June 9, 2018

Where Is The Tube? | Nursing Hacks # 4

As a critical care transition nurse (from PCU to ICU), my preceptor trained me to check diagnostics and progress notes for tube confirmations BEFORE continuing use during my shift. There have been times where I've entered a situation unaware of changes in a tube's location, and the change subsequently caused significant issues. For example, a patient was intubated yesterday, and the endotracheal tube was confirmed 2 cm above the carina, positioned 24 cm at the lip via CXR. When I go to perform my initial assessment and lean over to see that endotracheal tube, it better be at the 24 cm mark, or we have a problem. If it's not, I call the respiratory therapist and confirm the discrepancy. A combative patient can dislodge or advance an endotracheal tube without the nurse knowing. This isn't a competency issue. People are moving parts, they are not static. When I receive bedside report, I write down the details, but I make sure to confirm with diagnostics and visuals. Here is another example. The morning nurse placed a nasoduodenal feeding tube. The tube was confirmed as post-pyloric at the 85 cm mark via KUB XR. Upon your initial assessment, you find the feeding tube at 55 cm. The tube feeding pump is going as planned, no alarms will sound but obviously, the tube has been moved. It probably isn't post-pyloric anymore, you're probably feeding gastrically.

When I receive bedside report, I assume everything is messed up until I confirm it's not. Nothing personal, just nursing. Communication is complex and interruptions are plentiful. Inaccurate information isn't intentional. But it's your license and inheriting problems is common. Tubes slide, things move, don't be the last person to find an error 10 hours into your shift. Nothing beats good old eye-balling and research. These tubes are in people, don't assume they will remain in place. Oh, and by confirming placement, I mean reading the impression section of the diagnostic report. Don't over think it, scroll down and read. You don't have to be a radiologist to read two sentences. Remember, if you are using a line or tube, continued use is confirmation you're 100% aware of its location and trust the destination is appropriate. If you have reservations about the final destination of the device or product, you probably shouldn't be using it. You can't continue to use something and say, "Oh, I assumed it was right. I never checked." If you don't know, find out.