NG Tube

mh0712, MSN, RN · Dec 4, 2013

No worries, we all have our weaknesses. I'm so sorry you feel a little traumatized by NG tubes. Yes in the ED you will put more down, but remember you are doing the patient a favor. Whether it is giving them a tube to prevent aspiration or suctioning out the alcohol in their stomach- you are helping them. However, most ERs like to swarm and tackle tough patients all at once, so you should have backup. However, just try the first time to see if you can get it. This way you have the practice. Oh and your success rate sounds pretty good. I missed the last one I tried and IR had to put it down so don't worry. I wish you success in the ER and the conquering of NG tubes.

zmansc, ASN, RN · Dec 5, 2013

I have to say, I love the ER. And NG tubes, like all other procedures allow us to do great things....

I was a young nurse, probably less than a year out of school. I had just gotten to work and heard a yell from one of our rooms. I immediately went in to find two fellow nurses around this pt. It looked like poo was coming out of her mouth.

They told me that she had an obstruction and needed an NG tube placed. They were up to their elbows in it, literally! The NG tube was being placed and up came about 100cc of the brownest, nastiest stuff but her O2 sank immediately and she was gasping for air. I quickly grabbed the tube and pulled it out and her O2 came back up, but so did the poo. mouthful after mouthful.

We realized that we had placed the tube in her lung, but since there was so much aspirated poo in the lung, we actually got over 100cc out of that lung! We knew we had to get a tube into her stomach or she was going to aspirate and die. They handed me the tube and told me to try.

While I was getting ready she was spitting up poo and asked (screamed at us) why we had to do this, one of the other nurses blurted out "because your throwing up ****!". She was barely cooperative as she really didn't want to be there. I later learned she had come in the day before and left AMA.

I put the tube down until I thought it about at the pharynx and waited while the poo came out, knowing that I only had one chance. Then she took a breath, and I timed it just after more poo started to come out, advance, advance, advance, and in it went into the stomach. We got about 1500 out before it slowed down, all brown, all smelly.

She went straight to OR and I figured I wouldn't ever see her again, but about two weeks later she came in for a wound check, seems she had fired or been fired by the home health nurse, never figured out who got sick of whom first. Anyway, she told me that she had been told someone in the ER saved her life. I asked if she remembered us treating her that day and she said she didn't remember anything about the day. I told her a little bit about what her condition was when she came in, and that it took several of us to help her and get her ready for surgery, etc. When we were done, she thanked me and my coworkers for saving her life.

That was the day I realized that even the worst patient is only the worst patient because they are scared, and need you. That was the day when I realized even the messiest, smelliest, nastiest pt and room is where you need to be because that is the patient that needs you the most. And although you may think they hated everything you did for them, they probably are thanking you for saving their life, they just don't know who you are.

Not sure I helped your situation, other than to say, your son may have had miserable experiences with NG tubes, and you may not like them (I still don't particularly like them), but they can be the difference between life and death and like putting that IV in the little kid, or any other procedure we would rather not do, doing them well could help you to save the life of that pt. I recently had a hell day, flew every pt I treated out, didn't get to pee once in the entire shift. Hell, I tell you, total hell on wheels. And when I got home and started telling my wife about it, I realized I probably got to save four or more lives that day! Wow, who else can say that but an ER nurse! What a wonderful day! Miserable to live through, but wonderful to have done!

tech1000 · Dec 5, 2013

I have placed many NG tubes successfully and still HATE putting them in! I always take a second person- tech or nurse. I bend the tube a bunch and pull it and stretch it out. Have my pt look down, hit resistance, and tell my pt to drink water until the tube is down! And lube lube lube. It does take a bit of a push to get that tube moving, but it's usually just a second of resistance. Sometimes it gets coiled up and sometimes it gets a little bloody, but I've only had one that was REALLY difficult to get in!

Guests · Dec 6, 2013

1) Use an otoscope to visualize the back of the nasopharynx and then pass the tube straight back. My biggest hurdle was trying to put the tube up when it really just goes posteriorly.

1a) sit them as upright as you can.

2) Unless contraindicated, flex the neck... opposite of opening the airway which maximizes the entry into the esophagus... Pillows and blankets behind the head can help.

3) If the patient is a&o, have them swallow water through a straw.

4) Some nurses suggest icing the tube to make it stiffer in order to reduce having it curl out the mouth.

5) Except for the easiest ones, have somebody help... hold the head, hold a straw, etc. It recently took 4 of us to get an NG down.

6) Aim the tip slightly toward the midline as you put it in.

7) If you have time, some atomized lidocaine can help or viscous lido or even urojet... all depends on how much time you have, what the patient needs, what you have, and what the docs will go for...

8) Using the otoscope and the 'sniff test,' pick the clearest naris...

~~

And make peace with the fact that it's not a gentle procedure... but it is a necessary one.

SionainnRN · Dec 7, 2013

I'm the go to in my unit for these, I almost always have someone come in with me. I let the pt know exactly what I'm going to do, that it's not fun, it's going to hit their gag reflex and probably make them puke more, and that even if they tell me to stop I'm not going to because it's very important for us to get the tube in. I have my helper keep their chin down and then give them some water in a straw to help ease it in.

Most nurses have a hard time with the force it takes to get the tube in, just keep telling yourself it's for the pts own good and practice makes perfect!!

meanmaryjean, DNP, RN · Dec 7, 2013

Good tips from all of the above posters - but really, the only way to conquer your fear of them is to just do it as often as you possibly can. (I had the same issue with colostomies after my daughter had one- now I'm the unit expert at them)

tryingtohaveitall · Dec 7, 2013

I have to say, I have placed many, many NGs and NDs and I do NOT force. I do peds and try to be as gentle as possible. I use a decent amount of lube and if I'm meeting resistance, I will gently rotate it to find the opening. If it's being really difficult, I switch to the other nare.

turnforthenurse, MSN, NP · Dec 8, 2013

I was always taught to NEVER force an NG in. If I am meeting resistance, I will stop and attempt the other nare. Always ask about any nasal surgeries, deviated septum, nasal polyps, etc. If the patient is a chronic ETOHer and varices are a possible problem, have the MD place the tube. I have had patients who have had NG tubes placed before and I always ask them if they had any difficulties and which side of the nose it was placed.

Of course, you can always do an OG, too, but I only do that on intubated and sedated patients if I can't place an NG. The best way to overcome your fear is to keep practicing! Take a coworker with you, too as that can help. I usually allow the patient some small sips of water as I am advancing the tube as it helps facilitate the tube down the esophagus as opposed to the trachea.

RiccaV · Feb 6, 2014

Per the Emergency Nurses Association and American Association of Critical Care Nursing, A combination of tube length, color of aspirate, auscultation, and pH approaches the accuracy of an x- ray. Check out the RightSpot pH Indicator from RightBio Metrics. It's a small, inexpensive device that uses pH to verify gastric acidity. Our facility is trialing it now and it decreases the anxiety I feel when placing the device.

**canoehead, BSN, RN** · Feb 6, 2014

I'm the go to in my unit for these, I almost always have someone come in with me. I let the pt know exactly what I'm going to do, that it's not fun, it's going to hit their gag reflex and probably make them puke more, and that even if they tell me to stop I'm not going to because it's very important for us to get the tube in. I have my helper keep their chin down and then give them some water in a straw to help ease it in.
Most nurses have a hard time with the force it takes to get the tube in, just keep telling yourself it's for the pts own good and practice makes perfect!!

You can pause right where you are when they say stop, and wait for them to say go ahead. Having control over the procedure makes it less frightening. Tell them you won't remove the tube if they say stop, just pause, because you may have just gotten past a particularly difficult spot, and no one wants to start from the beginning.

it doesn't take force. Just shoving it in shows inexperience. If you encounter an obstruction pull back 1/2cm and try at a slightly different angle, or time it with their swallow. You CAN cause injury, and pain, keep that in mind.

CodeteamB · Feb 6, 2014

I have a near perfect track record with NG insertion. I missed my first one as a student and was given this tip by my preceptor. I have not missed an insertion since.

It's all in the wrist. Visualize the path that the tube must take, slightly up, back and down, like an arch. Hold the tube loosely in your hand and make that slight arching motion as you advance the tube. I swear, it works every time.

All the other tips above are great as well.