a few clinical practice questions

Trauma Columnist · May 5, 2004

I'm an ER RN in level one trauma center and no we don't use chloral hydrate as conscious sedation - too unpredictable for our docs. We use rectal Versed, IV Versed, IV ketamine. As to NGT placement - at least in the ER we don't place many but when we do - we use a chest xray to confirm placement. Good luck and welcome to All Nurses.

eb_rn · May 5, 2004

We use chloral a lot....is it available otc?....just kidding....we use it almost as much as tylenol, though....mostly we give it on the floor and closely observe the patient then he is taken to mri/ct etc....returns sleepy and often with a pOx.......as for ng placement....we measure just like for an adult, place w/ ky jelly--unless premie/newborn, then no ky....usually try og with those little ones, check placement by listening over the stomach, but dont use 5 ml air, just 1-2ml air........any more questions? glad to help...... :)

pedsnrs · May 5, 2004

We use chloral a lot....is it available otc?....just kidding....we use it almost as much as tylenol, though....mostly we give it on the floor and closely observe the patient then he is taken to mri/ct etc....returns sleepy and often with a pOx.......as for ng placement....we measure just like for an adult, place w/ ky jelly--unless premie/newborn, then no ky....usually try og with those little ones, check placement by listening over the stomach, but dont use 5 ml air, just 1-2ml air........any more questions? glad to help...... :)

i was wondering about ng placement because i recently read a journal article that basically stated auscultation was not a reliable method of placement verification,ph or cxr are preferred.also have heard of a recent wrong(pulmonary)placement where a feed was infused,and the nurse used auscultation to check placement.any thoughts?

eb_rn · May 5, 2004

ive seen an article where ng was place in an adult and the woman was post op nasal surgery...u gueessed it, the ng went into the cranial area, and the nurse completed a feed, i cant remember, but i think the lady later died...terrible thing.....i thing cxr would be a reliable method, but it isnt policy here......we also use tpt-transpyloric tubes here a lot....placed with a stylette and placement is verified with xray.....and reflux/aspiration risk is much lower....we check placement on the floor q shift and with any/all meds....place a syringe on the med port and pull the plunger back, it snaps back with a snap sound........

UK2USA · May 6, 2004

I am intrigued about the assessment of a NGT by x-ray.

In the UK we aspirate the NGT and test it for acidity, if there are no aspirates then we instill air and auscultate. If we have a good response to that, but still want to double check, we instill 5ml H2O and then aspirate.

All tube placements are checked prior to administering any feeds / meds. So regular checks are thus performed throughout the shift.

Do other countries not do this? How regularly are the patients x-rayed for placement verification?

PS. not intended to read as criticism, only interested to hear other protocols.

uk_nurse · May 6, 2004

I am intrigued about the assessment of a NGT by x-ray.
In the UK we aspirate the NGT and test it for acidity, if there are no aspirates then we instill air and auscultate. If we have a good response to that, but still want to double check, we instill 5ml H2O and then aspirate.
All tube placements are checked prior to administering any feeds / meds. So regular checks are thus performed throughout the shift.
Do other countries not do this? How regularly are the patients x-rayed for placement verification?
PS. not intended to read as criticism, only interested to hear other protocols.

i work on paeds and we do the same as you UK2USA.If we still cant get anything back we sometimes leave it on free drainage for a short while and sometimes we get something back. If in doubt remove NGT, but if it is wrong place i.e lungs child will cough etc.

Loving Life · May 7, 2004

We don't use chloral hydrate as much anymore because it usually has the opposite effect. Many tests have had to be cancelled because the child did not fall asleep. Thankfully, we have radiology whose nurse will sedate during the day shift. We also use our PICU docs for giving sedation.

If we do use chloral hydrate they must be on a pulse ox and accompanied by a nurse. We have a special form used to monitor vital signs, etc.

Ng's we do the auscultation with air. NJ's are checked with x-ray.

RN_Amy, RN · May 9, 2004

I am intrigued about the assessment of a NGT by x-ray.
In the UK we aspirate the NGT and test it for acidity, if there are no aspirates then we instill air and auscultate. If we have a good response to that, but still want to double check, we instill 5ml H2O and then aspirate.
All tube placements are checked prior to administering any feeds / meds. So regular checks are thus performed throughout the shift.
Do other countries not do this? How regularly are the patients x-rayed for placement verification?
PS. not intended to read as criticism, only interested to hear other protocols.

I'm am originally from Melbourne and in nursing school we were instructed that two of all three methods were accurate to verify correct NGT placement ie. auscultation post air insertion and pH test of aspirate (good luck finding litmus paper on the wards I have worked on!) were evidence enough to ensure correct placement without requiring an xray.

In every hospital where I have worked however, it was policy that (in addition to ausultation and a pH test of aspirate) that an xray be performed to ensure correct placement prior to either feeds/medications etc.

pedsnrs · May 11, 2004

I'm am originally from Melbourne and in nursing school we were instructed that two of all three methods were accurate to verify correct NGT placement ie. auscultation post air insertion and pH test of aspirate (good luck finding litmus paper on the wards I have worked on!) were evidence enough to ensure correct placement without requiring an xray.
In every hospital where I have worked however, it was policy that (in addition to ausultation and a pH test of aspirate) that an xray be performed to ensure correct placement prior to either feeds/medications etc.

do they really do an xray each time before a med or an intermittent bolus feed (for example) would be given?

UK2USA · May 14, 2004

In every hospital where I have worked however, it was policy that (in addition to ausultation and a pH test of aspirate) that an xray be performed to ensure correct placement prior to either feeds/medications etc.

I have just finished a shift where I accessed an NG tube 27 separate times for bolus feeds and meds etc. Would you really expose the patient to 27 xrays? The radiographers would have lynched me!!!:rotfl:

Mimi2RN, ASN, RN · May 14, 2004

We use ng or og tubes for feeding. It depends on the baby, whether or not they are starting to nipple.We do auscultate for placement, but also aspirate for residuals. When a tube is too high, it doesn't feel right when I aspirate. I've had nurses tell me they've had no residuals all day, and after I've checked placement, and pushed the tube in another cm or two, I get several cc's back. We have cm marks on the tubes, which also helps with correct placement. When we've had xrays done with the tube in place, I'm usually right on. We would never specifically check placement with an xray, though.

We do use Chloral hydrate on Peds for sedation. I've seen it work very well, and I've seen it not touch the kid. We put CR and sat monitors on and do frequent vitals.