my first NG tube insertion

  1. 0
    Unlike the plethora of IV starts I got in clinicals, I didn't get a chance to insert an NG tube in a real person.

    Got the chance now that I'm a GN and, although I followed the helpful advice of my mentors who were right there with me (wrapped tube around hand a few times to increase flexibility, lubed up the tip, and angled it slightly inwards?), I feel like I ended up doing a miserable attempt of it on the poor elderly lady.

    After a few seconds of some slight hindrance I was able to advance it and it seemed I actually might be successful even though she was quite uncomfortable. Then we realized it was coiled up in her mouth.

    Second attempt resulted in a pretty bad nose bleed. I'm not sure where it went that time - perhaps her airway instead of the esophagus. We weren't able to hear anything through the stethoscope after 30cc air bolus to verify placement. So we pulled it out.

    My mentor tried a third time in the opposite nostril and it went in with very, very little resistance and hardly any discomfort (it seemed) to the patient, much to my amazement.

    Thankfully my two mentors were very encouraging and kind otherwise it would have been even more traumatic (for both me and the patient).

    I know everything comes with practice, but do you have any helpful pointers on this?

    I felt really bad for her and I know that it was a tormenting experience. I provided oral care with those minty swabs afterwards but wish I could have done more to make her feel better.

    Thanks.
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  3. 9 Comments so far...

  4. 2
    oh my gosh, i don't know how many times an ng tube has coiled on me (and the pt obviously ).
    bed upright, chin to chest position, and having pt swallow water through a straw (if indicated) will help propel tube down esophagus.
    i know of a nurse who keeps them in the freezer, as she insists it prevents coiling.

    i'm sure you did just fine, and the more you do it, the more confident you will feel.

    keep it going.

    leslie
    FlorenceFrightengale and etymed like this.
  5. 0
    I forgot to add she was dysphagic.

    I'll keep those tips in mind next time, thanks.
  6. 0
    I have had to put in more ng tubes than I'd care to remember. My daughter had an ng tube for almost a year and I've had alot of babies come through my foster home with an ng tube and they LOVEd to pull them out. No amount of tape could keep them from eventually working them out. My only advice was that the more I did it, the better I became. Didn't matter anatomically what I was dealing with, it was just practice. I did find that the more flexible I made the tube, the more they were apt to coil.
  7. 1
    I caused a bad nosebleed on my first ng insertion as well. We place our tubes in hot water to increase flexibility. If the pt is dysphasic I have one person hold the head back at the beginning and the move the head forward to help ease the tube it. Also make sure they are sitting as straight as you can get them.

    As for the straw, I thought they were supposed to not use a straw. I always think it goes down easier with an open cup.
    FlorenceFrightengale likes this.
  8. 1
    Lots of lube, chin down (remember, you'd be opening the airway with a chin lift, right?), water to swallow and you advance the tube a bit with every swallow until you're sure it's cleared the pharynx and is into the stomach.If your patient is unconscious, you can put your two fingers of your other hand close together over the tongue, right back to the pharynx, and when it comes down from the nose you guide it between them and posteriorly over your fingernails so it slips right down the esophagus away from the (anterior) trachea. (I learned that from an anesthesiologist )

    Standard of care for checking placement is NOT to push air down and listen over the stomach....because it is possible to get a really nice gurgle if it's in the left lower lobe. Aspirate from the main lumen and check the pH of the return (have the tes-tape right there). Document. If it's not in the 2-3 range it's not gastric.

    Oh, and if you get resistance in one naris, remember that a lot of people have deviated septa. Try the other side.
    Last edit by GrnTea on Jan 30, '13 : Reason: idiocy on my part
    NurseOnAMotorcycle likes this.
  9. 0
    It is easier if the patient is cooperative and can swallow. Usually one nare is easier than the other so try both. Sometimes both are blocked so you go oral instead for a quick lavage or if intubated. If they are unconscious or intubated or dysphasic you can try your fingers in their mouth to help guide the tube but use a Yankeur if they can possibly bite you! I like Salem sump tubes better due to their rigidity and only do small feeding tubes on cooperative patients or if the doctor specifically asks because we do more decompression and suctioning initially and actual feeding later. It takes practice and trying different techniques. We confirm ngt placement with X-ray for all dysphasic and intubated patients.
    Last edit by dah doh on Jan 29, '13
  10. 0
    I agree with the Head Down positioning. Sometimes I put a pillow (or two if they're too flat) right behind their head while sitting up at 90 degrees. Also, if tube is advancing, Do Not Slow Down when pt says "Just stop for a minute" or "No, take it out". Like a foley, get it in quick and then let them recover, don't do the slow torture.
  11. 1
    I am known on my ward as the queen of NGs.

    Head to chest, lube, spray local if you have it, shine a light up the nose to see which nostril is bigger. Explain, prepare your naseo fix PH indicator paper and tape and pin to reduce the weight on the nose. Have the pt either sit on their hands or have someone hold them. (Learned that the hard way!).

    Insert confidently and keep going even when they ask you to stop. Quick and it is over. Connect drainage bag or manually drain with a 50 mo syringe.

    I get a size 14 or 16 down most times for drainage and decompression. I find anything smaller may get blocked with nasty drainage.
    GrnTea likes this.
  12. 0
    If patient has false teeth, have them take the top plate out. The hard surface seems to increase the resistance you find in the nasopharynx.


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