brought a g a i n s t you f o r doing so. P a r t i c i p a t i o n i n the study w i l l r e q u i r e attendance a t an i n s e r v i c e s e s s i o n , d u r i n g which the r e s e a r c h p r o t o c o l w i l l be d e s c r i b e d and data c o l l e c t i o n methods e x p l a i n e d . Your name w i l l not be i n c l u d e d i n the d a t a taken f o r the study, and data sheets w i l l be d e s t r o y e d f o l l o w i n g a n a l y s i s . You are f r e e t o withdraw from the study a t any time and w i l l i n c u r no p e n a l t y f o r doing so. I f you have any q u e s t i o n s r e g a r d i n g t h i s study f e e l f r e e t o ask them p l e a s e . Date: Nurse's S i g n a t u r e ( i n d i c a t i n g w i l l i n g n e s s to p a r t i c i p a t e i n the study) I n v e s t i g a t o r ' s S i g n a t u r e • APPENDIX THREE 61 N a s o g a s t r i c Tube Study P r o t o c o l 1. I n s e r t i o n Technique The i n s e r t i o n technique of a l l tubes i s to f o l l o w the b a s i c p r i n c i p l e s d e s c r i b e d by Griggs and Hoppe i n t h e i r a r t i c l e p u b l i s h e d i n The American J o u r n a l of Nursing, Vol.79, No.3. March, 1979, pp.481-485. The p r i n c i p l e s a r e : • 1. E x p l a i n the procedure to the p a t i e n t as necessary and support him throughout the i n t u b a t i o n . 2. Assess l e v e l of consciousness and determine presence or absence of gag and swallow r e f l e x e s . 3. Examine tube. D i s t a l end should be f r e e of rough or sharp edges and o u t l e t h o l e s should be open. 4. Determine approximate depth of i n s e r t i o n . Measure the d i s t a n c e from the x i p h o i d process of the sternum to the t i p o f the nose to the ear lobe. 5. I f the tube to be i n s e r t e d i s a r i g i d one, submerge the tube i n an i c e bath f o r 10 minutes. I f the i n i t i a l i n s e r t i o n i s not s u c c e s s f u l r e t u r n the tube to the i c e bath f o r 10 minutes preceeding second and subsequent attempts. I f the tube to be i n s e r t e d i s a f l e x i b l e one remove from the package and attempt to i n s e r t i n t o the p a t i e n t . 6. L u b r i c a t e both the t i p and f i r s t few inches of the tube. 7. Pass the tube g e n t l y along the f l o o r of the n a s a l passageway. A common mistake i s to push the t i p both p o s t e r i o r and s u p e r i o r , l o s i n g i t i n the t u r b i n a t e s and c a u s i n g p a i n and b l e e d i n g . To prevent t h i s , aim down and back toward the ear. 8. In the conscious p a t i e n t the p a t i e n t w i l l f e e l a lump i n the back of the t h r o a t when the tube begins to curve downward i n t o the pharynx. At t h i s p o i n t i n s t r u c t the p a t i e n t t o begin swallowing. 9. Continue p a s s i n g the tube u n t i l the d e s i r e d l e n g t h i s reached. 10. V e r i f y tube placement by a s p i r a t i o n of g a s t r i c contents w i t h a s y r i n g e . 11. Tape the tube s e c u r e l y , a v o i d i n g p r e s s u r e on the nares. 2. Study Week and Type of Tube to be Used: R i g i d tubes are to be used on odd study weeks and f l e x i b l e tubes on even weeks. Each week w i l l b e gin a t 0001 hours Sunday 62 and end a t 2359 hours Saturday. 3. C r i t e r i a f o r I n c l u s i o n : A l l p a t i e n t s i n whom n a s o g a s t r i c tube placement has been approved by the a d m i t t i n g r e s i d e n t and who have e n d o t r a c h e a l tubes i n p l a c e . APPENDIX FOUR 64 Data to be C o l l e c t e d - ( P l e a s e check one of each of the f o l l o w i n g ) 1. Information Regarding the P a t i e n t and Procedure: a) L e v e l of consciousness i ) conscious ( ) i i ) obtunded ( ) i i i ) unconscious ( ) b) Degree of tube s t i f f n e s s i ) r i g i d ( ) i i ) f l e x i b l e ( ) c) Number of attempts b e f o r e s u c c e s s f u l i n s e r t i o n i ) i n i t i a l ( ) i i ) subsequent w i t h number ( ) S i z e i ) 14 of N a s o g a s t r i c Tube ( ) i i ) 18 ( ) i i i ) other ( ) S i z e i ) 7 of e n d o t r a c h e a l tube ( ) i i ) 8 ( ) i i i ) 9 ( ) iv) other ( Side i ) e f f e c t s from n a s o g a s t r i c tube i n s e r t i o n complaints of d i s c o m f o r t w i t h s p e c i f i c s i i ) b l e e d i n g and source i i i ) change i n ICP r e a d i n g iv) other g) Was t h i s procedure: i ) e l e c t i v e ( ) i i ) emergent ( ) 2. Information Regarding the Nurse: a) L e v e l of a n x i e t y r e g a r d i n g t h i s procedure I) none ( ) i i ) low ( ) i i i ) moderate ( ) i v ) h i g h ( ) b) Approximate number of n a s o g a s t r i c tube i n s e r t i o n s per month ( ) c) How were you taught to i n s e r t an NG tube? i ) r i g i d ( ) i i ) f l e x i b l e ( ) d) Do you have a p e r s o n a l p r e f e r e n c e f o r the type of tube used? i ) r i g i d ( ) i i ) f l e x i b l e ( ) i i i ) no d i f f e r e n c e ( ) iv ) depends upon circumstances ( ) i f i v , d e s c r i b e : e) How c o n f i d e n t were you r e g a r d i n g success w i t h t h i s i n s e r t i o n ? i ) very ( ) i i ) moderately ( ) i i i ) not a t a l l ( ) 

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