NG tube trouble

[zacarias, ASN, RN]

hey all!

i have a question for y'all. yesterday i had a patient who needed an ngt to suction the patient before a bronchoscopy. (apparently a ct showed he had stuff to come out). anyway, this patient is not a nice/fun patient as he's been an alcoholic all his life, and it took me 30 min to convince him to have it done. he said it never worked and well i think he may have been right about this.

first i tried and he wouldn't swallow or lean his head forward (it came out his mouth) so i took it out and and called a senior nurse to do it. she was firm with and made sure he swallowed and kept his head forward and it seemed to work. i was skeptical because the only thing i could aspirate was small amounts of slimy, clear liquid making me concerned it wasn't in the stomach. i didn't hear "swooshing" with the auscultatory method of checking placement either. i called the charge nurse finally and she didn't think it was in the stomach. so, she took it out and reinserted it. still getting the same secretions. she seemed happy but i still was not sure. finally the pulmonary fellow came and thought it was strange no secretions were being suctioned out. him and i were with the patient for like 20 min and he was listening while insufflating air...the doctor thought it might no be in the stomach yet which i suspected..he moved it around. finally we got more secretions but still clear (wouldn't we see some stomach acid?) anyway, finally we took it out since his stomach wasn't distended. the doc thought it might have gotten coiled in the back of his throat but then he thought had finally got it into his stomach. i had measured it and we went it way far, farther than necessary to reach a normal stomach.

thanks for not falling asleep yet. my question is, how do you make sure the ngt makes it to the stomach? it seemed to coil in this guy, come out his mouth. and i got so behind trying to figure out what was going on and only getting slimy, clear stuff and i had two senior nurses help me. is there any secrets you can tell me? one nurse said to put the ngt tube in ice to make it stiff to go down easier. please help!

[gwenith, BSN, RN]

Sometimes all you get is clear white stuff especially if they are on ranitidine or a similar drug. Did you test it with litmus paper??? When you blew air down the tube what exactly did you hear - was it clear gurgles??

PS DON't post in orange it makes it too difficult to read.

[Surgical Hrt RN]

One of the things that I found is to take the tube in your hand and bend it and twist it, making it more pliable. After you do that, smear lube all over your gloved hand and run the tube through your hand. This lubes up the tube and makes it easier to go in. Before you go to insert it though, take a little lube and squeeze it in the nare you are going to insert it in. The more lube the easier to insert. Once you hit the spot where they start coughing and gagging, wait for it to subside. Usually when it subsides, the natural response is to swallow. When they look they are going to swallow start inserting a little faster and it should easily go right in the stomach. I have a pretty good success rate with getting these in pts. Hopefully this will help!

[sharann, BSN, RN]

Surgical HrtRN has some excellent pointers there. I am not fond of passing NGT's down but I aslo found that for really tense pts, sometimes helps to get an order for a

SMALL dose of Ativan or Valium(not enough to knock out the Resps or gag). Some people just tense so much that you can't help but coil. I would worry about placement as you did with clear secretions and not hearing the "whoosh". Oh, and I think an x-ray might be helpful in these rare situations.

[leslie :-D]

Sometimes all you get is clear white stuff especially if they are on ranitidine or a similar drug. Did you test it with litmus paper??? When you blew air down the tube what exactly did you hear - was it clear gurgles??

PS DON't post in orange it makes it too difficult to read.

gwen- excuse my ignorance..but what would gurgles indicate? are you talking about the swoosh?

[LesJenRN]

Gurgles? What you hear on auscultation when you inject air over the stomach.....What's a swoosh?? Maybe a swoosh gurgle gurgle??:) :)

I'd say just get a film if it is that difficult to assess the placement. That way you'll have more time to get your charting done....:)

[gwenith, BSN, RN]

To me it sounds more like gurgles or bubbles than a swoosh I usually push at least twice to make sure that what I am hearing is not naturally occuring sounds lol

One of my tricks with getting NG tubes down is to insert it not upwards as is the natural inclination but horizontal parallel to the floor of the nose. A common mistake is to angle the tube upwards - don't it causes more trauma. If you look at the cut away picture below you will see how the floor of the nose is flat.

LesJenRN is right in fact the only definite way of ensuring that the ng placement is correct is by doing an x-ray.

[TaraER-RN]

I have used the ice method and the curling it in my hands trick. I always numb the patients throat with hurricane spray, and the tube with lidocaine jelly and then tilt the head forward until I get it past the nose, and then tilt their head up and have somebody hold a cup of water with a straw for the patient to drink out of and then keep telling them to swallow the water as I advance the tube-works almost everytime. I always listen for the "swoosh" with pushing air into the tube-you should be able to hear it. But in this case, I would have definitely gotten an xray to confirm.

[leslie :-D]

i personally keep my ngt's refrigerated; pt's head down, prelube with ky and press tube against septum under the lowest turbinate. with head down, swallow water through straw. so far i've had great luck, although can't say it's any picnic for the patients. to measure tubing, i was taught from nare to ear to (either) xyphoid process or manubrium...which one is it, the one at the bottom.do you know what anatomical point i'm talking about? i honestly forget which is which.

[Surgical Hrt RN]

Earle,

It's the xiphoid process. Good job!!!! :)

[CCU NRS]

lots of good tips here, if the Pt is continuing to gag and cough probably in lung, you can submerse end in cup of water to check for bubbles, if lung you will gets bubbles,X-Ray for placement when in doubt. swoosh vs gurgles I have heard both swoosh with empty stomache or perhaps still a little too high and gurgle if fluid being moved with air bolus.

[zacarias, ASN, RN]

I have used the ice method and the curling it in my hands trick. I always numb the patients throat with hurricane spray, and the tube with lidocaine jelly and then tilt the head forward until I get it past the nose, and then tilt their head up[/Quote]

Thanks all for the tips. Sorry for the confusion with "swoosh" and "gurgles". Either one is fine LOL.

I have a question, why do you have them tilt their head up Tara, to me that sounds like it would make it harder to swallow and stay in the esophagus??

Also, what does putting the NGT in the fridge do? Make it more stiff?