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Reflective Journaling

Name: Alexis Daubney Date: February 13, 2018

Noticing
• Subjective and objective data
Patient presented to the emergency department on 02/11/2018 from an assisted living facility. Upon
arrival, patient had an altered mental status, low blood glucose level of 29, cultured for a urinary tract
infection, and low blood pressure. Patient was in septic shock and proceeded to be admitted to the
intensive care unit. Patient has a past medical history of hypertension, dementia, atrial fibrillation, and
deep venous thrombosis. Patient had a femoral central line inserted and bilevel positive airway pressure
(BiPap) initiated on 02/11/2018. Patient was not holding adequate oxygen saturation and was intubated
02/12/2018. An orogastic (OG) tube was inserted after intubation to allow for administration of tube
feedings (TF).
We had the patient on 02/13/2018. The patient had an order to replace the femoral central line with an
internal jugular line at 1740, due to the risk of infection with a femoral line. We had the TF on hold about
five minutes prior to placing the patient in trendelenburg for the procedure. However, upon positioning
the patient, he had small amount of emesis. We suctioned his mouth. We then connected the OG to low
intermittent wall suction to ensure that the patient did not vomit anymore during the procedure. There was
a total of 1200 mL of gastric contents that was suctioned from the patient’s OG. We notified the provider,
who ordered a dextrose solution, and held TF. The nutritionist, and ICU team were going to re-evaluate
nutrition the next morning
• How did you know there was a problem? Abnormal patient presentation or your
“gut feeling”?
The patient prior to position changes had not vomited. No previous issues noted with TF. We
auscultated bowel sounds which were normoactive, and placement was checked with auscultated and
upon insertion with a chest x-ray. When we noted the large amount of gastric contents that were
suctioned, we knew that the patient was not tolerating the TF. This resulted in a need to contact the
provider to ensure that we had another source of nutrition for the patient. They ordered a dextrose
solution, until they could re-evaluate with a nutritionist.
Interpreting
• W hat other information do I need to make a decision? Is there anyone else I need
to involve or notify?
There was a lot of information we needed to notify the provider, such as how long have the TF been
going, the rate, bowel sounds, where there any previous episodes of emesis, etc. Thankfully the ARNP
was in the room doing central line procedure so we were able to discuss a new plan of action
immediately. Quick notification of the provider allowed us to initiate another route for some level of
nutritional intake, and discontinue the TF, which clearly the patient was not tolerating well.
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• W hat could be happening and how critical is this situation?

The patient was not digesting the TF properly. The contents were siting in the stomach for almost 21
hours (TF was running at a rate of 55 mL/hr). This could potentially lead to a critical situation. Since the
patient was intubated there was a cuff in place that hopefully provided a barrier for any potential aspirates
getting to the lungs. Aspiration of these gastric contents can lead to infections, such as pneumonia. We
performed suction afterwards, and held the TF per provider orders.
Responding
• Should I do something now or wait and watch? How will I know if I am making
the best decision? W hat interventions can I delegate to other members of the
healthcare team? Include evidence-based practice (peer reviewed) here to justify
why you might make one decision over another.
This required immediate action of initiating suction, since the IJ insertion was required as soon as
possible to replace the femoral line. According to hospital policy, it is recommended to replace femoral
lines within 24 hours, if patient can tolerate, to decrease the risk of infection. An article by Ling et al.
(2016) in the journal of Antimicrobial Resistance & Infection Control, femoral central lines are related to
“higher risk of infection and deep venous thrombosis” and subclavian lines are preferred. We needed to
remove the gastric contents to prevent further vomiting episodes to continue safely with the central line
insertion.
The problem may have been caught earlier if we were checking residuals. However, monitoring
residuals is no longer standard of care in the ICU. An article by Reignier, Mercier, and Le Gouge (2013)
explored the possible benefits of not continuously monitoring residuals; they found that it leads to
improved delivery of feedings, less instances of discontinuation leading to underfeeding, and allowed
more focus from nurses on decreasing ventilator associated pneumonia. There are other studies that
support these findings, and thus the ICU has adopted not monitoring residuals based on evidenced based
practice.
In this instance, there was no delegation but rather collaboration of working and notifying the
providers. Bringing the attention of the intensivist, team of providers, and dietician is required to ensure
that the patient will continue to receive nutrition.
Reflecting
• Did I make the right decision? Did I achieve the desired outcome? W hat did I do
really well? W hat could I have done better?
I believe we made the right decision. Suctioning to allow for the IJ procedure was more immediate.
Nutrition is important but having a central line that will provide intravenous access and prevent further
infections is priority. The patient was already in septic shock and required vasopressors, and an insulin
drip due to the impact steroids and TF had on his blood sugar resulting in the use of EndoTool. The team
can re-evaluate the plan of care with regards to nutrition/diet. The desired outcome to ensure that the
patient was receiving adequate enteral nutrition was not achieved; however, we were able to initiate
dextrose orders so the patient will have some form of nutrition.
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My nurse and I initiated the orders accurately and evaluated the TF by monitoring bowel sounds and
monitoring blood glucose. In the future, I will be quicker to action in aiding in suctioning of the patient.
Since the sterile field was being set up in the situation to place the IJ central line, I had to be hyper aware
of what was sterile and where I could be. The sterile field was not set up on the patient at the time but the
tray was set up at the bedside. With more experience around sterile fields, I hope to become more
comfortable and not as hesitant in aiding my patients, but continue to protect and be aware of the sterile
fields in the room.

References

Ling, M. L., Apisarnthanarak, A., Jaggi, N., Harrington, G., Morikane, K., Thu, L. T. A., Ching, P.,
Villanueva, V., Zong, Z., Jeong, J. S., & Lee, C. M. (2016). APSIC guide for prevention of
central line associated bloodstream infections (CLABSI). Antimicrobial Resistance & Infection
control, 5. doi:10.1186/s13756-016-0116-5
Reignier, J., Mercier, E., & Gouge, A. L. (2013). Effect of not monitoring residual gastric volume on risk
of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral
feeding: A randomized controlled trial. Journal of American Medical Association, 309(3), 249-
256. doi:10.1001/jama.2012.196377