nasogastric tube insertion with complication - Nursing Case Study

Pathophysiology

• Primary mechanism: Insertion of nasogastric (NG) tube involves threading a long, flexible tube through the nasal passage, down the esophagus, and into the stomach. It allows for gastric decompression, feeding, or administration of medication. Incorrect placement can cause serious complications.

• Secondary mechanism: The NG tube may stimulate the gag reflex during insertion. If the patient is not adequately sedated, there is a risk of aspiration, which can lead to pneumonia, a potentially serious lung infection.

• Key complication: If the NG tube is accidentally inserted into the trachea instead of the esophagus, it can result in tracheal injury or pneumothorax. Incorrect placement can also lead to feed or medications being introduced into the lungs (aspiration), causing a serious form of pneumonia (aspiration pneumonia). Regular monitoring for correct tube placement is crucial.

Patient Profile

Demographics:

62-year-old female, retired school teacher

History:

• Key past medical history: Diagnosed with diabetes type 2, controlled with medication; previous stroke with partial recovery

• Current medications: Metformin, Aspirin, Lisinopril

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Experiencing discomfort and pain since nasogastric tube insertion 3 days ago

• Key symptoms: Severe throat pain, difficulty swallowing, increased salivation, fever, nasal discharge, slight shortness of breath

• Vital signs: Temperature 38.5°C (101.3°F), Pulse rate 106 bpm, Respiratory rate 22 breaths per minute, Blood pressure 145/90 mmHg, Blood glucose 190 mg/dl

Section 1

New Diagnostic Results:

Upon assessment, the nurse noted that the patient's throat appeared inflamed and swollen. A chest X-ray was ordered to check for signs of aspiration or pneumonia, and the results revealed an infiltrate in the right lower lobe, indicating a possible pneumonia. Blood cultures were drawn and sent to the lab; results showed a positive growth for Streptococcus pneumoniae. Meanwhile, a check of the NG tube placement using a pH strip showed a pH of 6.0, suggesting possible misplacement in the respiratory tract instead of the stomach, which typically has a pH of 4.0 or lower.

Change in Patient's Status:

Over the next several hours, the patient's condition worsened. Her respiratory rate increased to 28 breaths per minute and her SpO2 levels dropped to 90% on room air. She was visibly distressed, coughing frequently, and her fever rose to 39.5°C (103.1°F). Her blood glucose levels also spiked to 220 mg/dl, suggesting her diabetes was not well controlled amidst the stress of her body fighting an infection.

In light of these changes, the healthcare team had to reassess the patient's condition and plan of care. This would involve reevaluating the necessity and placement of the NG tube, initiating antibiotic therapy for the pneumonia, and managing her heightened blood glucose levels. The patient's worsening condition demanded immediate interventions and careful monitoring to prevent further complications and to promote her recovery.

Section 2

Response to Interventions:

The patient was started on IV antibiotics for the pneumonia, specifically Penicillin G, considering the identified pathogen was Streptococcus pneumoniae. The reinsertion of the NG tube was performed to ensure proper placement in the stomach. A follow-up pH test showed a reading of 3.5, confirming correct placement. Meanwhile, her diabetes management was intensified with sliding scale insulin to control her elevated blood glucose levels.

In spite of these interventions, the patient's respiratory status did not show significant improvement. Her respiratory rate remained high at 26 breaths per minute and her oxygen saturation fluctuated between 88-92% on 2L of supplemental oxygen via nasal cannula. The patient was still febrile with the temperature fluctuating between 38.5°C (101.3°F) and 39.2°C (102.6°F). The patient's blood glucose levels, although still high, showed a slight decrease to 200 mg/dl after initiating the sliding scale insulin. These findings raised concerns about the effectiveness of the initiated interventions and prompted a need for reevaluation of the management plan.

Section 3

A new complication arose when the patient started to become increasingly tachypneic and dyspneic, despite the supplemental oxygen. Her oxygen saturation dropped further to 84-88% on 3L of supplemental oxygen. Simultaneously, the patient reported increasing discomfort and fullness in the stomach, which was distended on examination. On auscultation, bowel sounds were found to be hypoactive. Given the sudden change in her status, a chest and abdominal X-ray was ordered immediately.

The X-ray results revealed two important findings. First, a persistent consolidation was noted in the lower lobe of the right lung, suggesting that the pneumonia was not resolving with the current antibiotics. Second, an abnormal gas pattern with multiple air-fluid levels was noted in the abdomen. This suggested the possibility of an intestinal obstruction, possibly related to the NG tube. The patient's bloodwork showed an elevated white blood cell count of 16,000 cells/mcL, further suggesting an ongoing infection and possible sepsis. These new findings necessitated immediate reevaluation of the patient's treatment plan, with an urgent need to address her respiratory status and potential intestinal obstruction.

Section 4

The patient’s condition continued to deteriorate, with her respiratory rate increasing to 30 breaths per minute and her oxygen saturation dipping to 82% on 4L of supplemental oxygen. Heart rate was elevated at 110 beats per minute and blood pressure dropped to 100/60 mmHg, indicating potential septic shock. She appeared increasingly uncomfortable and her abdomen remained distended. Given her worsening respiratory status and the potential intestinal obstruction, a stat consult with both pulmonary and gastrointestinal teams was called.

After reviewing the patient’s case, the pulmonary team recommended increasing the supplemental oxygen to 5L and considered the initiation of noninvasive ventilation. The gastrointestinal team recommended an urgent CT scan to further evaluate the abnormal gas pattern noted on the abdominal X-ray. Meanwhile, the primary team decided to change the antibiotic regimen, given the lack of improvement in the pneumonia, and started the patient on broad-spectrum antibiotics. Cultures were taken to guide future antibiotic changes. The patient was also started on intravenous fluids to counteract the potential sepsis and maintain blood pressure. These decisions required a complex balancing act to address both the patient’s immediate respiratory distress and the potential intestinal obstruction. The next steps would depend heavily on the results of the CT scan and the patient’s response to the interventions.

Section 5

The CT scan results revealed a partial small bowel obstruction, with signs of early ischemia. The gastrointestinal team determined that nasogastric tube decompression was necessary to alleviate the obstruction. The patient was prepared for the procedure, however, her respiratory status was posing a significant challenge. The oxygen saturation level had improved slightly to 85% after increasing the oxygen to 5L, but her respiratory rate was still high at 28 breaths per minute. The noninvasive ventilation was initiated to ease her breathing and stabilize her condition before the nasogastric tube insertion.

During the nasogastric tube insertion, the patient suddenly developed bradycardia with a heart rate dropping to 50 beats per minute, and her oxygen saturation level decreased to 78%. The procedure was immediately stopped and a rapid response team was called. The patient was administered atropine to counteract the bradycardia, and her oxygen was increased to 6L. The primary team suspected this might be a vagal response triggered by the nasogastric tube insertion. This new complication further complicated the management of the patient, requiring a decision whether to proceed with the nasogaic tube insertion or to explore other therapeutic options. The patient's immediate management and long-term treatment plan now depended on her response to the interventions and the team's ability to stabilize her condition.