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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 E F F E C T OF THE PATIENT'S L E V E L OF CONSCIOUSNESS THE DEGREE OF NASOGASTRIC TUBE F L E X I B I L I T Y ON THE OF INSERTION OF THE TUBE  IN PATIENTS WITH AN  TUBE  IN PLACE  JANE E L I Z A B E T H HEASLIP The U n i v e r s i t y  of Manitoba,  1977  A THESIS SUBMITTED IN PARTIAL FULFILMENT THE REQUIREMENT FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING  in  THE FACULTY OF GRADUATE  STUDIES  (School of Nursing)  We  accept t h i s to  thesis  the required  as c o n f o r m i n g standard  THE UNIVERSITY OF BRITISH COLUMBIA March ©  1982  Jane E l i z a b e t h  Heaslip,  19 82  EASE  ENDOTRACHEAL  by  B.A.,  AND  OF  In  presenting  requirements  this thesis  British  it  freely available  for  that  Columbia,  I agree  that  f o r reference  permission  scholarly  f u l f i l m e n t of the  f o r an a d v a n c e d d e g r e e a t t h e U n i v e r s i t y  of  agree  in partial  the L i b r a r y  shall  and s t u d y .  I  f o r extensive  p u r p o s e s may  for  that  shall  Nursing  The U n i v e r s i t y o f B r i t i s h 2075 Wesbrook P l a c e V a n c o u v e r , Canada V6T 1W5 Date  16th A p r i l ,  1982  of this  It is thesis  n o t be a l l o w e d w i t h o u t my  permission.  Department o f  thesis  be g r a n t e d by t h e h e a d o f my  copying or p u b l i c a t i o n  f i n a n c i a l gain  further  copying of t h i s  d e p a r t m e n t o r by h i s o r h e r r e p r e s e n t a t i v e s . understood  make  Columbia  written  ABSTRACT The Degree  Effect  of the Patient's  L e v e l o f C o n s c i o u s n e s s and t h e  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  Of t h e Tube i n P a t i e n t s W i t h  on t h e E a s e o f I n s e r t i o n  an E n d o t r a c h e a l Tube i n P l a c e  Jane E . H e a s l i p  The the  purpose o f t h i s  patient's  nasogastric of  level  tube  s t u d y was t o examine t h e e f f e c t  that  o f 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  f l e x i b i l i t y would  have on t h e e a s e o f i n s e r t i o n  t h e t u b e i n p a t i e n t s w i t h an e n d o t r a c h e a l t u b e i n p l a c e .  statistical 1.  2.  hypotheses t e s t e d  The D e g r e e  The  were:  of nasogastric  tube f l e x i b i l i t y w i l l n o t  influence  t h e ease w i t h which  the tube i s i n s e r t e d .  The l e v e l  o f consciousness of the patient w i l l not  influence  t h e ease w i t h which  the nasogastric  tube i s  inserted. 3.  There w i l l flexibility  be no i n t e r a c t i o n  between t h e d e g r e e o f  of the nasogastric  t u b e t o be i n s e r t e d  and  the l e v e l of consciousness of the patient  the  tube i s p l a c e d .  The  sample  f r o m whom d a t a was c o l l e c t e d  f o r the study  consisted  o f 121 p a t i e n t s a d m i t t e d t o t h e r e s p i r a t o r y  care unit  of a large  teaching  i n whom  intensive  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  intubation number  and s u b s e q u e n t p l a c e m e n t  o f attempts per p a t i e n t  of a nasogastric  f o r s u c c e s s f u l placement  t u b e were r e c o r d e d o v e r a f o u r month p e r i o d analysed using  a 2 X 3 factorial  design.  v a r i a b l e s were d e g r e e o f n a s o g a s t r i c levels: three  flexible  levels: The  of  w i t h which rigid  and l e v e l  c o n s c i o u s , obtunded  data c o l l e c t e d  nasogastric  the  and r i g i d ,  tube r e q u i r i n g  than the f l e x i b l e  tube.  The two  independent  of consciousness with  and u n c o n s c i o u s .  i n an i n t u b a t e d  a statistically The d i f f e r e n c e  that  affects  the degree t h e ease  patient  f e w e r number among l e v e l s  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 this  o f each  t u b e f l e x i b i l i t y w i t h two  significantly  a t u b e c a n be i n s e r t e d  The  and t h e d a t a  from the study i n d i c a t e  tube f l e x i b i l i t y  tube.  ( c v = . 0 5 )  o f attempts of patient  significant i n  i n v e s t i g a t i o n b u t t h e i n t e r a c t i o n between t h e d e g r e e o f  tube f l e x i b i l i t y and l e v e l statistical  of patient  consciousness revealed  significance.  T h e s i s Chairman  TABLE  OF  CONTENTS Page  CHAPTER  ONE :  THE  PROBLEM  AND  PURPOSES  1  Introduction Statement o f the Problem Purposes o f the Study D e f i n i t i o n o f Terms CHAPTER  CHAPTER  TWO:  REVIEW  THE L I T E R A T U R E  7  Introduction H i g h l i g h t s o f the H i s t o r i c a l Development o f the 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  7 8  THREE:  OF  1 4 4 5  METHODOLOGY  28  Preliminary Experiment Research Design P o p u l a t i o n and Sample Data C o l l e c t i o n Method M e t h o d o f S c o r i n g t h e Number E t h i c s a n d Human R i g h t s Data A n a l y s i s C H A P T E R FOUR:  of Insertions  THE F I N D I N G S  FIVE:  28 28 30 30 31 31 32 34  Descriptive Statistics Inferential Statistics P o s t Hoc A n a l y s e s a n d A d d i t i o n a l CHAPTER  18  Observations  SUMMARY, RECOMMENDATIONS, I M P L I C A T I O N S AND C O N C L U S I O N S . .  Summary Implications Recommendations Conclusions  35 35 38  42 42 45 46  BIBLIOGRAPHY  49  APPENDICES  56  One: Two: Three: Four:  Forces Required to Deflect a n d 18 C Consent Form I n s e r t i o n Technique Data C o l l e c t i o n Sheet n  iv.  NGT  at 0 C  L I S T OF  TABLES Page  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 Three D i f f e r e n t L e v e l s o f Consciousness using 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  37  3.  ANOVA Summary T a b l e .  39  4.  t - T e s t C o m p a r i n g Mean I n s e r t i o n a t t e m p t s o f Unconscious P a t i e n t s  39  Forces Required t o D e f l e c t Nasogastric a t 0 C and 18°C  57  5.  Tube I n s e r t i o n A t t e m p t s  v  Tube '  L I S T OF FIGURES  Page 1.  2.  Graphic representation of i n s e r t i o n s required nasogastric intubation three d i f f e r e n t levels  o f t h e mean number f o r successful i n patients with of consciousness  I l l u s t r a t i o n of forces required to d e f l e c t N a s o g a s t r i c T u b i n g a t 0°C and 18°C  vi  37  57  ACKNOWLEDGEMENTS  The  author  gratefully  a c k n o w l e d g e s t h e c o n t r i b u t i o n s made  by many i n t h e p r e p a r a t i o n o f t h i s given  Ratzlaff  fortheir  sustained  e n t h u s i a s m , and g u i d a n c e . Bruce f o r h i s i n s t r u c t i o n Posnikoff Barbara  Moore o f F i l t n e s s  carried  experiments,  and Cameron who t y p e d  and t o  the manuscript.  R e s e a r c h Committee, t h e Head  fortheir  i n the u n i t  o u t and s p e c i a l  faithfullness  encouragement,  Nurse,  D i r e c t o r o f t h e I n t e n s i v e Care U n i t i s  extended  working  and P r o f e s s o r  i n c o m p u t e r programming, t o Mr. M i k e  t h e r e s e a r c h programme.  nurses  thanks a r e  Thanks a r e e x t e n d e d a s w e l l t o Mr. Bob  t o the Nursing  the Medical  gratefully  support,  f o rh i s supervision of the physics  Appreciation  out  Particular  t o t h e Committee members, Ms. Sue R o t h w e l l  Harold  and  thesis.  permission  t o use t h e u n i t  Without the cooperation this  research  and a d h e r i n g  p r o t o c o l w h i l e m e e t i n g t h e demands o f t h e i r  vii  of the  c o u l d never have been  thanks a r e extended  i n recording data  to carry  t o them f o r t h e i r to the research busy  unit.  1  CHAPTER  THE  ONE  PROBLEM  Introduction The may  well  ease  be  w i t h which a n a s o g a s t r i c tube  related  t o such  the p a r t of the nurse,  the  factors level  as  i s inserted  the degree  of the nurse's  t h e anatomy o f t h e n a s o p h a r y n x , e s o p h a g u s , and degree  of patient  manageability a nurse's decrease  as  she  knowledge stomach,  cooperation during the procedure,  of the  level  of anxiety  tube  itself.*'  and  on  concerning  the the  A recent a r t i c l e suggests  of anxiety concerning nasogastric intubation becomes more aware o f t h e a n a t o m i c  that will  and 2  physiologic  principles  Procedures have r e c e n t l y  that  that  govern  are based  3 been d e l i n e a t e d .  ^ C e c i l i a Volden, Jacquelyn "Nasogastric Intubation," Nursing  placement  upon t h e s e  of the  tube.  findings  M a n a g e a b i l i t y of the Grinde, and D a v i d 8 0 . 1 0 (September  tube  to  Carl, 1980):14-17.  2 B a r b a r a A, G r i g g s and Mary C. Feeding," American J o u r n a l of Nursing 3  Hoppe, " N a s o g a s t r i c Tube 7 9 (March 1 9 7 9 ) : 4 8 1 - 4 8 5 .  See B a r b a r a A. G r i g g s and Mary C. Hoppe, " 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 7 9 (March 1979): 4 8 1 - 4 8 5 ; E d w i n a A. 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 7 5 5 ( S e p t e m b e r 1 9 7 5 ) : 3 1 - 3 6 ; and C e c i l i a V o l d e n , J a c q u e l y n G r l n d e , and D a v i d C a r l , " T a k i n g t h e Trauma Out 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 8 O i o ( S e p t e m b e r 1980): 14-17.  2  be . i n s e r t e d  has  anaesthetised  been d i s c u s s e d i n r e l a t i o n  patients with  endotracheal  to  tubes  in  4 place. placed  Volden on  i c e before  tube i n the without  e t a l recommend  back o f  insertion the  i n order  t h r o a t , but  benefit of a controlled The  t h a t the  n a s o g a s t r i c tube to prevent  this  clinical  s u g g e s t i o n was trial.  a p p r o a c h e s most f r e q u e n t l y u s e d by  problems are  trial  and  error,  coiling  r e l i a n c e on p a s t  be of  the  made  5  nurses  to  solve  experience,  g "common s e n s e " ,  "faith",  b e e n u s e d i n d e c i d i n g how  and  custom.  best  A l l these  to i n s e r t  methods h a v e  a nasogastric  tube.  The  r a t i o n a l e f o r i n s e r t i n g a t u b e t h a t has b e e n c o o l e d b e f o r e "*See D a v i d A. C h a d w i c k , "The 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 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 ( 1 9 7 3 ) : 3 4 1 - 3 4 2 ; L i e w Pak C h i n , "A M e t h o d o f P a s s i n g N a s o - g a s t r i c Tube D u r i n g A n a e s t h e s i a i n t h e Newborn," A n a e s t h e s i a 27 ( O c t o b e r 1 9 7 2 ) : 4 5 8 ; A.R. H u n t e r , "The 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 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 ( 1 9 7 3 ) : 7 0 8 - 7 0 9 ; R.K. M i r a k h u r , " S i m p l e and R e l i a b l e M e t h o d o f I n s e r t i n g a N a s o g a s t r i c Tube 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 ( 1 9 7 3 ) : 1 0 6 2 ; K i e - C h u l Ohn,and Wen-Hsien Wu, "A New M e t h o d 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') : 5 6 8 ; A k i t o m o M a t s u k i and E l e m e r K. Z s i g m o n d , " 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 Tube 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 26 ( 1 9 7 2 ) : 6 1 0 ; D o n a l d A. Mundy, "Another Technique f o r I n s e r t i o n o f 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 ( 1 9 7 9 ) : 3 7 4 ; E . R o b i n s o n J r . , e t a l , " F e e d i n g 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 o f N a s o g a s t r i c T u b e s 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 ( 1 9 7 4 ) : 3 6 7 ; R o b e r t M. S m i t h , " S i m p l e and S a f e M e t h o d f o r 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 , " 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 4 5 ( 1 9 7 3 ) : 1 1 6 8 ; and R.W. V i r t u e , " S i m p l e and R e l i a b l e M e t h o d o f I n s e r t i n g a N a s o g a s t r i c Tube 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.  ^ C e c i l i a Volden, Jacquelyn "Nasogastric Intubation," Nursing  G r i n d e and C a r l , D a v i d , 8QlO(September 1 9 8 0 ) :14.  6  T h e l m a 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 A m e r i c a n J o u r n a l o f N u r s i n c ? 9 ( O c t o b e r 1 9 7 9 ) : . 1757-1760.  3  insertion ensure  t o promote r i g i d i t y  flexibility  b e e n done" o r method  fails  achieved  or stored  i s the s a m e — " t h i s  "I b e l i e v e a second  a t room t e m p e r a t u r e  i s t h e way  t h i s method works b e s t " .  i s adopted,  i t i s more o f t e n  i s most l i k e l y  than not a t t r i b u t e d  described that  in this  inserting that  i n placing patient  forces  tube.  finally In  i n p l a c e the  of the a l t e r n a t i v e s  just  t h e r e i s an a d v a n t a g e  t o p e r m i t them t o s l i d e  of  i s g i v e n f o r a moment t o t h e  d r a i n a g e a r e made o f p l a s t i c . t o g e t h e r by  when h e a t e d ,  in  consideration  c o n t r i b u t e t o the ease  Most n a s o g a s t r i c t u b e s  chains i s held  and,  one  to "luck".  I t seems a l o g i c a l  i f one's a t t e n t i o n  f e e d i n g and polymeric  at least  tube might  o f t h e .tube i t s e l f .  always  a n a s o g a s t r i c t u b e d e s p i t e some e v i d e n c e  a more r i g i d  a stiffened  insertion  t o u s e one  When  and when s u c c e s s i s  t h e c a s e o f a p a t i e n t w i t h an e n d o t r a c h e a l t u b e nurse  i t has  to  now The  i n use b o t h f o r assembly  a number o f  t h e s e c h a i n s move a p a r t o v e r one  another  nature  of  different sufficiently  but r e t a i n  their  7 c o h e s i v e n e s s because that  the type of p l a s t i c  made, p o l y v i n y l  chloride,  a t room t e m p e r a t u r e advantage cause it  less  still  operating.  T h i s means  f r o m w h i c h most n a s o g a s t r i c t u b e s i s softer  and  t h a n when c o l d .  i n terms o f p a t i e n t  comfort  less easily  are  directed  and  s a f e t y because  r e g a r d i n g i n s e r t i o n because  from b e i n g e a s i l y  when  T h i s s o f t n e s s i s an i t will  oropharyngeal d i s c o m f o r t than a harder m a t e r i a l ,  i s a disadvantage  tube  of the forces  i t prevents  but the  directed.  7 . W i l l i a m L. M a s t e r s o n and E m i l J . S l o w i n s k i , C h e m i c a l P r i n c i p l e s ( P h i l a d e l p h i a / T o r o n t o / L o n d o n : W.B. S a u n d e r s Company, 1976), p.327.  4 Statement Literature  of the  r e v i e w has  Problem  shown t h a t quantitative , o b j e c t i v e o  m e a s u r e s h a v e n o t as y e t been  u s e d t o examine t h e f a c t o r s  influence  a nasogastric  the ease w i t h which  introduced.  Since the recent  consciousness of the p a t i e n t , e n d o t r a c h e a l t u b e , and all  influence  controlled  the ease w i t h which  problem  solving  Thelma W e l l s c a l l s alone,  significant  purpose of t h i s  degrees of f l e x i b i l i t y  an  flexibility  inserted,  replace  what  and/or  custom.  Study  s t u d y was  t o examine t h e e f f e c t s  of the nasogastric  t u b e and  level  gastric  t u b e i n p a t i e n t s w i t h an e n d o t r a c h e a l t u b e i n p l a c e .  The  hypotheses  The  level  influence is 3.  t o be t e s t e d  of a  will  the n a s o g a s t r i c  not i n f l u e n c e  the  tube i s i n s e r t e d .  of consciousness of the p a t i e n t w i l l  not  the ease w i t h which  tube  the n a s t o g a s t r i c  inserted.  There w i l l flexibility  be no  i n t e r a c t i o n between t h e d e g r e e o f  of the nasogastric  and t h e l e v e l  t u b e t o be  inserted  of consciousness of the p a t i e n t  that of  naso-  were:  degree o f tube f l e x i b i l i t y  ease w i t h which 2.  Such  i f i t s implementation could  c o n s c i o u s n e s s have on t h e e a s e o f i n s e r t i o n  1.  a  be h e l p f u l .  patient  statistical  of  t h e methods o f r e l i a n c e on p a s t e x p e r i e n c e  Purpose of the  two  of  tube  t h a t t u b e c a n be  t e c h n i q u e s t h a t would  common s e n s e , f a i t h ,  The  the l e v e l  the p r e s e n c e or absence  the degree of n a s o g a s t r i c  be e s p e c i a l l y  be  claims that  s t u d y t o examine t h e s e f a c t o r s w o u l d  a s t u d y would encourage  literature  tube can  that  i n whom  The  5  nurses  the  tube  The  objective  have  experience, there tube is  is  come but  placed. of  what  patient  dependent  has  and  the  the  investigation  which  the  placement varying  of  not  who  has  an  was  of  to  the  accumulated 14  tube  tube X-ray  opaque  location Degree 1.  Salem  at  could  tubes  Sump  normal  of  of  or  vacuum liquid,  i s 4.7  i s 6.0  insertion  of  the  be  a  that  nasogastric  i n place tube  The  scientific  that  inserted  aim.of  base  made c o n c e r n i n g  i n intubated  past  (i.e.,  the  patient).  or  patients  upon  the with  of  the  Terms  R  drainage  break  validated  f l e x i b i l i t y of  Tube.  This  thermosensitive polyvinyl  suction  error  what  Tube  Argyle  flexibility  of  and  test  of consciousness.  R  made o f  trial  t o p r o v i d e a more  decision  formally  e n d o t r a c h e a l tube  Definitions Nasogastric  to  y e t been  ease  degree  nasogastric  levels  as  consciousness of  clinical of  through  i n the  upon.the  level  s t u d y was  to believe  i s a difference i n the  the  mm  mm  body  a i r and  Tube  tube  Line and  R  the  stomach small  i n diameter  Sentinel the  while  the  i n diameter  chloride  temperature.  feeding when  i s a double  and  and and  122  which  One  has  been  cm  -tube  increases  lumen  a i r vent  evacuated matter.  i n length.  of A  A  number  number  tube  18  i n length. The t u b e has a n R S e n t i n e l Eye which permit exact  drainage  cm  eyes.-  Stiffness  Flexible:  in  serves for  o t h e r p r o v i d e s an  particulate 122  lumen  i n i t s natural  pliable  state  at  room  6  temperature. 2.  Rigid:  tube  minute immersion Level of  i n the  i n an  stiffened  state  as p r o d u c e d  i c e bath.  Consciousness  1. C o n s c i o u s : t h e p a t i e n t and p l a c e , has  a gag  is alert  and  r e f l e x p r e s e n t and  oriented  Obtunded: the p a t i e n t  because  of h i s p h y s i c a l  s e d a t i v e s and/or  and  swallow  and  o f the" n a s o -  reflexes  either  to p h y s i c a l  i s unable  to  either of  actively  of h i s n a s o g a s t r i c tube;  there are  present.  the p a t i e n t  to painful  impaired  or the a d m i n i s t r a t i o n  a n a l g e s i c s so t h a t he  3. U n c o n s c i o u s : nonresponsive  i s neurologically  condition  cooperate w i t h the i n s e r t i o n  due  person  tube.  2.  gag  to  i s a b l e t o swallow  to cooperate w i t h the•nurse d u r i n g the i n s e r t i o n gastric  by a t e n  i s inappropriately  stimuli  condition  and  has  no  gag  responsive or  or swallow  or a d m i n i s t r a t i o n  reflex  of  anaesthesia. Endotracheal Portex Ease  Tube soft  cuffed  endotracheal  tube.  o f I n s e r t i o n MeasureThe  number o f a t t e m p t s  of the n a s o g a s t r i c tube aspiration  of g a s t r i c  of the tube determines attempts  a r e t o be  i n the  fluid  necessary f o r successful stomach as e v i d e n c e d  with a syringe.  the p o i n t  counted.  a t which  Any  second  by  "pull and  placement  back" subsequent  7  CHAPTER  TWO  REVIEW OF THE LITERATURE -Introduction The intensive and  n u r s e new t o t h e 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 care  catheters  u n i t i s o f t e n o v e r w h e l m e d by t h e number o f t u b e s e m a n a t i n g f r o m any g i v e n  patient.  There are tubes  coming from below t h e d u r a t h a t a t t a c h t o t r a n s d u c e r s intracranial veins  pressure.  Swan-Ganz c a t h e t e r s  r e c o r d pulmonary a r t e r y p r e s s u r e s .  the  subclavian vein provides  the  seriously i l l .  inserted i n jugular  Silastic  Fine wires  introduced  administration o f medications  and f l u i d .  an a b d o m i n a l wound t h r o u g h a sump t u b e .  teral  and u r e t h r a l c a t h e t e r s  drain  liquid  and t r a c h e o s t o m y  The  and v e i n s  l a r g e bore catheters  m o n i t o r any g i v e n  of the h i s t o r i c a l  saline  uretubes  Endotracheal, patient  placed  to treat,  chapter  irri-  Rectal  connections  i n femoral machines.  d i a g n o s e and  p a t i e n t d e p e n d s upon h i s p a r t i c u l a r  i s the purpose o f t h i s  slowly  Suprapubic,  attach patients to hemodialysis  number o f t u b e s and c a t h e t e r s u s e d  It  drains  bowel.  tubes provide  and t h e  f o r the  d r a i n u r i n e i n t o bags.  from n o n f u n c t i o n i n g  to v e n t i l a t o r s while arteries  a route  Blood  gates  nasotracheal,  heart  t u b e t o a b o t t l e on t h e f l o o r w h i l e  stool  of  through the femoral  i n the peripheral vein provides  through a chest  tubing i n  an avenue f o r h y p e r a l i m e n t a t i o n  v e i n a c t as a t e m p o r a r y pacemaker f o r t h e f a i l i n g humble j e l c o  to record  needs.  to discuss highlights  d e v e l o p m e n t o f t h e u s e o f t u b e s and c a t h e t e r s  8 in  the provision of patient  historical  care.  Emphasis w i l l  be p l a c e d on t h e  development o f t h e use o f the n a s o g a s t r i c tube  cussion w i l l  include  specific  overcome d i f f i c u l t i e s  and d i s -  r e f e r e n c e t o methods d e v i s e d t o  encountered  i n nasogastric intubation.  Highlights o f the H i s t o r i c a l Development o f the Nasogastric Tube The of  early  tubes  and c a t h e t e r s r e f l e c t e d  technology a v a i l a b l e  first  urethral  the primitive  to the ancient p r a c t i t i o n e r .  catheters,  venous d r a i n a g e  systems,  level  Thus, t h e  and t r a c h e o s g  tomy t u b e s o f 3,0 00 y e a r s B.C. were made o f h o l l o w As  knowledge o f m e t a l s  became a v a i l a b l e  fashioned of gold, iron, metal u r e t h r a l one  lead  t h e s e t u b e s began t o be  and b r o n z e .  By 1036 t h e r i g i d  c a t h e t e r h a d b e e n r e p l a c e d by a more  made o f s i l v e r , arterial  silver  of  c a n e were r e p l a c e d w i t h t h o s e made o f s i l v e r .  t u b e s , and by 1869 t r a c h e o s t o m y 9  19th c e n t u r y f o l l o w i n g  t h e d i s c o v e r y o f r u b b e r .and  advancement i n m a n u f a c t u r i n g  methods t h e f i r s t  c a t h e t e r was i n t r o d u c e d i n F r a n c e . " ^ rubber  flexible  by t h e 1 6 t h c e n t u r y t h e v e n o u s r e e d s r e p l a c e d  by  the f i r s t  reeds.  t u b e s made In the early with  rubber  urethral  Twenty y e a r s l a t e r ,  e n d o t r a c h e a l t u b e was d e s c r i b e d . ' ' "  1  i n 18 80,  I n t h e 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 t h e H i s t o r y o f M e d i c i n e , ( P h i l a d e l p h i a and L o n d o n : W.B. S a u n d e r s Company, 1929), p.55, a n d M. J a s t r o w , J r . , "The M e d i c i n e o f t h e B a b y l o n i a n s a n d A s s y r i a n s , " L a n c e t 2 (1913):1137. 9 See F. Adams, The E x t a n t Works o f A r e t a e u s , t h e Cappod o c i a n (London, 1956), p.346; A n d r e a s L i b a v i u s , Syntagma A r c a n o r u m e t Commentationum Chymicorum, ( F r a n k f u r t , 1613), p.34 and F r e i d r i c h T r e n d e l e n b u r g , " B e i t r a g e Z u r Den O p e r a t i o n e n An Den L u f t w e g e n . 2. Tamponnade d e r T r a c h e a , " 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 O b s e r v a t i o n s on t h e I n t r o d u c t i o n o f T r a c h e a l T u b e s by t h e Mouth I n s t e a d o f P e r f o r m i n g T r a c h e o t o m y o r L a r y n g o t o m y , " 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 reed  with  and  the  advent of the  c a n e t h a t had  been r e p l a c e d  o f r u b b e r were r e p l a c e d lumen c a t h e t e r s  stiff  plastics  once a g a i n  by  by  i n d u s t r y , the  tubes  t u b e s o f m e t a l and  a new  enough t o t r a n s m i t  material.  of then  Double  i n t r a c a r d i a c pressures 12  and  yet not  catheters  i n j u r e the  h e a r t were i n v e n t e d .  thought t o harbour fewer b a c t e r i a than the  c a t h e t e r s were now  13 available.  new  m a t e r i a l s would  urethral  rubber  Soft cuffed endotracheal  t r a c h e o s t o m y t u b e s were i n t r o d u c e d these  Silastic  i n the  l e s s e n the  hope t h a t t u b e s  possibility  of  and of  tracheal  14 erosion. Although the by  discovery  advances i n technology  catheters  history. history  use  o f new  materials  r e s u l t e d i n improved  these  appearance of these  f a c t o r s alone devices  of the  nasogastric  imagination  has  tube w i l l played  are not  throughout  demonstrate the  i n the  accompanied  tubes  I t i s h o p e d t h a t a more d e t a i l e d a c c o u n t o f  individual tube or  has  f o r patient care,  to e x p l a i n the  and  e v o l u t i o n of  and enough  medical the part any  given  catheter. 12  A. C o u r n a n d , R.A. B l o o m f i e l d , and H.D. Lauson, "Double Lumen C a t h e t e r f o r I n t r a v e n o u s and I n t r a c a r d i a c B l o o d S a m p l i n g and P r e s s u r e T r a c i n g , " P r o c e e d i n g s o f t h e S o c i e t y o f B i o l o g y and M e d i c i n e 60 ( 1 9 4 5 ) : 7 3 . 13 S a l l y Thomas, " P a s s i n g T u b e s and C a t h e t e r s , " N u r s i n g M i r r o r , 1 4 8 (March 29 ,.1979) : 33 . 14 J o h n L. S t a u f f e r , D a n i e l E. O l s o n , and Thomas L. P e t t y , " 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, (January, 1981):65.  10 Even p r i o r various  t o the use o f t h e p r i m i t i v e  stomach  tube,  p r a c t i c e s were i n d u l g e d i n by t h e Romans t o i n d u c e  vomiting  a t the completion, o f a banquet i n o r d e r t o prevent  the a f t e r  effects  o f an o v e r l o a d e d  place again f o r another  as t o g i v e  A t times  emetics  were  b u t t h e s e seemed t o o u n c e r t a i n i n t h e i r  results  and i t was  soon r e a l i z e d  that  meal.  stomach a s w e l l  i t was o n l y n e c e s s a r y  employed  to apply the f i n g e r 15  to  the throat t o accomplish  matter  t h e same r e s u l t .  I t was o n l y a  o f t i m e b e f o r e t h e p i n n a o r " v o m i t i n g f e a t h e r " was  employed a s a s u b s t i t u t e  f o r the finger i n order to give a 16 sense o f r e f i n e m e n t t o t h e procedure. The p i n n a , b e f o r e u s i n g , was o f t e n d i p p e d i n t o some n a u s e a t i n g m i x t u r e t o 17 increase i t s effectiveness. I t was O r i b a s i u s , w r i t i n g i n the fourth  c e n t u r y , however, who gave u s what i s p r o b a b l y t h e 18  first  d e s c r i p t i o n o f a stomach tube.  made o f s o f t hollow into  leather  filled  T h i s was an i n s t r u m e n t  w i t h wool i n t h e lower  i n t h e u p p e r p a r t so t h a t t h e f i n g e r  it.  I t was t h e l e n g t h o f s i x t e e n  reach a t l e a s t stomach. 15  into  p o r t i o n and  c o u l d be i n t r o d u c e d  fingers  t h e e s o p h o g u s and p e r h a p s  so t h a t  i t would  even i n t o t h e  The s t o m a c h c o n t e n t s o b v i o u s l y d i d n o t e s c a p e  through  R a l p h H. M a j o r , " H i s t o r y o f t h e Stomach Tube," A n n a l s M e d i c a l H i s t o r y 6, (1934):500. 16 J u l i u s F r i e d e n w a l d and Samuel M o r r i s o n , "The H i s t o r y o f t h e D e v e l o p m e n t o f t h e Stomach Tube w i t h Some N o t e s on t h e D u o d e n a l Tube," B u l l e t i n o f t h e I n s t i t u t e o f t h e H i s t o r y o f M e d i c i n e 4, (June 1936):426. 17 S u e t o n i u s , H i s t o r y o f T w e l v e C a e s a r s , e d . J.H. F r a s e r , t r a n s . P h i l a m o n H o l l a n d ( L o n d o n ) , p.46. 18 O r i b a s i u s , C o l l e c t i o n M e d i c a l e , e d . Daremberg ( E r l a n g e n , 1 6 1 2 ) , Book 8, C h a p t e r 6. of  the  lumen  when  the  known  as  of  the  sound  and  patient  began  to vomit.  lora  poisoning  and  The  the  v o m i t o r i a , were proved  further  quite  instrument  probably  Instruments  often  used  effective.  developments  was  of  of  i n the  this  withdrawn type,  treatment  of  19  this  instrument  are described  20 in  many o f  for  the  instrument  confined down  to  into  distal as  or end  fish  for  ancient physicians.  i n c r e a s e d so the  stomach  These  the  tubes  silver.  They  that  they  were  but  also  included  stomach  and  extracting  were h o l l o w often  had  t o make i t p o s s i b l e  The  to  foreign and  no  uses  longer forcing  bodies  from  w e r e made o f  food  the  lead,  small  sponges  tied  to  remove  foreign  bodies  the such  bones. An  159 8 b y  of  emptying  the  esophagus. copper,  the works  advance  i n the  Hieronymus  .  . .  artificial  use  of  Capivacceus  feeding.  21  He  the  stomach  when he  tube  devised  a t t a c h e d an  was  made i n  an.instrument  animal  bladder  to  the  19 S e e 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 (Lugduni, P i l l e h a t t e , 1 5 2 3 ) , 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 S e e 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 ( L o n d o n : D r i n g , H a r p e r a n d L e i g h , 1 6 7 9 ) , p.23; Guilhelmi Fabricii Hildani, 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 X X X V I , 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 Lib.l,  Hieronymus Cap.53.  Capivacceus,  Medical  Practice,  ( V e n i c e , 159 8)  p r o x i m a l end it  into  1670  the  of a hollow metal  stomach o f a p a t i e n t  Fabricius  silver  and  through  tube  and  expressed  suffering  from  fluid  tetanus.  ab A q u a p e n d e n t e d e s c r i b e d a c u r v e d  covered with  t h e n o s e and  s h e e p i n t e s t i n e w h i c h he  into  through In  t u b e made o f introduced  t h e stomach f o r t h e p u r p o s e  of  22 feeding.  He  felt  h i s t u b e was  a b l e t o p a s s more e a s i l y  into  t h e stomach when c o v e r e d w i t h t h e s h e e p i n t e s t i n e w h i c h a c t e d as a  lubricant. In  1744  the use  o f t h e stomach t u b e was  extended  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 unconscious later  o r o b t u n d e d and  the f i r s t  l o n g term  unable  use  t o swallow.  to  in patients  Forty-six  o f a stomach t u b e was  years  described 23  by J o h n H u n t e r i n t h e management o f a p a t i e n t w i t h b u l b a r p a l s y . The  i n s t r u m e n t u s e d was  p r o b a n g and  tied  p r o x i m a l end  a t the d i s t a l  just  a b l a d d e r and  over  required  no  In  end  over  a sponge and  below a s m a l l l o n g i t u d i n a l  slit  at  a  the  through  which  a wooden p i p e were i n t r o d u c e d t o a d m i n i s t e r w i n e ,  eggs, m i l k , sugar, improved  made o f a f r e s h e e l s k i n drawn o v e r  and m e d i c a t i o n s  the next  further  seventeen  twice d a i l y .  days w i t h t h i s  c a r e o n c e he was  179 7 A l e x a n d e r  able to  used  patient  treatment  and  swallow.  Monro p o i n t e d o u t t h a t  when a t t a c h e d t o a s y r i n g e c o u l d be  The  the  stomach  f o r the a s p i r a t i o n  tube of  stomach c o n t e n t s i n c a s e s o f p o i s o n i n g and f o r t h e 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 A q u a p e n d e n t e , O e u v r e s C h i r u r g i c a l e s , ( L y o n : H i g u e t a i n and B a r b i e r , 1 6 7 0 ) , p.594. 23 J o h n H u n t e r , T r a n s a c t i o n 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, (London: S t . P a u l ' s C h u r c h y a r d , 1 7 9 3 ) , p.182.  of  food  in patients  introduced  into  with  France  dysphagia.  by  Renault  24  The  and  was  stomach used  by  tube him  was  and  by  25 Dupuytren in  i n the  America  John  by  Hunter  treatment of poisoning.  Philip  and  who  P h y s i c k who was  t u b e i n France.  A  connection  the use  patient. first  with This  stomach  familiar  heated  of  the also  studied  with  discussion  discussion pump, b u t  had  I t was  the  arose  stomach  concerned  i t i s difficult  i n Edinburgh  use  of  i n the  tube the  introduced  the  under  stomach  literature  i n the  in  poisoned  invention  to establish  of  the  who  27 actually It  inventedi t . remained  K u s s m a u l24 i n 1869  f o r L e f e v r e i n 1842,  to urge  the  use  of  the  Canstatt stomach  i n 1843, tube  and  in  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 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),  de  p.78. 25  F. C a d e t , D'apres l a Methode ( F e b . , 1810):62.  " S e c o u r s a A d m i n i s t r e r Dans L e s E m p o i s o n n e m e n t s d e M. D u y p t r e n , " B u l l , d e P h a r m . 2  26  P.S. P h y s i c k , " A c c o u n t o f t h e New M o d e o f E x t r a c t i n g Poisonous Substances from t h e Stomach," E c l e c t i c R e p e r t o r y a n d A n a l y t i c a l R e v i e w 3 (1812):11.  27  S e e E . J u k e s , "New M e a n s o f E x t r a c t i n g O p i u m f r o m t h e S t o m a c h , " L o n d o n M e d i c a l a n d P h y s i c a l J o u r n a l 48 (1822):218; F . B u s h , "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 T u b e , A s 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 S t o m a c h , " L o n d o n M e d i c a l a n d 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 a n d 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 a n d W a l e s 1 (1823) :208; and J . R e e d , " 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.  different  clinical  the treatment Canstatt  0  L e f e v r e recommended  of patients with l i f e  i n the treatment  as a method b o t h stomach.  settings.''  I n 1871  threatening vomiting,  of g a s t r i c  f o r d i a g n o s i s and  dilatation,  and  Kussmaul  treatment of diseases of  Leube e s t a b l i s h e d  m e a l " w h i l e u s i n g t h e stomach t u b e  i t s use i n  the concept i n studies  of the  the  "test  concerned  with  29 gastric motility this had  time  after  the i n g e s t i o n of c e r t a i n  t h e n , t h e stomach t u b e was  been r e c o g n i z e d b o t h  an  the tube  itself.  t h e use o f a s o f t introduction, during  tube  Jurgensen  insertion,  wrote the f i r s t  the p o s i t i o n  and  t h e r a p e u t i c s and  at the p r o p e r t i e s  rubber tube, e x p l a i n i n g  describing  advising  By  i n s t r u m e n t whose v a l u e  f o r d i a g n o s i s and  p h y s i c i a n s b e g a n t o l o o k more c l o s e l y  foods.  article  of  recommending  i t s method o f  the p a t i e n t  should  take  the reader of the type  suction  of  t o be a p p l i e d . ^ J u r g e n s e n ' s t u b e ended i n a p e r f o r a t e d 28 See A r n o l d I . W a l d e r , "A H i s t o r i c a l Review o f t h e 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. K u s s m a u l , "Ueber D i a B e h a n d l u n g d e r M a g e n e r w e i t e r u n g D u r c h E i n e Neue M e t h o d a , M i t t e l s t d e r Magenpumpe," D e u t c h A r c h , 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 T h e r a p i e , " E r l a n g e n 4 (1843):382. 29  W.O. L e u b e ,  " D i e Magensonde," E r l a n g e n  "^T. J u r g e n s e n , (1870):239.  Deutsch  Arch,  f. Klin.  (1879):28.  Med.  ivory and  ball  1875  and was  g u i d e d by means o f a w i r e s t y l e t .  E w a l d and  Oser  In  independently introduced a soft  1874 rubber 31  t u b e w h i c h c o u l d be In  inserted without  an emergency s i t u a t i o n  the a i d of a  i n which a s t i f f  stylet.  t u b e was  a v a i l a b l e E w a l d i m p r o v i s e d a t u b e made f r o m r u b b e r in  w h i c h he  oiled  c u t o f f t h e s h a r p end  the tube  little  succeeded  difficulty.  tube because the  and  he  Oser  first  sought  he was  the p a t i e n t ' s  intubation  s u p p o r t has  been s t r e s s e d  through by  important observation.  patients,  h i s rubber  cooperation during  e v e n t h o s e who  suggests  that  the purpose what he  several  may  appear  t o be  unconscious, 32  patient wishes  and  c a n be  of  made  after  receive She  i n f o r m a t i o n about  f o r the p a r t i c u l a r the i n s e r t i o n ,  o f t h e t u b e as a t r a u m a t i c  patient, and  what  as  emphasizes the p o i n t t h a t a l t h o u g h a l l t h i s  information i s necessary f o r every p a t i e n t presented w i l l  s i n c e Oser  b e f o r e i t i s begun.  o f the n a s o g a s t r i c tube  McConnell  the p r o v i s i o n  recommends t h a t a l l  an e x p l a n a t i o n s h o u l d i n c l u d e  t o make t h e p a s s a g e  possible.  clinicians  McConnell  c a n e x p e c t b o t h d u r i n g and  c a n do  cooperation during  b o t h t e a c h i n g and  an e x p l a n a t i o n o f t h e p r o c e d u r e  is  He  t h e stomach w i t h  a b l e to pass  need f o r a s s u r i n g p a t i e n t  nasogastric  he  tubing  c u t o u t two e y e l e t s .  i n passing i t into  felt  gas  procedure. The  his  and  not  t h e manner i n w h i c h i t  depend upon t h e needs o f t h e determined  by  individual  a s k i n g t h e p a t i e n t b o t h what  he  t o know and what he a l r e a d y knows. G r i g g s and Hoppe i n 31 D a v i d C h a r l e s S c h e c h t e r and H e n r y 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 E d w i n a A. 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,' .197-5),.: 31.  their  review  o f n a s o g a s t r i c tube  p a t i e n t s undergoing  gastric  intubation require  e n c o u r a g e m e n t , and r e a s s u r a n c e . . specific  a s t o how t h i s  feeding,. point out that a l l  during the procedure  s h o u l d be g i v e n .  recommends a " f i r m b u t s y m p a t h e t i c "a s k i l l calm  acquired with  the fear  support,  33  but are not  Thomas, however,  approach"  coupled  the confidence of experience"  surrounding  the procedure  with i n order t o  which she f e e l s a l l  34 p a t i e n t s have. procedure  The need f o r a d e q u a t e e x p l a n a t i o n o f t h e  as w e l l as t h e p r o v i s i o n o f e m o t i o n a l  nasogastric  tube  These a u t h o r s  insertion  suggest  i s also  no r e c o m m e n d a t i o n s  i n f o r m a t i o n and s u p p o r t  intubation in  in a critical  principle  mentioned  who w i l l  provide  emotional 35  to the p a r t i c u l a r  care unit  have b e e n made i t i s c l e a r  treatments  care  o f t h e h e a l t h team p u s h e s i t i n t o  environment  designed  o u t i n a h u r r i e d manner.  i s likely  that  authors p r e v i o u s l y  In the c r i t i c a l  when r e s t o r a t i v e  framework and t h i s  needs  of the p a t i e n t requiring nasogastric  s h o u l d be a p p l i e d .  supportive are carried activity  specific  t h e s u g g e s t i o n s made b y t h e  there a r e times  of  et a l .  by h o l d i n g t h e 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 for  s t r e s s e d by V o l d e n ,  during  t h a t i t i s o f t e n a d v i s a b l e t o h a v e an  a s s i s t a n t during the procedure support  support  a goal  t o be  The h u r r i e d directed  t o convey t o t h e p a t i e n t a f e e l i n g  a n x i e t y o r sense o f urgency. In her d i s c u s s i o n of the 33 . B a r b a r a A. G r i g g s and Mary C. Hoppe, " N a s o g a s t r i c  Tube F e e d i n g , "  American J o u r n a l o f Nursing  79 (March, 1979) : 485 .  34 S a l l y Thomas, " P a s s i n g Tubes and C a t h e t e r s , " M i r r o r , 148 (March 29, 1 9 7 9 ) : 3 2 . 35 C e c i l i a V o l d e n , J a c q u e l y n G n n e , and D a v i d C a r l , 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, 1 9 8 0 ) : 1 6 .  Nursing  "Taking  17 psychological environment  equilibrium  Roberts  of the patient  says t h a t  i n the c r i t i c a l  the primary s t a b i l i z i n g  care  force  36 is  the nurse.  She s t r e s s e s  t h e need  f o r adequate  e x p l a n a t i o n o f a l l e q u i p m e n t and p r o c e d u r e s u s e d provision of patient reassuring  c a r e and e m p h a s i z e s  f o r the  the teaching, supportive,  r o l e o f nurses i n the i n t e n s i v e  o f c o n s c i o u s n e s s o f any g i v e n p a t i e n t w i l l  care unit. certainly  The l e v e l d i c t a t e the  t y p e o f e x p l a n a t i o n and s u p p o r t n e c e s s a r y a t t h e t i m e o f nasogastric  i n t u b a t i o n b u t as Oser, M c C o n n e l l ,  Thomas, and V o l d e n  G r i g g s and Hoppe,  e t a l have p o i n t e d o u t , 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 t o be c a r r i e d  out with  the c o o p e r a t i o n o f the p a t i e n t . The  advantages  and t h e f a c t  that  pure n a t u r a l  latex  unpleasant odor remove.  o f t h e r u b b e r t u b e were i t s f l e x i b i l i t y  i tcould absorbs  and s t a i n ,  b e made r a d i o p a q u e .  c o n s i d e r a b l e water both o f which  F o r t h e s e r e a s o n s many m a t e r i a l s  d e s i g n have been used stomach t u b e .  i n an e f f o r t  of platinumchloride. body t i s s u e s ,  However,  and p i c k s up an  are d i f f i c u l t to and a l t e r a t i o n s i n  to further  improve  upon t h e  The t u b e s now i n u s e a r e made o f p o l y v i n y l  softened with p l a s t i c i z e r s  odor  body t e m p e r a t u r e . regarding  easily  insertion  resins  and made r a d i o p a q u e by t h e a d d i t i o n  The t u b e s  and t a s t e  are non-toxic, non-reactive to  free,  They s t i l l ,  and t h e r m o s e n s t i v e a t n o r m a l  however, p o s e  certain  and much o f t h e r e c e n t l i t e r a t u r e  problems concerning  t h e stomach tube a d d r e s s e s 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 R e f e r e n c e f o r C r i t i c a l C a r e N u r s i n g , e d s . M a r g u e r i t e R o g e r s K i n n e y , C y n t h i a Boyd D e e r , Donna R o g e r s P o c k a and D o r o t h y M. N a g e l h a u t Voorman. (New Y o r k : M c G r a w - H i l l Book Company, 1981) p.341.  18 Methods o f I n s e r t i n g N a s o g a s t r i c Tubes Methods o f i n s e r t i n g  nasogastric  tubes a r e d e s c r i b e d i n 3.7  b o t h t h e m e d i c a l and n u r s i n g l i t e r a t u r e . establish  I t i s d i f f i c u l t to  p r e c i s e l y when n u r s e s b e g a n t o i n s e r t  tubes but i t i s u n l i k e l y thirties  '  that  as i t i s a t t h i s  this  nasogastric  o c c u r r e d much b e f o r e t h e l a t e  t i m e when t h e p r o c e d u r e  described  i n t h e n u r s i n g p r o c e d u r e manuals i n t h i s  certainly  true,  have g e n e r a l l y time  so t h i s  however, t h a t p r o c e d u r e s been e s t a b l i s h e d  d a t e must  found  i n practice  insertion  t h a t v a r y from h o s p i t a l  ward i n t h e same h o s p i t a l .  That  at times experience d i f f i c u l t y by for  t h e number o f a r t i c l e s overcoming  insertion  i n policy  It is manuals  guideline f o r  as a n u r s i n g p r o c e d u r e .  A t t h e moment b o t h d o c t o r s and n u r s e s i n s e r t situations  city.  f o r some p e r i o d o f  be t a k e n o n l y a s a r o u g h  the acceptance o f n a s o g a s t r i c  is first  stomach tubes i n  to hospital  a l l who i n s e r t  and f r o m ward t o t h e s e t u b e s do  with the procedure  t h a t has appeared 38 problems.  i s evidenced  with suggestions  ~"'See A. T u c k e r and J e n n i f e r L e w i s , " P r o c e d u r e s 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 ( O c t o b e r 25, 1980):1128-1129; L a w r e n c e 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 S u r g e r y 59 ( A u g u s t , 1972):637-641; E d w i n a A. 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 (September, 1975):31-37; and V o l d e n e t a 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):14-17. 38 See E a r l P. R o b i n s o n J r . and P a u l M. Cox, J r . , " F e e d i n g 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 C a r e M e d i c i n e 7 ( 1 9 7 9 ) : 349-350; R o b e r t M. S m i t h , " 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; 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 e s t h e s i o l o g y 51 (1979):568; and B a r b a r a A. G r i g g s a n d Mary C. Hoppe, " U p d a t e : 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.  19 The  major problem  relate  areas  to the experience of the person  nasogastric  tube w i t h  a n a t o m i c a l and inserting  alterations  in  that  to i n s e r t  the  relate  those  that  relate  result  of immaturity,  that  foreign bodies from  the p a t i e n t ' s l e v e l  nature of the i n s e r t i o n  aging, i n j u r y ,  the p a r t relate  or  c h a n g e s due  of consciousness, those as a b l i n d  procedure,  to  that and  to or  the  i n the nasopharyngeal  physiological  the  person  t o a n x i e t y on those  to  i n t h e anatomy o f t h e mouth, n o s e , e s o p h a g u s  of other  that  those that  r e g a r d i n g the procedure,  stomach as a r e s u l t presence  the procedure,  attempting  are those  p h y s i o l o g i c a l knowledge base o f the  the tube,  of the p a t i e n t  those  t h a t have b e e n i d e n t i f i e d  cavity,  alterations relate  to  the  finally, 39  those  that relate  t o the n a t u r e o f the tube  t o be  inserted.  "See S a l l y Thomas, " P a s s i n g T u b e s 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): 32-34; M a r j o r i e L . Beck, " T h r e e 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 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 n , (May ,19 81) : 5-6 ; M a r j o r i e L. Beck, " T h 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 ( A p r i l , 1981): 34-35; L i e w Pak C h i n , "A Method o f P a s s i n g N a s o g a s t r i c Tube D u r i n g A n a e s t h e s i a i n t h e Newborn," A n a e s t h e s i a 27 ( O c t o b e r , 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," N u r s i n g M i r r o r 150 ( A p r i l 24, 1980):25-27; J o h n D. B u l l o c k , "A C o n v e n i e n t Method f o r I n s e r t i n g S m a l l F e e d i n g T u b e s , " Gut 10 (1969):599-600; A s h i q H. T a h i r and J o h n A d r i a n i , "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 (March, A p r i l , 1971):179-180; R.H. M i r a k h u r , " 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 Tube 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):1062; 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 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 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 ( 1 9 7 9 ) : 7 3 .  20 Various issues.  authors  Thomas,  experience  with  have  addressed  f o r example, the  procedure  stresses as  a  one  or  the  another  of  importance  positive  factor  these  of  in  attaining  40 successful other  nasogastric intubation.  hand,  state  that  experience  Volden i s not  et  a l . , on  likely  to  the  lessen  the 41  anxiety  experienced  authors,  calm,  cooperative patient anatomy  well  the  These  involved  as  by  and  as  nurse  f o r any  others, and  a  stress  sound  particular the  importance  knowledge  physiology  i n ensuring  based  the  insertion.  base  of  successful  of  a  the tube  42 placement. basis is,  as  a  Advice rationale  however,  extension  of  neck  provision  in guiding insertion  conflicting the  upon  at  during  times. the  of  McConnel  procedure  as  of a  an  anatomical  nasogastric  advises the  tube  hyper-  best  43 40 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 . 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 ( M a r c h 29 , 1 9 7 9 ) :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 , "Taking t h e T r a u m a 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 ( S e p t e m b e r , 1980) :14. 42 S e e C a r o l P e r s o n s , "Why R i s k TPN w h e n T u b e F e e d i n g W i l l Do?" RN 44 ( J a n u a r y , -1981) : 3 5 - 4 1 : E d w i n a M c C o n n e l l , " 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 75 5 ( S e p t e m b e r , 1 9 7 5 ) : 3 1 - 3 7 ; M a r j o r i e B e c k , " T h r e e Common G a s t r o i n t e s t i n a l Tests—And. 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 1 1 : 3 4 - 3 5; a n d B a r b a r a G r i g g s a n d M a r c h C. H o p p e , " U p d a t e : N a s o g a s t r i c T u b e 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.  T u c k e r and L e w i s o f f e r gastric  i n s e r t i o n b a s e d on p r o b l e m s t h a t a r i s e  anatomical  • . v a r i a t i o n s t h a t a r e found  Two i n f o r m a t i v e that  infant  autopsies  f o r naso-  as a r e s u l t o f  . 44 from p a t i e n t t o p a t i e n t . relationships  placement o f t h e n a s o g a s t r i c  Ziemer a n d . C a r r o l l arranged  i n order  a conventional  tips  s t u d i e s b a s e d upon a n a t o m i c a l  i n f l u e n c e the proper  have b e e n r e p o r t e d .  by  helpful "troubleshooting"  to verify  tube  t o be p r e s e n t a t  tube placement  accomplished  measurement t a k e n f r o m t h e t i p o f t h e i n f a n t ' s  nose t o t h e l o b e o f t h e e a r t o t h e x i p h o i d p r o c e s s ,  a measurement  45 in  common c l i n i c a l  recommend taken  use.  B a s e d on t h e i r  f i n d i n g s a t autopsy  t h a t a b e t t e r and more a c c u r a t e  measurement i s one  from t h e t i p o f t h e nose t o t h e lobe  midway between t h e x i p h o i d p r o c e s s R o b e r t Hanson i n h i s s t u d y  of the ear to a point  and t h e u m b i l i c u s . sought t o f i n d  measurement f o r p l a c e m e n t o f t h e n a s o g a s t r i c 46 the  a d u l t stomach.  and  5 normal a d u l t v o l u n t e e r s .  position various  H i s study  they  the best  tube i n t h e fundus o f  was c o n d u c t e d u s i n g With the subjects  e x t e r n a l measurements u s e d  99 c a d a v e r s  i n the supine  in clinical  practice  were made a n d compared, t o measurements t h a t w o u l d be r e q u i r e d t o secure adult.  proper  p l a c e m e n t i n the. c a d a v e r and i n t h e n o r m a l  living  He f o u n d t h a t t h e b e s t measurement i n u s e i n c l i n i c a l  p r a c t i c e was t h a t made f r o m t h e t i p o f t h e n o s e t o t h e t i p o f t h e 44 A. T u c k e r a n d J e n n i f e r L e w i s , " 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 ( O c t o b e r 25, 1980):1129. 45 Mary Z i e m e r and J a n e Schupay C a r r o l l , " I n f a n t Gavage R e c o n s i d e r e d , " A m e r i c a n J o u r n a l o f N u r s i n g 78 (September, 1978) : 1543-1544. 46 R o b e r t L . Hanson, "New A p p r o a c h t o M e a s u r i n g A d u l t N a s o g a s t r i c T u b e s f o r I n s e r t i o n , " A m e r i c a n J o u r n a l o f N u r s i n g 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  ensure He  proper  went on  placement  to develop  i n o n l y 72%  placement  necessary  for accurate  T h o s e who  tube  and  altered  2  arise  i s drug  tube,  induced  the f a c t and  tube which a l t e r s  either  nasogastric nasogastric  suggest  cut or uncut, tube tube  length of  tube  approach  into  are the that  anaesthetists.  the a l t e r a t i o n  r e q u i r e s the presence  of  in an  t h e n o r m a l anatomy o f t h e r e g i o n  i n order to accomplish authors  i n 91%  (Nose, ear and  most p r a c t i c a l l y  l e v e l of consciousness  consciousness  S e v e r a l of the  measurement  i n regard to introduction of a nasogastric  i s compounded by  concerned  sample.  placement.  T h e i r problem  endotracheal  o f t h e NEX  + 5 0 = the  most f r e q u e n t l y and  the problems t h a t  clinical  of the n a s o g a s t r i c tube  T h i s f o r m u l a makes u s e NEXcm-50cm  xiphoid), and i s expressed as:  t h i s measurement w o u l d  of the s u b j e c t s i n h i s  a formula using t h i s  t h a t would secure proper o f h i s sample.  that  ventilation  inserting  of the  a second  t h e e s o p h a g u s and  patient.  endotracheal directing  the  through t h i s tube. Once p l a c e m e n t o f t h e i n t h e stomach i s a s s u r e d 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  rectal  "'See A.R. H u n t e r , "The 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 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 ( 1 9 7 3 ) : 7 0 8 ; D a v i d H. S p r a g u e and S t e v e n 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 ( 1 9 8 0 ) : 4 3 6 ; A s h i q H. T a h i r and J o h n A d r i a n i , . "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 ( M a r c h - A p r i l , 1 9 7 1 ) : 1 7 9 ; D a v i d 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 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, 1 9 7 1 ) : 1 0 1 0 ; R.H. M i r a k h u r , " 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 Tube 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 ( 1 9 7 4 ) : 1 0 6 2 ; R o b e r t W. V i r t u e , " 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 Tube 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 ( 1 9 7 3 ) : 2 3 4 ; D a v i d A. C h a d w i c k , "The 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 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 ( 1 9 7 3 ) : 3 4 1 .  tube He  rather  thinks that  greater for  t h a n an e n d o t r a c h e a l t u b e be u s e d the f i r m but  l e n g t h , and  blind  methods t h u s  far described require  significantly  the n a s o g a s t r i c tube  itself.  or o r a l l y  difficult and  The  i n t r a u m a t o t h e n o s e and  nasally  Cox  a r e more  suitable  larger  the i n s e r t i o n  of  than the diameter  of  use o f t h e s e l a r g e the use  of large  i n a conscious or semiconscious  and p a i n f u l  tube, i t s  intubation.  tubes with diameters  result  procedure.  f l e x i b l e w a l l of the r e c t a l  i t s smooth t e r m i n a l o u t l e t  nasoesophageal  The  for this  even w i t h t o p i c a l  tubes  tubes  either  patient i s  anaesthesia.  Robinson  d e s c r i b e a method f o r t h e i n s e r t i o n o f p e d i a t r i c  tubes which does not r e q u i r e  the use o f a tube o f  can  feeding  larger  49 diameter. straight  They s u g g e s t stainless  steel  threading, the f e e d i n g tube w i t h guide wire.  When t h e t u b e  i s i n the  the tube  i n place.  stomach t h e g u i d e w i r e  i s removed and  T h i s 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 M a t s u k e and  D u r i n g a n a e s t h e s i a they use thread  a well  a  lubricated  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  left  guitar and  Zsigmond.  string  they r e p o r t  to good  R.B. Kamal, "Use o f 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 o r 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 ( J a n u a r y - F e b r u a r y , 1974):156. 48 A n n i s B a r a k a , " S i m p 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 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 (MarchA p r i l , 1975):304. 49 E a r l P. R o b i n s o n and P a u l M. Cox, " F e e d i n g 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 C a r e M e d i c i n e 7 (1979):349  r e s u l t s w i t h t h i s method i n b o t h a d u l t s O t h e r methods r e p o r t e d to a i d i n the i n s e r t i o n unconscious p a t i e n t  f o r example,  children.  i n the a n a e s t h e t i c  of n a s o g a s t r i c placement  do n o t r e l y  as t h e most i n f l u e n t i a l Chin,  and  factor  50  literature i n the  on t h e d e g r e e o f t u b e i n tube placement.  rigidity  Liew  s u g g e s t s t h a t p a c k i n g t h e mouth w i t h  Pak gauze  a r o u n d an u n c u f f e d e n d o t r a c h e a l t u b e i n t h e i n f a n t w i l l p r o v i d e 51 a  "tunnel"  through which  a nasogastric  tube w i l l 52  S m i t h recommends an e v e n more n o v e l a p p r o a c h . holding  the d i s t a l  end o f t h e n a s o g a s t r i c  and b l o w i n g r e p e a t e d l y on i t u n t i l action,  he s a y s , d i s t e n d s  provides  f o r immediate  easily He  pass.  recommends  t u b e i n t h e mouth  i t r e a c h e s the stomach.  t h e esophagus  ahead  o f the tube  This and  recognition of obstruction or kinking  of 53  the tube. He  passes a tap-water cooled, w e l l  into  the p o s t e r i o r  thyroid it  A n o t h e r i n t e r e s t i n g manoeuvre i s d e s c r i b e d  pharynx  and  lubricated  then g r i p s  c a r t i l a g e between t h e thumb and  anteriorly.  c o l l a p s e50 d due  T h i s opens t h e esophagus to gravity  and  by Mundy.  nasogastric  tube  the alae of the  index f i n g e r s which  and  lifts  i s usually  the n a s o g a s t r i c tube then passes through  A k i t o m a M a t s u k i and E l e m e r K. Zsigmond, " 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 Tube 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 44 (1972):234. ^ L i e w Pak C h i n , "A Method o f P a s s i n g N a s o g a s t r i c Tube D u r i n g A n a e s t h e s i a i n t h e Newborn," A n a e s t h e s i a 27 ( O c t o b e r 1972) 458. 52 R o b e r t S m i t h , " 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. 53 D o n a l d A. Mundy, " A n o t h e r T e c h n i q u e f o r 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 , " A n a e s t h e s i o l o g y 50 (1979):374.  the  esophagus i n t o  carefully thyroid  during  the  stomach.  a c t i v a t e the  c h a n g e s i n h e a r t r a t e and  blood  carotid  manipulation  e q u i p m e n t and  i t s use  are  readily  available.  nurses  and  doctors  i n t h e h o s p i t a l wards  tube b e f o r e  recommended i n t h e unconscious  nasogastric  The  insertion.  literature,  o r obtunded. and  areas  personnel most common  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  nasogastric  causing  a r e most o f t e n u s e d i n h i g h l y s p e c i a l i z e d  method u s e d by  the  pressure.  o f t h e h o s p i t a l where t h e n e c e s s a r y f a m i l i a r with  of  sinus r e f l e x  e x t r a o r d i n a r y methods u s e d t o f a c i l i t a t e  tube i n s e r t i o n  facilitate  must m o n i t o r t h e p a t i e n t  t h i s p r o c e d u r e as v i g o r o u s  c a r t i l a g e may  The  One  to  the  This action i s widely  particularly  unable.to  when p a t i e n t s  cooperate  during  are  the  54 procedure. While an u n e v e n t f u l  i t i s usually true that nasogastric intubation i s procedure,  certain  complications  include e r o s i o n of nasal c a r t i l a g e , stricture, with  sinusitis,  i n a d v e r t a n t c a n u l a t i o n of the  or without  t o remove t h e  tube,  and  of the  reflux  occur.  tree  media, r u p t u r e  esophagus o r 55  esophagxtis.  These  esophageal  tracheobronchial  laryngeal obstruction, o t i t i s  esophageal v a r i c e s , rupture  can  stomach, . .  of  inability  In a d d i t i o n ,  54 See Thomas, p.33; B e c k , p.5; N e t h e r c o t t , p.26; V o l d e n e t a l , p.15; P e r s o n s , p.37; M c C o n n e l l , p.34; and T u c k e r and L e w i s , p.1130. 55 See J . S . C h a f f e e , " 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 , " A n n a l s o f S u r g e r y 130 (1949);113-123; J.M. Farris and G.K. S m i t h , "An E v a l u a t i o n o f Temporary G a s t r o s t o m y — 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 , " A n n a l s o f S u r g e r y 144 (1956): 475-486; G.N. G r a n t , 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 D e c o m p r e s s i o n by T e m p o r a r y G a s t r o s t o m y o r N a s o g a s t r i c Tube: An O b j e c t i v e C o m p a r i s o n , " A r c h i v e s o f S u r g e r y 85 ( 1 9 6 2 ) : 844-851.  26 there  have  been  nasogastric  reports  tube  both  of  intracranial  i n the  presence  penetration  and  absence  by  of  a  existing  56 cranial  trauma.  passage  of  the  For  this  nasogastric  reason tube  c e r t a i n authors  under  direct  advise  vision  no  matter  57 what m a n i p u l a t i o n s abdomen  for  tube  are  used.  position at  Others least  recommend  i n the  case  X-ray  of  of  the  the  58 critically  i l l  This attempted  has  used  problems use of  demonstrate by  advances  resulted in  been  of  for  thesis  review  of  that  use  new  of  address  i n tubes  I t has  i n tube  materials to  the  i n technology  centuries.  best  patient.  oriented  improvements  encountered  the  this  unconscious  historically  to  accompanied  or  been  technology the  and  catheters  may  of  has  materials  individual  can  question  literature  and  shown  insertion  the  as  well  exist  offer. whether  imagination that that  despite It or  have  the  i s the not  purpose  the  a n d R.C. H a n s e l m a n , R.C. Meyer, "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 , " S u r g e r y , G y n e c o l o g y a n d O b s t e t r i c s 114 (1962):  207-222. ^ S e e R o n a l d F . Y o u n g , "CSF R h i n o r r h e a Following Nasogastric I n t u b a t i o n , " T h e J o u r n a l o f T r a u m a 19 (October, 1979):789-790; J o h n D. F r e m s t a d a n d 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 from 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 Severe B a s i l a r S k u l l F r a c t u r e , " T h e J o u r n a l o f T r a u m a 18 ( D e c e m b e r , 1978):820-822; J a y A . Gregory, P a u l T. T u r n e r , a n d 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 of 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 T r a u m a 18 ( D e c e m b e r , 197.8) : 823-824; a n d 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," Neurosurgery 8 (February, 1981):245-247. 5  57 S e e A.K. S a h a , "The 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 t h e Anaesthetised Patient," Anaesthesia 29 ( 1 9 7 4 ) : 3 6 7 ; a n d C. V a n 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 Anaesthesia 51 (1979):73. the  P a u l D. L a r s e n , "Knotted Nasogastric Tubing," Journal 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.  of  degree of  o f n a s o g a s t r i c tube  flexibility  c o n s c i o u s n e s s have b e a r i n g on  nasogastric  tube.  The  and  the p a t i e n t ' s  the ease  of i n s e r t i o n  next chapters w i l l  d e s c r i b e the  level  of  m e t h o d o l o g y employed t o answer t h i s q u e s t i o n , t h e f i n d i n g s resulted and  from  implemention  implications  that  o f t h e s t u d y , and  a r o s e as a r e s u l t  the  of those  the  that  recommendations findings.  28  CHAPTER  THREE  METHODOLOGY  An as  experimental approach  review o f the l i t e r a t u r e  affect  t h e ease  have  been  were  collected  study  w i t h which  fairly  well  a nasogastric  tube  c a n be  from  the experiment  The d a t a  bath. of  o r one which  stiffness  scope  of this  determine  measurements  study.  the effect  i n the unit  a  difference  with  t o determine  between  t h e optimum  tube  i c eb a t h  were  a t room  i n a t e n minute i c e  an experiment  and measurements  i n which the  a tube  immersed  o f a t e n minute  tube  i n the  design.  of a nasogastric  However,  nasogastric threefold  tube  had been  f o rinsertion  inserted  Experiment  o u t was p e r f o r m e d  Sophisticated  involved  a 2 X 3 factorial  of the nasogastric  temperature  which  factors  and r e c o r d e d by t h e n u r s e s  was c a r r i e d  study-  that  Preliminary  study  f o rthis  demonstrated  defined.  and a n a l y s e d u s i n g  Use  was s e l e c t e d  were  beyond t h e  was p e r f o r m e d t o immersion  taken which  the force  degree  required  on t h e  demonstrated t o bend  a  59 flexible  and a r i g i d  tube.  Research This  59  investigation  . The  experiment  .  used  Design a 2 X  .  i s described  3 factorial  design  . i n Appendix  One.  involving  29 a  fixed-model  considered  level  variables,  of patient  respectively. tube the  of  One  flexibility, other,  upon  level  the physical  level little  as review  study  was  manipulated  of patient  of unit  t o week  which  with  consciousness,  variable  statistics  on a d m i s s i o n  of 2 X  flexibility  was  Assignment  considered  regarding  Design  A  Factor  B  t o be  patients'  t o the unit  3 Factorial  while  dependent  patient.  was  levels  of nasogastric  by t h e e x p e r i m e n t e r  a-1  Factor  had two  variation.  Schema  was  two a n d t h r e e  degree  s t a t u s o f any g i v e n latter  a design  o f n a s o g a s t r i c tube  consciousness,  of consciousness week  degree  Such  of the variables,  subjects to this  random  of variance.  appropriate f o r this  independent and  analysis  showed  very  30 Population The those  population  bed  endotracheal The requiring  tertiary and  t o an  care  tube i n t u b a t i o n admitted over a p e r i o d of the  study  sample was  Respiratory  h o s p i t a l who  c o n s i s t e d of  p l a c e m e n t and  to the  Intensive  s i x t e e n weeks.  Criteria  121  the  admitting  r e s i d e n t and  tracheostomy or nasotracheal endotracheal  t u b e as  Unit  require  both  patients nasogastric  Respiratory  Care  for exclusion  from  intubation  presence of  o p p o s e d t o an  Unit  as  a  oral  tube.  Data C o l l e c t i o n In o r d e r  to conduct the  approval  from both the N u r s i n g  hospital  and  C o l u m b i a was  Care  subsequent  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  d e t e r m i n e d by  drawn were  intubation.  study  endotracheal  study  Intensive  teaching  nasogastric  sample f o r t h e oral  Sample  from which the  p a t i e n t s admitted  o f a 9 40  and  Method  study  i n the  R e s e a r c h Committee a t  t h e E t h i c s Committee a t t h e s o u g h t and  Intensive  obtained.  Care  Unit  the  U n i v e r s i t y of  British  C o n s e n t forms were s i g n e d  by 60  the  u n i t nurses  indicating  The  u n i t nurses attended  conducted to e x p l a i n the the  technique  by  t h e i r w i l l i n g n e s s to  an  inservice training  research  which n a s o g a s t r i c  proposal  and  participate. session to  t u b e s w o u l d be  standardize inserted  during  61 the  study.  i n use  The  technique  i n the u n i t a t the 60, Two. 61 A p p e n d i x Appendix Three.  u s e d was  time of the  compatible study.  with  that  Systematic  already  randomization of the degree a s s u r e d by tubes was  assigning  rigid  t o e v e n weeks.  a s s e s s e d by  immediately  tubes level  the nurse  prior  data c o l l e c t i o n  The  o f n a s o g a s t r i c tube t o odd  s t u d y weeks and  inserting  the nurse  was  flexible  of c o n s c i o u s n e s s of each  patient  the n a s o g a s t r i c tube  t o the procedure.  sheet.by  flexibility  D a t a was inserting  collected  on  a  the n a s o g a s t r i c  62 tube  immediately  following  the  procedure.  Method o f S c o r i n g t h e Number o f Any resulting gastric  continuous  f o r w a r d movement o f t h e n a s o g a s t r i c t u b e  i n stomach placement,  c o n t e n t s was  Insertions  as e v i d e n c e d by  considered a successful  g i v e n a s c o r e o f one.  Any  "pull  b a c k " on  aspiration  insertion  the tube,  interruption  o f t h e f o r w a r d movement, d e t e r m i n e d  which second  and  attempt  subsequent  ( f o r w a r d movement) was  meant, f o r example, t h a t b a c k t h r e e t i m e s on motion  attempts  resulted  attempts  t h e r e f o r e , was  Ethics  sought  and  This to  pull  and  t h e number o f The  score  appropriate f o r data  analysis  Human R i g h t s  implementation  Four.  four.  forward  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  o b t a i n e d from both  Appendix  of the tube,  i n s e r t i o n w o u l d be  s c a l e , making p a r a m e t r i c s t a t i s t i c s  Preceeding  required  at  Each  g i v e n a s c o r e o f one.  i n proper p o s i t i o n i n g  was  the p o i n t  the n a s o g a s t r i c tube b e f o r e a steady  or score f o r t h i s  obtained,  and  that i s ,  were c o u n t e d .  s h o u l d a n u r s e be  of  of t h i s  study approval  the h o s p i t a l  and  was  university  ethics  committees. obtained Care  as  from  Unit  under  Permission f o r implementation  who  their  Patient  tube  i n place  protection  aspiration  tubes  willing ment  as each  and  i t was  t o do  one  and  of nurses nurse  was  n o t known  this.  patient  the insertion  then would  The tube  number  consciousness and  were  were  to  gastric  being  rigid  randomly  from  and  flexible be  i f i n :their  judge-  indicated  as they  the  was  initially  clinically  should proceed  excluded  conducted  i n the study  to use both  was  an  patient.  advised that  o f tube  thought  in a proper  study.  Analysis  required  i n three groups were  standards deviations  all  was  also  the interaction  consciousness  and  for successful  of patients  r e c o r d e d and d i s p l a y e d  and d i s p l a y e d  of  i n the  tubes  unnecessary  had  of possible  i f a l l nurses would  of attempts  calculated groups  i n the face  Intensive  patients  who  procedure  also  Statistics  placement  means  of the  c o n s i d e r e d t o be  a routine  required  Data Descriptive  Nurse  i n the patient  and r i g i d  they be  Head  to participate  Nurses type  was  tube  was  flexible  of the other  particular  consent  for insertion  Permission  and  f o r the welfare of the  of the airway  and b o t h  i n the u n i t  obtained  responsible  of a nasogastric  endotracheal  used  were  care.  insertion  ensure  the Medical Director  o f t h e s t u d y was  that  existed  the degree  varying  form.  i n order  levels  i n g r a p h i c form.  of the s i x groups  i n table  constructed  with  nasogastric  A  graph  between t h e t h r e e  of nasogastric  tube  The  of subjects  were  o f t h e means  to demonstrate levels  of  from  the nature of  patient  flexibility.  Inferential An  Statistics  analysis of variance  difference  i n ease o f i n s e r t i o n  the  different  for  significant  decided  that  of  normality,  d i f f e r e n c e s between t h e g r o u p s .  Hypothesis testing  as t h e t h e o r e t i c a l  among  I t was a t t h e .05  based on t h e F  model i n v o l v e d  the assumptions  randomness, h o m o s c e d a s t i c i t y , i n d e p e n d e n c e , A summary t a b l e was u s e d t o r e p o r t  Finally,  a pooled variance estimate t - t e s t  p e r f o r m e d on t h e d a t a f r o m t h e two g r o u p s patients  tube  An F t e s t was u s e d t o t e s t  t h e n u l l h y p o t h e s i s w o u l d be r e j e c t e d  and a d d i t i v i t y . results.  of the nasogastric  groups o f p a t i e n t s .  level of significance. distribution  (ANOVA) was u s e d t o a n a l y s e t h e  and t h e r e s u l t s  reported  i n table  t h e ANOVA was  of unconscious form.  34  CHAPTER FOUR THE FINDINGS The d a t a were a n a l y s e d u s i n g t h e A n a l y s i s o f V a r i a n c e (ANOVA) p r o c e d u r e f o u n d i n t h e S t a t i s t i c a l Social Sciences, Version Columbia test 1.  Computing  three  The p u r p o s e o f t h e a n a l y s i s was t o  significant  difference  t u b e i n a n i n t u b a t e d p a t i e n t when a  t u b e i s compared w i t h a r i g i d  level  of s t a t i s t i c a l  There w i l l the  Centre.  t h e mean number o f a t t e m p t s r e q u i r e d t o i n s e r t a  flexible  2.  8.00 a t t h e U n i v e r s i t y o f B r i t i s h  be no s t a t i s t i c a l l y  nasogastric  .05  f o r the  hypotheses:  There w i l l in  Package  tube  a t t h e a'=  significance.  be no s t a t i s t i c a l l y  significant difference i n  mean number o f a t t e m p t s r e q u i r e d  to insert a  n a s o g a s t r i c t u b e i n t h e i n t u b a t e d p a t i e n t when  three  l e v e l s o f c o n s c i o u s n e s s a r e compared a t t h e a=.05 l e v e l o f statistical 3.  There w i l l  significance. be no s t a t i s t i c a l l y  significant  between t h e d e g r e e o f n a s o g a s t r i c patient  interaction  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 when t h e s e  different  t r e a t m e n t s a r e compared a t t h e a=.05 l e v e l o f statistical  significance.  35 Descriptive The Forty-two tube  total  patients  insertion,  unconscious. tubes  and  required groups  patients  mean number  six  different  was  not  and  the  of  of  the  of  trauma.  last  had  One  to  are  In  analysing  the  assigned  to  main  the  ease  of  insertion  and  the  patient  letter  B  effect  to  of  main  consciousness  one  and  his  One tube  (the  in  this  effect  nasogastric two  interaction  consciousness  and  the  flexibility)  was  designated  AB.  of  (the  The  patient  flexible  attempts  in  different  Table  deviations i n Table  four  for  the  2.  A 1.  patients  study.  of  1.  in Figure  One  nasogastric  patient  intubation  hemorrhaging for  nasogastric  as  a  multi-system tube  required  had  tracheostomy  place.  of  the  tube in  effect  level  of  was on  patients),  level  of  nasogastric  tubes  (that between  level  nasogastric of  A  flexibility  effect-..of  of  letter  intubated  insertion  degree The  study  tubes  patients).  of  form  patient  ease  intubated  three  the  were  Data  from  effect  in  admitted  the  in  on  data  using  of  possibility  Inferential  nasogastric  number  the  and  121.  thirty-seven  period  p a t i e n t was  nasotracheal  of  reported  from  hundred  surgery.  was  i s represented  study  the  and  standard  excluded  of  time  graphic  means  four  study  intubated,  tubes  in  esophagectomy  a  the  The  the  week  because  inserted prior the  the  u n i t were  following  rigid  patients of  the  obtunded,  attempts and  count  at  tubes.  and  sixteen  performed  failure been  to  in  patients-were  rigid  representation  platelet  result  of  the  were  is displayed  groups  During  a  using  patients  conscious  flexible  The  had  were  Sixty-one  using  admitted  of  forty-two  sixty  of  graphic  number  Data  tube  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 T u b e I n s e r t i o n i n P a t i e n t s with Three D i f f e r e n t Levels of 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 Tubes.  1  2  3  4  5  6  7  8  9  10  number o f attempts  1 2 3 4 5 6 7 8 9 1 0  number o f attempts  1 2 3 4 5 6 7 8 9 1 0  number o f attempts  R i g i d Tubas  1 2 3 4 5 6 7 8 9 1 0  number o f attempts  1 2 3 4 5 6 7 8 9 1 0  number o f attempts  1 2 3 4 5 6 7 8 9 1 0  number o f 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 A t t e m p t s  •  Tube Type State  of Patient  Flexible  Rigid  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  Figure  r  1  r  61  Graphic representation of i n s e r t i o n s required nasogastric intubation three d i f f e r e n t l e v e l s  121  60  o f t h e mean number f o r successful i n patients with of consciousness.  flexible rigid  cOAKi«u'%  ebtundfei  uniotJScuju.4  Level o f consciousness  tube  tube  38 statistical set  at  Table  significance  .05.  The  summary  table  for this  f o r the analysis  on the e x p e r i m e n t a l  for  F a c t o r B was  and  the i n t e r a c t i o n An  employed  accepted AB  additional  varied.  number  The  significant  were  hypothesis  i n this  Analysis  i s found  i n  case  level  was  from  rejected  the  groups  of conscious  due  t o chance  and obtunded  the variation  the significant  flexibility  o f the n a s o g a s t r i c tube  degree  this  tube  rigid  tube  i n the unconscious  o f attempts  Post In  Hoc  inserted  required  Analyses  report  their  of  n a s o g a s t r i c tube  the variation patients  t o which  i n these  i n obtaining  most  successful  tests  likely  patients of  the ease  patients.  with  Use  of a  reduced  the  insertion.  Observations the nurses  the procedure performed  of anxiety regarding a particular  confidence  null  present i n  significantly  f o r the study  they  was  3)  the degree  for successful  insertions  was  influenced  patients  experiences with  and t h e  (Table  was  obviously  of a l l s t a t i s t i c a l  and A d d i t i o n a l  recording the data  to  A  patients  calculation  i n the unconscious  represented  which  this  as w e l l .  i n light  of  subgroups  of significance  l e d to the conclusion that  c o u l d be  for Factor  group  i n t h e two  resulted  of the data,  while  hypothesis  variance estimate,  the unconscious  of insertions  t h e .01  the n u l l  hypotheses  a pooled  performed,  level  was  rejected.  statistic,  t value which beyond  findings  and t h e n u l l  t o examine f u r t h e r  t h e mean  number  experiment,  2. Based  as  or alpha,  i n terms  of  p e r month,  insertion,  placement  were  asked number  their  their  o f the tube,  the  Table 3  ANOVA o f t h e E f f e c t o f t h e 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 and D e g r e e 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 t h e E a s e o f Insertion.  Source  SS  df  MS  F  Ratio  Probability  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  Error  358.389  115  3.116  Total  478.095  120 .—  Table  4  t - T E S T C o m p a r i n g Mean I n s e r t i o n A t t e m p t s on Two Unconscious P a t i e n t s .  Group  Number . o f .'cases  1  20  4.800  2  17  1.588  Group 1 - f l e x i b l e Group 2 - r i g i d  Mean  nasogastric  nasogastric  Value  df  Probability  4.53  35  0.000  tube.  tube.  40 method t h e y were t a u g h t t o i n s e r t  n a s o g a s t r i c t u b e s , and w h e t h e r  o r n o t t h e y had a p e r s o n a l p r e f e r e n c e f o r t h e type o f tube They were a l s o  asked  t o record the presence  of side  used.  effects  i n d u c e d by t h e i n s e r t i o n o f t h e n a s o g a s t r i c t u b e . All prior  n u r s e s had a t l e a s t  t o employment i n t h e u n i t  the u n i t  ranged  reported  inserting  and  two y e a r s o f work e x p e r i e n c e  from  and l e n g t h o f t i m e w o r k i n g i n  t h r e e weeks t o e l e v e n y e a r s .  fewer  nurse  t h a n two n a s o g a s t r i c t u b e s p e r month  one n u r s e r e p o r t e d i n s e r t i n g  number o f m o n t h l y i n s e r t i o n s was all  No  an a v e r a g e 4.23.  of s i x .  The mean  I t was c o n c l u d e d  that  n u r s e s were e x p e r i e n c e d w i t h t h e p r o c e d u r e . Although  during  two n u r s e s  some i n s e r t i o n s  these cases  reported a high level  t h e number o f a t t e m p t s  f o r successful  reporting  from  t h e mean number o f  i n s e r t i o n s performed  low o r m o d e r a t e l e v e l s  The  necessary i n  t o s e c u r e 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  n o t seem t o v a r y s i g n i f i c a n t l y required  of anxiety  attempts  by n u r s e s  of anxiety.  mean number o f a t t e m p t s  required  for successful  nasogastric  i n t u b a t i o n , by n u r s e s who had b e e n t a u g h t t o i n s e r t  their  using either  tubes  rigid  or f l e x i b l e  s i m i l a r . ( a mean o f 3.2 f o r t h e f o r m e r I t was n o t p o s s i b l e a flexible  or r i g i d  i n t u b a t i o n because  t u b e s was  very  and 3.4 f o r t h e l a t t e r ) .  t o determine  whether p r e f e r e n c e f o r  t u b e h a d any b e a r i n g o n s u c c e s s f u l n a s o g a s t r i c o f t h e l a r g e number o f n u r s e s who  reported that  it  w o u l d depend upon t h e c i r c u m s t a n c e s b u t t h e n d i d n o t e l a b o r a t e  on  those  circumstances.  T h e r e were no s i g n i f i c a n t t h a t c o u l d be a t t r i b u t e d  side effects  t o the degree  noted  i n this  o f n a s o g a s t r i c tube  study  41 flexibility  except f o r s u b j e c t i v e c o m p l a i n t s o f 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 .  T h e r e were a g r e a t e r number o f  c o m p l a i n t s o f d i s c o m f o r t f r o m t h o s e who were i n t u b a t e d rigid of  tubes.  complaints stressed  the uncomfortable  P a t i e n t s who h a d s u b d u r a l s c r e w s  nasogastric  pressure tube  intubation experienced a r i s e  (ICP) d u r i n g  i n place  a t the time  i n intracranial  the procedure r e g a r d l e s s o f the type o f  used. The  number  18.  size  of nasogastric  Two p a t i e n t s ,  tube used  i n 119 i n s e r t i o n s was a  one a s i x t e e n y e a r - o l d b o y a n d t h e  o t h e r a 72 y e a r o l d 40kg woman were i n t u b a t e d Sumps.  I t would appear  for  nasogastric  the  fact  that  insertion  the largest  i n this  unit  t h a t t h e tubes a r e i n i t i a l l y  c a n o n l y be s u c c e s s f u l l y The in  feeling  c o l d n e s s o f t h e t u b e , and were e x p r e s s e d i n t h e f o r m o f  expletives. of  These  using  mean s i z e  tube p o s s i b l e  and t h i s used  i s used  probably  f o r drainage  reflects which  a c c o m p l i s h e d t h r o u g h a wide bore  of oral  t h e s t u d y was a number  w i t h #14 S a l e m  endotrachial  tube used  7 f o r women and a number  tubing.  for patients 8 f o r men.  42  CHAPTER  SUMMARY,  FIVE  RECOMMENDATIONS,  IMPLICATIONS AND CONCLUSIONS  Summary The the  purpose o f t h i s  degree o f f l e x i b i l i t y  level  s t u d y was t o examine t h e e f f e c t s of the nasogastric  o f c o n s c i o u s n e s s would  tube i n p a t i e n t s  insert  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 .  stomach  practice.  for successful constituted  number o f t u b e subsequent  "pull  o f a more  scientific  be made a b o u t how b e s t t o  patients.  i n t h e s t u d y were t h o s e commonly Thus,  thedefinition  t h e number o f a t t e m p t s tube placement  i n the  o f e a s e o f i n s e r t i o n and t h e  back m a n o e u v r e s " , t h e p o i n t  i n s e r t i o n s must be c o u n t e d .  upon w h e t h e r  The u l t i m a t e  t h e s t u d y f i n d i n g s w o u l d be  nasogastric  degree o f tube f l e x i b i l i t y depending  could  tube i n i n t u b a t e d  procedures used  use i n c l i n i c a l  required  decisions  order t o ensure t h a t  generalizable, in  clinical  a nasogastric In  t u b e and t h e p a t i e n t ' s  have on t h e ease o f i n s e r t i o n o f t h e  aim o f t h e i n v e s t i g a t i o n was t h e p r o v i s i o n b a s e upon w h i c h  that  a t which  I n t h e same manner t h e  was d e s i g n a t e d r i g i d  or flexible  o r n o t t h e t u b e was a t room t e m p e r a t u r e o r  submerged i n a n i c e b a t h .  I n p r a c t i c e t h e s e t u b e s were  referred  t o a s "warm" a n d " c o l d " . The consisted  sample  f r o m whom t h e s t u d y d a t a was c o l l e c t e d  o f 121 p a t i e n t s  a d m i t t e d t o an e l e v e n bed r e s p i r a t o r y  43 medical-surgical hospital  who  placement required over a  required  for successful month  period  3 factorial  i n a large  intubation T h e number  and  design.  flexibility  levels  o f f l e x i b i l i t y were  the data  The  two  and  level  data  significantly could tube  be  required  stiffness  and l e v e l  significant.  value  estimate o f 4.53  therefore obtunded  the that  groups  type  t-test  performed  that  resulted  alone  i n t h e two was  c o u l d be  fewer  used  groups  the  found  The  insertion  of  tube  statistically  unconscious pooled  groups  .001.  yielded  i n the conscious  likely  from  chance  for intubation.  i t was  a  I t was  of unconscious  so g r e a t t h a t  of  t o be  of  and a  two  rigid  tube.  not found  i n the  than  more  levels  number  on ease  on t h e s e  the v a r i a t i o n  o f n a s o g a s t r i c tube  used  (p=.001);  dramatic  less  two  a n a s o g a s t r i c tube  h o w e v e r , was  i n t h e means  particularly  of patients  o f tube  chance  of consciousness,  The  stiffness  the f l e x i b l e  effect  were  unconscious.  between t h e degree  and a p r o b a b i l i t y  produced  which  than  seemed  concluded  the type  variation  interaction  The d i f f e r e n c e  of patients  variance  from  The  Three  o f tube  significantly  i n their  variables  and  o f c o n s c i o u s n e s s were  significant  study.  with  placement  recorded  by computer u s i n g  and r i g i d .  intubated patient  a statistically  i n levels  statistically  group  i n an  attempts  of consciousness.  the degree  the ease  for successful  differences  this  that  affected  inserted  attempts  in  showed  subsequent  was  analysed  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 The  of  independent  flexible  teaching  and  n a s o g a s t r i c placement  of tube  t  unit  endotracheal  degree  of  care  o f a n a s o g a s t r i c tube.  a four  2 X  intensive  than  The  patients  highly  and  by  unlikely  responsible f o r the v a r i a t i o n  noted.  44 The  experimental  nasogastric  i n t u b a t i o n of  endotracheal  Carter,  Tahir, and  voluntary,  Zsigmond.  the  various  stages that are  could  i s obtunded.  nasogastric the  of t h i s can  be  expected  action, at  this  study the  authors  that  supported.  This  level  swallowing  are  during  these  this  s u c h as of  s t u d y and use  to  the  of  tube can  rigid  tube.  i n d i c a t i o n of  unable t o swallow, f o r i n s t a n c e ,  An  intubation to  Hoppe,  the  be  and  influences  influence  that  ease of i n s e r t i o n patient  easier to intubate  t u b e t h a n a c o n s c i o u s p a t i e n t who  the  not  unconscious intubated  may  swallow,  and  i n s e r t e d was  c h a r a c t e r i s t i c s h a v e upon t h e  nasogastric  indicate  practice  in itself be  large  tube.  in clinical  consciousness  patient  the  inability  Thomas, G r i g g s and  an  however,  i n the  nasogastric  a rigid  held  tube  act of d e g l u t i t i o n while  i n the  using  belief  i s probably  patient  given  nasogastric  the  l e a s t , i s present  i n part  ease w i t h which a n a s o g a s t r i c  individual  neither  conscious patient,  recommending t h e  due  somewhat overcome by  e x p r e s s e d by  any  The  encountered  and  Cox,  t u b e s i n u n c o n s c i o u s p a t i e n t s w o u l d seem t o  group o f p a t i e n t s  Nethercott  in  to a i d i n nasogastric  r e s u l t s of  reports  difficulties  In  of  unconscious p a t i e n t  absent.  Both the  anecdotal  in  an  Hunter, Sprague  movements i n i t i a t e d  be  therefore,  tube  supports  esophageal stages of  peristaltic  secondary p e r i s t a l t i c  that  In the  to a c t i v e l y p a r t i c i p a t e i n the  number o f  a rigid  unconscious p a t i e n t with  tube i s i n t r o d u c e d  p h a r y n g e a l , nor  insertion,  of  Cohen, A d r i a n i , B a r a k a , R o b i n s o n and  and  who  use  d o e s p o s i t i v e l y i n f l u e n c e t h e .ease  nasogastric  present  able  the  t h o s e manouvres recommended by  Matsuki,  is  the  tube i n p l a c e  with which the principle  finding that  i s able  to  with  swallow  a  45  b u t whose a n x i e t y d u r i n g  the procedure  adversely a f f e c t s the  e x t e n t o f h i s c o o p e r a t i o n , d e s p i t e a d e q u a t e e x p l a n a t i o n and support  by t h e n u r s e .  Recommendations and I m p l i c a t i o n s Implications study  are limited  controlled  forclinical  by t h e f a c t  clinical  trials  p r o b l e m and t h a t d a t a indicate  p r a c t i c e which arose  t h a t t h e r e have b e e n no o t h e r  concerned  with  this  particular  a t e x a c t l y which degree o f f l e x i b i l i t y directed  and s t i l l  for  s a f e t y and c o m f o r t .  the  f o l l o w i n g r e c o m m e n d a t i o n s a r e made:  Notwithstanding  Where t h e c l i n i c i a n  technique  a nasogastric  fulfill  these  criteria  cautions,  i s knowledgeable about t h e  o f n a s o g a s t r i c i n t u b a t i o n and i s e x p e r i e n c e d  application,  this  has n o t y e t been p u b l i s h e d t h a t would  t u b e c a n be most e a s i l y  1.  from  the use o f a r i g i d  i ni t s  n a s o g a s t r i c tube reduces t h e  number o f a t t e m p t s n e c e s s a r y  f o r s u c c e s s f u l tube placement i n  the unconscious  an e n d o t r a c h e a l  used  Although  using  t h e r e was no s i g n i f i c a n t  a flexible  patient  or r i g i d  tube i n t h e c o n s c i o u s  tube i n conscious  a flexible  o r obtunded  of discomfort  p a t i e n t s and i t i s a d v i s e d  group o f p a t i e n t s t h e i n i t i a l  insertion  using  that i n  a t t e m p t be made w i t h  tube.  Implications result  d i f f e r e n c e between  t h e r e were more s u b j e c t i v e c o m p l a i n t s  the r i g i d  1.  t u b e and s h o u l d be  i n this patient.  2.  this  p a t i e n t with  of this  f o r f u r t h e r r e s e a r c h w h i c h c a n be made a s a  study a r e :  The s t u d y  should  be r e p l i c a t e d  t o ensure confidence i n  46 the f i n d i n g s . 2.  Patients with  were n o t  included  tracheostomies  in this  the  effect  the  ease of n a s o g a s t r i c  including 3. study  study.  these  tube f l e x i b i l i t y  except  techniques  were n o t  f o r the  intubation with A l l 22  subjective  a p p l i c a t i o n of these very  o c c u r r i n g as  a result  and  had  complaints:6f  of  in knowledge  tubes. screws i n p l a c e  interesting  a rise  in  to repeat  levels  of  at  the  intracranial  of the  i f t h e d e g r e e and  varying  or  nasogastric  the degree of n a s o g a s t r i c  i n patients with  visual  techniques  the procedure r e g a r d l e s s  I t w o u l d be  Direct  increase.our  i n t u b a t i o n experienced  i s a f f e c t e d by  flexibility  rigid  subdural  g r o u p o f p a t i e n t s t o see  rise  well  this  nasogastric  nasopharyngeal  during  tube f l e x i b i l i t y .  degree of  to assess  flexible  on  by  in  employed  p a t i e n t s who  (TCP)  noted  group.  both  time of n a s o g a s t r i c  side effects  conscious  s u b s e q u e n t i n v e s t i g a t i o n s may about s i d e e f f e c t s  gained  i n the  e s o p h a g e a l damage and  ICP  about  study.  a t t r i b u t e d to the  from those  this  tubes  information  t u b e i n s e r t i o n m i g h t be  significant  discomfort  in  Further  p a t i e n t s i n the  t h a t c o u l d be  pressure  nasotracheal  a l t e r e d t r a c h e a l a n d / o r o e s o p h a g e a l anatomy has  T h e r e w e r e no  4.  and  degree the  of  study  duration  of  tube  consciousness.  Conclusions In order and  to t r e a t  man  has  t o s e e k more i n f o r m a t i o n  concerning  h i s own  body  o r d i a g n o s e t h e m a l a d i e s t h a t sometimes a f f l i c t i t ,  f o r c e n t u r i e s i n s e r t e d t u b e s and  numerous o r i f i c e s .  The  tubes used  catheters  in this  into  the  e x p l o r a t i o n have  body's  increased  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  k n o w l e d g e and t e c h n o l o g y .  Initial  manner i n w h i c h t h e s e t u b e s  attempts  made t o e a s e t h e  h a v e b e e n i n t r o d u c e d were f o c u s s e d  upon m a n i p u l a t i o n o f t h e m a t e r i a l s u s e d  and e x p e r i m e n t a t i o n  new a n d d i f f e r e n t m a t e r i a l s a s t h e s e became I t has been t h e purpose  of this  with  available.  study t o apply  quantitative measurements t o two methods o f n a s o g a s t r i c t u b e insertion effect  each  inserted The  i n common c l i n i c a l h a s on t h e e a s e  w i t h which those  i n patients with varying levels  results  patient  nasogastric  tube  necessary  significantly  c a n be i n s e r t e d  t o secure placement  a flexible  tube, levels  introduced.  i n that  of consciousness  tube  fewer  i n the  w i t h which a  attempts a r e  type o f tube t o show  have any o v e r a l l  than  with  that effect  that  on t h e e a s e w i t h w h i c h a t u b e c a n  I m p l i c a t i o n s have b e e n drawn and r e c o m m e n d a t i o n s  i s hoped t h a t  results.  implementation  f o c u s on a q u e s t i o n o f c l i n i c a l  of this  interest  b e e n a b l e t o p r o v i d e a more s c i e n t i f i c clinical  c a n be  t h e ease  t h e r e h a s b e e n no e v i d e n c e  made on t h e b a s i s , o f t h e s e It  tubes  of consciousness.  affects  with this  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 be  t o determine the  h a v e shown t h a t w h i l e u s e o f a r i g i d  unconscious  different  u s e i n an e f f o r t  study w i t h i t s  and s i g n i f i c a n c e h a s  b a s e upon w h i c h t o make  d e c i s i o n s r e g a r d i n g n a s o g a s t r i c placement  p a t i e n t s with varying, l e v e l s  of consciousness.  of intubated  BIBLIOGRAPHY  49  BOOKS  B e e s o n , P a u l B. , McDermott, W a l s h , and Wyngaarden, James B., e d s . 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"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 : Intracranial Penetration." T h e J o u r n a l o f T r a u m a 18 (December 1978):  823-824.  52 G r e m i l l i o n , Daniel E. "Simple Method f o r Passage o f Small Nasograstric Feeding Catheter." Annals o f I n t e r n a l M e d i c i n e 91 ( O c t o b e r 1979):655-656. Griggs,  B a r b a r a A . , a n d H o p p e , M a r y C. Tube F e e d i n g . " American Journal 481-485.  H a n a f e e , W i l l i a m N. "External Guided Tube." R a d i o l o g y 89 ( D e c e m b e r Hanson,  Bore  "Update: N a s o g a s t r i c o f N u r s i n g 7 9 (March 1 9 7 9 ) :  Passage o f an I n t e s t i n a l 1967):1100-1102.  Robert L. "New A p p r o a c h t o M e a s u r i n g A d u l t N a s o 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 o f N u r s i n g 80 (July 1980):1334-1335.  Hassan,M.A.-,- a n d H o b s l e y , M. "Positioning of Nasogastric Without Fluoroscopy." 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.  Tubes  Hodge,  Joseph. "New, I m p r o v e d 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 T u b e f o r u s e i n t h e M a n a g e m e n t o f I n t e s t i n a l Obstruction." T h e 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.  Hunter,  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 Anaesthetised Patient." Anaesthesia  Hunter,  John. "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 b y 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 a n d M e d i c i n e s into the Stomach." Transactions of a Society f o r the I m p r o v e m e n t o f M e d i c a l a n d C h i r u r g i c a l K n o w l e d g e (1793) : 182-189.  Inglefinger, Jacox,  Franz  J.  "Tubes."  Tubes i nt h e 28 ( 1 9 7 3 ) : 7 0 8 - 7 0 9 .  Gastroenterology  Ada. " S t r a t e g i e s t o Promote N u r s i n g R e s e a r c h 29 ( J u l y 1 9 8 0 ) : 2 1 3 - 2 1 7 .  74  Research."  (1978):310-318. Nursing  johnstone> Robert E. and L i e f , Peter L. "Complication of Intubation of Gastrointestinal Tract." Journal of the 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 221 ( J u l y 1 9 7 2 ) : 1 9 2 . Kamat,  R.D. "Use o f 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 o r Comatose P a t i e n t s . " Anaesthesia a n d A n a l g e s i a 54 ( J a n u a r y - F e b r u a r y 1974):156.  Larsen,  P a u l D. "Knotted Nasogastric Tubing." Journal of the A m e r i c a l M e d i c a l A s s o c i a t i o n 238 ( J u l y 1 9 7 7 ) : 2 1 1 - 2 1 2 .  McConnell, Edwina A. " A l l About G a s t r o i n t e s t i n a l N u r s i n g 75 ( S e p t e m b e r 1 9 7 5 ) : 3 1 - 3 7 .  Intubation."  53 M c G u i r t , W. F r e d e r i c k and S t r o u t , J o h n J . "Securing of I n t e r m e d i a t e D u r a t i o n F e e d i n g Tubes." The L a r y n g o s c o p e (1980):2046-2048. Major,  R a l p h H. " H i s t o r y o f t h e Stomach Tube." M e d i c a l H i s t o r y 6 (1934) .-500-509.  Annals  90  of  M a t s u k i , A k i t o m o and Zsigmond, E l e m e r K. " 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 Tube D u r i n g Anaesthesia." 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 (1972):610. Matthew, H e n r y , M a c i n t o s h , T. F., T o m p s e t t , S. L., and Cameron, J e a n C. " G a s t r i c A s p i r a t i o n and L a v a g e i n A c u t e Poisoning." 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. M i r a k h u r , R. K. " 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 Tube D u r i n g A n a e s t h e s i a . " B r i t i s h Journal o f A n a e s t h e s i a 45 (1973):1062. Mundy, D o n a l d 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. Tube." S u r g e r y , G y n e c o l o g y and 1979):581-582.  Nethercott, Sally. "Clearing ( A p r i l 1980):25-27. Ohn,  "A New L o n g I n t e s t i n a l O b s t e t r i c s 149 (October  a Pathway."  Nursing Mirror  150  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 R i s k TPN When Tube F e e d i n g W i l l 44 ( F e b r u a r y 1 9 8 1 ) : 3 5 - 4 1 . Peters,  Do?"  RN  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 NarrowBore N a s o g a s t r i c Tubes." L a n c e t ( O c t o b e r 28, 1978):944.  Pope, C h a r l e s E. "Esophageal P h y s i o l o g y . " Medical C l i n i c s o f N o r t h A m e r i c a 58 (November 1974):1181-1199. Ravdin,  I.S. "The Modern R o l e o f t h e E s o p h a g o s c o p e i n S u r g e r y 51 (March 1962):420-422.  Robinson, An Sader,  E a r l P., and E a s i e r Way."  Surgery."  Cox, P a u l M. " F e e d i n g Tube I n t r o d u c t i o n — C r i t i c a l C a r e M e d i c i n e 7 (1979):349.  A l b e r t A. "New Way t o S t a b i l i z e N a s o g a s t r i c T u b e s . " A m e r i c a n J o u r n a l o f S u r g e r y 130 (1975):102.  Saha, A. K. "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 Anaesthetised Patient." A n a e s t h e s i a 29 (1974):367.  Schechter, David Charles S u r g e r y 51 ( M a r c h Smith,  R o b e r t M. "Simple N a s o g a s t r i c Tube." (1973):1168.  S p r a g u e , D a v i d H., and for Nasogastric (1980):436.  a n d Swan, H e n r y . 1962):415-419. and S a f e British  "Levin  and  His  Method f o r I n s e r t i n g a Journal of Anaesthesia  C a r t e r , S t e v e n R. Tube I n s e r t i o n . "  Tube."  45  "An A l t e r n a t e M e t h o d Anaesthesiology 53  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 Endotracheal I n t u b a t i o n and Tracheotomy." The A m e r i c a n J o u r n a l Medicine 70 (January 1981):65-76.  of  Tahir,  A s h i q and A d r i a n i , J o h n . Tube i n the A n a e s t h e t i s e d A n a e s t h e s i a and A n a l g e s i a  Tanner,  C h r i s t i n e and P a d r i c k , K a r e n . "Research U t i l i z a t i o n F o c u s o n AACN 8 ( O c t o b e r / N o v e m b e r 1 9 8 1 ) : 3 3 - 3 4 .  Thomas,  Sally, "Passing Tubes ( M a r c h 1979) :.32-33.  "The I n s e r t i o n o f a N a s o g a s t r i c o r Comatose P a t i e n t . " 50 ( M a r c h - A p r i l 1973):179-180.  and  Catheters."  Nursing  Q  Mirror  Tinckler, Laurence. " N a s o g a s t r i c Tube Management." J o u r n a l o f S u r g e r y 59 (August 1972):637-641.  British  T i n c k l e r , Laurence. " N a s o g a s t r i c Tube Management." Times#( J a n u a r y 1973):12-15.  Nursing  T o r r i n g t o n , K e n n e t h a n d Bowman, M a c . "Fatal Hydrothorax and Empyeme C o m p l i c a t i n g a M a l p o s i t i o n e d N a s o g a s t r i c T u b e . " C h e s t 79 ( F e b r u a r y 1981) : 2 4 0 - 2 4 2 . Tos,  M.,  a n d B o n d i n g , P. " M i d d l e E a r P r e s s u r e D u r i n g and A f t e r Prolonged Nasotracheal and/or N a s o g a s t r i c Intubation." A c t a O t o l a r y n g o l 83 (1977);353-359.  Tucker,  A., and L e w i s , B r i t i s h Medical  Van  der  W e y d e n , C. "Insertion of Nasogastric J o u r n a l o f A n a e s t h e s i a 51 (1979):73.  Van  Ess, Lester J. "Use o f a C o l o r C o d e d G a s t r i c T u b e . " I n t e r n a t i o n a l Surgery 62 (August 1977):418-419.  Virtue,  Jennifer. " P a s s i n g a N a s o g a s t r i c Tube." J o u r n a l 281 (October 1980):1128-1129. Tubes."  British  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 Nasogastric.Tube During Anaesthesia." British Journal o f A n a e s t h e s i a 45 (1973):234.  &  A  148  Volden,  C e c i l i a , Grinde, J a c q u e l y n , and C a r l , D a v i d . "Taking 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 (September 1 9 8 0 ) : 1 4 - 1 7 .  Walder, A r n o l d Surgery Wells,  I. 51  "A H i s t o r i c a l - Review o f t h e N a s o g a s t r i c (March 1 9 6 2 ) : 4 0 7 - 4 1 3 .  Tube."  T h e l m a J . " 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 . " A m e r i c a n J o u r n a l o f N u r s i n g 7 9 ( O c t o b e r 1979) : 1 7 5 7 - 1 7 6 0 .  Young, R o n a l d F. "Cerebrospinal F l u i d Rhinorrhea Following Nasogastric Intubation." The J o u r n a l o f Trauma 19 (October 1979):789-791. Z i e m e r , Mary and C a r r o l l J a n e S c h u p a y . " I n f a n t Gavage Reconsidered. " American J o u r n a l of Nursing ^(September 7  1978):1543-1544.  10  APPENDIX ONE  57 Experiment  t o Determine  an E f f e c t  of Cooling  of Nasogastric  Obj e c t i v e :  on a D e f l e c t i o n  Tube  To m e a s u r e and compare t h e f o r c e s r e q u i r e d t o deflect  a lubricated polyvinylchloride nasogastric  t u b e a t room t e m p e r a t u r e  and 0 ° C .  TABLE 5 F o r c e s r e q u i r e d t o 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 I I  Data  tubing temperature 18°C (room temperature)  1.0. Newtons  2.0 Newtons  0°C (ice water bath)  3.0 Newtons  5.0 Newtons  The f o r c e r e q u i r e d  to deflect  chloride nasogastric force required results forces about  force t o d e f l e c t tubing from 20-50cm  The above r e s u l t s are averages of 80 t r i a l s f o r each conditon.  N a s o g a s t r i c tube deflection  Conclusion:  force t o d e f l e c t tubing from 0-20cm  tubing  in this  experiment  required to deflect  deflect  a t 0°C i s g r e a t e r  a t room t e m p e r a t u r e  obtained  three  lubricated polyvinyl-  t i m e s as g r e a t  the tubing  a t 18°C.  o r 18°C.  than the The  i n d i c a t e that the  the tubing  a t 0°C a r e  as t h e f o r c e s r e q u i r e d t o  APPENDIX TWO  5 9  Nurse's  I n f o r m a t i o n and  Consent  Form  Mr . / M i s s / M r s ./Ms ._ My name i s J a n e H e a s l i p . I am a s t u d e n t i n t h e g r a d u a t e programme i n n u r s i n g a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a . I am i n t e r e s t e d i n s t u d y i n g how n u r s e s c a n 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 intubated 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 u n d e r s t o o d , n u r s e s h a v e n o t y e t b e e n a b l e t o document w h e t h e r o r n o t c h a n g e s i 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 h a v e any b e a r i n g on t h e e a s e w i t h . w h i c h . t h e t u b e i s i n s e r t e d . In o r d e r t o d i s c o v e r i f t h e r e i s an e f f e c t f r o m t h e d e g r e e 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 t h e n a s o g a s t r i c t u b e , I w o u l d l i k e t o a s k y o u t o p a r t i c i p a t e i n a s t u d y t o be i m p l e m e n t e d i n t h e ICU t h a t w o u l d r e q u i r e y o u t o u s e a n a s o g a s t r i c t u b e t h a t has b e e n submerged i n an i c e b a t h f o r t e n m i n u t e s t o e n s u r e r i g i d i t y , and one t h a t has b e e n s t o r e d a t room t e m p e r a t u r e t o e n s u r e 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 y o u r p e r m i s s i o n as p a r t o f t h e s t u d y t o c o l l e c t some d a t a c o n c e r n i n g y o u r 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 t h e p r o c e d u r e and your o p i n i o n s about i t . S h o u l d y o u a t any t i m e f e e l t h a t i n t h e i n t e r e s t s o f t h e p a t i e n t t h e r e s e a r c h p r o t o c o l s h o u l d be a b a n d o n e d , y o u a r e f r e e t o do s o . You a r e a t a l l t i m e s e n c o u r a g e d t o f o l l o w y o u r c l i n i c a l j u d g e m e n t and no c r i t i c i s m w i l l be b r o u g h t a g a i n s t you f o r d o i n g so. P a r t i c i p a t i o n i n t h e s t u d y w i l l r e q u i r e a t t e n d a n c e 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 w h i c h t h e 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 d a t a c o l l e c t i o n methods e x p l a i n e d . study,  will  Y o u r name w i l l n o t be i n c l u d e d i n t h e d a t a t a k e n f o r t h e and d a t a s h e e t s 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 incur  t o ask  a r e f r e e t o w i t h d r a w f r o m t h e s t u d y a t any no p e n a l t y f o r d o i n g s o .  I f y o u h a v e any them p l e a s e .  questions regarding  this  study f e e l  Date: Nurse's Signature (indicating willingness Investigator's  to p a r t i c i p a t e  Signature  •  i n the  time  study)  and  free  APPENDIX  THREE  61 N a s o g a s t r i c Tube S t u d y 1.  Insertion  Protocol  Technique  The i n s e r t i o n t e c h n i q u e o f a l l t u b e s i s t o f o l l o w t h e 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 G r i g g s 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 A m e r i c a n J o u r n a l o f N u r s i n g , V o l . 7 9 , No.3. M a r c h , 1979, pp.481-485. The p r i n c i p l e s a r e : • 1.  2.  E x p l a i n t h e p r o c e d u r e t o t h e p a t i e n t as n e c e s s a r y s u p p o r t him t h r o u g h o u t t h e i n t u b a t i o n .  and  2.  A s s e s s l e v e l o f c o n s c i o u s n e s s and d e t e r m i n e p r e s e n c e a b s e n c e o f gag and s w a l l o w r e f l e x e s .  3.  Examine t u b e . D i s t a l end s h o u l d be f r e e o f r o u g h s h a r p edges and o u t l e t h o l e s s h o u l d be o p e n .  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 p r o c e s s of the sternum t o the t i p o f t h e nose t o t h e ear l o b e .  5.  I f t h e t u b e t o be i n s e r t e d i s a r i g i d one, submerge t h e t u b e i n an i c e b a t h f o r 10 m i n u t e s . 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 t o the i c e b a t h f o r 10 m i n u t e s p r e c e e d i n g s e c o n d and s u b s e q u e n t attempts. I f t h e t u b e t o be i n s e r t e d i s a f l e x i b l e one remove f r o m t h e p a c k a g e and a t t e m p t t o i n s e r t i n t o t h e patient.  6.  L u b r i c a t e b o t h t h e t i p and  7.  Pass t h e tube g e n t l y a l o n g the f l o o r o f the n a s a l passageway. A common m i s t a k e i s t o p u s h t h e t i p b o t h 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 t h e 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 p r e v e n t t h i s , aim down and b a c k t o w a r d t h e e a r .  8.  I n t h e c o n s c i o u s p a t i e n t t h e p a t i e n t w i l l f e e l a lump i n t h e b a c k o f t h e t h r o a t when t h e t u b e b e g i n s t o c u r v e downward i n t o t h e p h a r y n x . 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 to begin swallowing.  9.  Continue p a s s i n g the tube u n t i l reached.  10.  V e r i f y tube placement with a syringe.  11.  Tape t h e t u b e s e c u r e l y ,  S t u d y Week and  first  few  inches of the  the d e s i r e d  by a s p i r a t i o n  or  or  tube.  length i s  of g a s t r i c  contents  a v o i d i n g p r e s s u r e on t h e n a r e s .  Type o f Tube t o be  Used:  R i g i d t u b e s a r e t o be u s e d on odd s t u d y weeks and t u b e s on e v e n weeks. E a c h week w i l l b e g i n a t 0001 h o u r s  flexible Sunday  62  and  end  a t 2359 h o u r s  3.  Criteria  Saturday.  for Inclusion:  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 t u b e p l a c e m e n t has b e e n a p p r o v e d b y t h e a d m i t t i n g r e s i d e n t and who h a v e e n d o t r a c h e a l tubes i n p l a c e .  APPENDIX FOUR  64 D a t a t o be 1.  C o l l e c t e d - ( P l e a s e c h e c k one  Information a) b) c)  Regarding  of each of the  t h e P a t i e n t and  L e v e l of consciousness i) conscious ( ) i i ) obtunded Degree of tube s t i f f n e s s i) r i g i d ( ) i i ) flexible  Procedure:  ( )  Side i)  b)  tube iii) 9  ( )  ( )  iv)  other  (  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 discomfort with s p e c i f i c s  ii)  bleeding  iii)  c h a n g e i n ICP  iv)  other  and  source reading  Was t h i s p r o c e d u r e : i) e l e c t i v e ( ) i i ) emergent  Information a)  ( )  Number o f a t t e m p t s 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 ) s u b s e q u e n t w i t h number ( )  S i z e of e n d o t r a c h e a l ii) 8 ( ) i) 7 ( )  2.  i i i ) unconscious  ( )  S i z e o f N a s o g a s t r i c Tube i i ) 18 ( ) i i i ) other i ) 14 ( )  g)  following)  Regarding  the  ( )  Nurse:  L e v e l of anxiety regarding t h i s procedure I) none ( ) i i ) low ( ) i i i ) moderate ( )  iv) high  A p p r o x i m a t e 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 month ( )  c) How were y o u t a u g h t t o i n s e r t an NG i) r i g i d ( ) i i ) flexible ( )  per  tube?  d)  Do y o u h a v e a p e r s o n a l p r e f e r e n c e f o r t h e t y p e o f t u b e used? i) r i g i d ( ) i i ) flexible ( ) i i i ) no d i f f e r e n c e ( ) i v ) d e p e n d s upon c i r c u m s t a n c e s ( ) i f i v , describe:  e)  How c o n f i d e n t were y o u r e g a r d i n g s u c c e s s 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 all ( )  at  ( )  

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