NG Tubes... Sigh.

Pediatric Critical Care Columnist · Nov 15, 2007

It's much easier putting in NGs on unconscious patients! (Most of the ones I do these days are.) But I can give you a couple of tips from when my son was NG fed... Have the person's head in a neutral position, not chin up or chin down. Explain how it will work, and have them practice deep, slow breathing while you get everything organized. Local anaesthetics are not a good idea, because it impairs their swallowing and you can end up intubating thier trachea or causing them to aspirate. Measure from the nose to the the ear to the angle of the jaw and make a mark with a Sharpie. Then measure again from the nose to the ear to about 1 finger width below the xiphoid and make a second mark. Fill a glass with water and get a straw. Lube up the tip of the tube for at least 3 inches. Aim slightly medial and straight back and use steady, even speed. Tell the patient that when you get to the curve of nasopharynx you'll pause so s/he can take another nice slow deep breath. When you have advanced to the first mark, you're at the throat. Get the patient to take a sip of water and as s/he swallows, advance the tube a little. With each swallow, keep advancing the tube and the gagging should be avoided. You also won't be likely to go down the wrong path. When you get to the second mark on your tube, the tip should be in the fundus of the stomach. Secure the tube to the face near the nose. I like to use Tender-Grips (little flesh colored adhesive patches intended for securing nasal cannulae to faces) because they stay on well, if you need to adjust, the tube is secured between the layers and is easily freed and it looks nicer than a swath of tape all across their cheek. You can apply them to the skin before you do anything else. Once the tube is secured, aspirate to check for stomach contents, insufflate and listen for the whoosh but don't trust either method... get an x-ray! If you can't let the person drink then have them swallow anyway, but if the tube is placed properly you should be able to aspirate out all the water. I use many of the same techniques when performing blind placement of nasojejeunal tubes too.

Some people say to put the tube in the freezer for 10 minutes before you try placing it, but in my experience that's the source of many nosebleeds.

al7139, ASN, RN · Nov 15, 2007

OMG!

The same thing happened to me the first time I attempted an NG tube! I am glad to know I am not the only one! I thought that since I had not done it on a pt in school I didn't know what I was doing, but from your experience, it tells me that it is a difficult procedure and I did everything right that time.

My preceptor said that I just needed more experience, but I felt so bad that I made the pts nose bleed...Now I feel better about the whole experience.

Amy

longjourneydream · Nov 15, 2007

OK,

There are so many ways that I see nurses do NG placement.

1st hyper extend to get past the throat(when they start to gag) then tell them to put chin to chest and swallow, with or without water.

I find the main problem is the patient is in a panic , tense and does not listen to instruction.

The tube can be either warmed or it can be iced.

Warmed makes more flexible to go down.

Iced helps make it stiff.

I like to use a Salum Sump, it is already stiff and the best to use, it does not adhere to stomach wall and damage the protective mucosa lining in the stomach, when hooking up to suction.

Sometimes there is no way of stopping the bleeding, intranasal drug users, damage thier noses to where no matter what side you go down there will always be some bleeding; very difficult people for NG placement.

My biggist challenge is going down far enough to the stomach or too far, the measurments for me are so approximate.

Hope this helps; I am also just green nurse, but I have observed for a long time...

OMG!
The same thing happened to me the first time I attempted an NG tube! I am glad to know I am not the only one! I thought that since I had not done it on a pt in school I didn't know what I was doing, but from your experience, it tells me that it is a difficult procedure and I did everything right that time.
My preceptor said that I just needed more experience, but I felt so bad that I made the pts nose bleed...Now I feel better about the whole experience.
Amy

HappyJaxRN · Nov 15, 2007

The best way that I have found....is that the person DOES put their head forward, it opens the esphagus. But only after you have entered the nare. You have them bring their head back so you can examine the nare. Once in the back of their throat, have them sitting up at 90% and lean their head forward. Make sure that there is lube on the NGT. Make sure that they don't have a deviated septum. Have them swallow water as you are advancing it. Have a basin nearby, they may gag and throw up. This method works almost 100% of the time. By the time the NGT is down, it will be sucking out all of that fluid he/she drank.

Do the air check with your stethy to make sure you're not in the lungs. You will know when you feel air coming out of the line and they are coughing uncontrollably. If you are in the right place, when you pass about 20-30mL air into their belly, you will hear it in the stethy.

Hope that helps!

Oh ps- it's not abnormal to irritate the nare or esphagus when placing an NGT.

Hey guys.
I need some help.
What is the best way to put in NG tubes that you know of.
Easiest that is.
Put in an NG tube and the pt's nose started bleeding and then they threw up and tried to do it again (RN that was helping said that the pt was trying to put his head forward when it was supposed to go back, coiled in mouth), but the pt said that they needed more time to catch breath ect.. Any tips? These things/putting these things in seems prehistoric. There has got to be a better way. Putting them in helps so much, but com'on, it's so hard to put them down without a lot of pt discomfort. My preceptor and I put some in, in the ER using Cepacol Spray, and Xylocaine gel in the nose, but had another RN (30+) years telling me that, that would make it hard for them to swallow, and not to do that. Need real world/done it a whole buncha times before advice.
Thanks!

longjourneydream · Nov 15, 2007

Hey,

The other day I put one down which was also a challenge in the ER.

1st I twisted the end of the Lavene 18 gauge tube around my finger several times, until I got it soft, and it no longer had a coil to it.

I then had him keep his head nutral, put tube in nose(which made him hyper -extend,when got to throat, made him put chin to chest and quickly I inserted. There was not a problem getting it down, it was just that it would somehow curl when it got down to his stomach, it took a few times to get just right in the stomach.

Only thing different about this was NG was to be used for hydration for a high Na of 180!!! So tap water was to be delivered @ 100 ml per hour, this was a new one for me!!!! I'm always used to suction of emptying of stomach content, from obstruction.

RNcDreams · Nov 15, 2007

Hey

I'm a new grad in the ED and I think I have had to do more NG tubes than I have Foleys, which is weird....

but anyway, I'm pretty comfortable with it now.

Here are my thoughts/methods:

-Explain everything first

-Have bucket, cup of water with straw, and chux ready

-Warm up the tube by wrapping it around your hand a few times to make it flexible

-Do the "sniff check"- occlude one nostril at a time and have the patient inhale through their nose, to see if you can hear a difference in air intake-- if one nostril sounds crowded, consider avoiding that one

-Bring another person with you to facilitate holding the water and the patient's head down (this also helps close off the airway!)

-Plenty of lube on the tip of the tube

-Measure nose to ear to xiphoid (I've begun to think that you can measure all you want, but at the end of the day, you have no idea what the anatomy in there looks like... so do your best to estimate)

-DON'T start until you make sure you have:

a.) functioning suction

b.) a 60cc syringe

c.) mastisol

d.) silk or cloth tape

e.) a safety pin

f.) stethoscope

-Insert the tube in the nare, with steady but gentle pressure and speed. (pt's head is chin to chest) In my experience, it is best not to stop unless the pt is having breathing difficulty or is vomiting profusely (you know you're in the airway/lung if they cannot speak to you or take in a breath)

-check placement before you secure the tube... have your tech hold the tube while you get your ears on and your syringe with 20cc of air... inject, and listen for the "whoosh" in the epigastric area

-Hook up to suction, and see what you get... you can be reasonably sure you're in the right place if you see what looks like vomit in the canister!

-use mastisol on the nose, with tape on the tube and onto the nose to secure

-tape on the tube with a safety pin to the gown for slack and security

-use high suction at first if the material is thick, just to open up the tube, and then set at prescribed/low wall suction

-position patient for comfort, and double check 02 sats

* use throat spray if pt is very sensitive to pain, otherwise can do without... may inhibit swallowing abilities

* Don't CRAM the tube down... just commit to sliding it in with finesse. :) I have seen a few old timers where I work use the "cram it in" method, and it's never pretty or pleasant for anyone

*Gagging is going to happen, plain and simple. A tube in your throat will do that.

* A little blood in the nose is ok- profuse bleeding is obviously not. Use your judgement.. but you're smooshing a tube in what is usually open space, so some tissue trauma is expected.

Go in with the mindset that you will succeed.. and remember, it is never pleasant for anyone, so don't feel bad. The end results are generally worth it!

:)

longjourneydream · Nov 15, 2007

Yes, isn't it weird...

Question:Are these from EMS or from triage out front, sending them back to you? Just curious...

Hey
I'm a new grad in the ED and I think I have had to do more NG tubes than I have Foleys, which is weird....
but anyway, I'm pretty comfortable with it now.
Here are my thoughts/methods:
-Explain everything first
-Have bucket, cup of water with straw, and chux ready
-Warm up the tube by wrapping it around your hand a few times to make it flexible
-Do the "sniff check"- occlude one nostril at a time and have the patient inhale through their nose, to see if you can hear a difference in air intake-- if one nostril sounds crowded, consider avoiding that one
-Bring another person with you to facilitate holding the water and the patient's head down (this also helps close off the airway!)
-Plenty of lube on the tip of the tube
-Measure nose to ear to xiphoid (I've begun to think that you can measure all you want, but at the end of the day, you have no idea what the anatomy in there looks like... so do your best to estimate)
-DON'T start until you make sure you have:
a.) functioning suction
b.) a 60cc syringe
c.) mastisol
d.) silk or cloth tape
e.) a safety pin
f.) stethoscope
-Insert the tube in the nare, with steady but gentle pressure and speed. (pt's head is chin to chest) In my experience, it is best not to stop unless the pt is having breathing difficulty or is vomiting profusely (you know you're in the airway/lung if they cannot speak to you or take in a breath)
-check placement before you secure the tube... have your tech hold the tube while you get your ears on and your syringe with 20cc of air... inject, and listen for the "whoosh" in the epigastric area
-Hook up to suction, and see what you get... you can be reasonably sure you're in the right place if you see what looks like vomit in the canister!
-use mastisol on the nose, with tape on the tube and onto the nose to secure
-tape on the tube with a safety pin to the gown for slack and security
-use high suction at first if the material is thick, just to open up the tube, and then set at prescribed/low wall suction
-position patient for comfort, and double check 02 sats
* use throat spray if pt is very sensitive to pain, otherwise can do without... may inhibit swallowing abilities
* Don't CRAM the tube down... just commit to sliding it in with finesse. :) I have seen a few old timers where I work use the "cram it in" method, and it's never pretty or pleasant for anyone
*Gagging is going to happen, plain and simple. A tube in your throat will do that.
* A little blood in the nose is ok- profuse bleeding is obviously not. Use your judgement.. but you're smooshing a tube in what is usually open space, so some tissue trauma is expected.
Go in with the mindset that you will succeed.. and remember, it is never pleasant for anyone, so don't feel bad. The end results are generally worth it!
:)

AliRae · Nov 15, 2007

Another tip? If you're going to be putting an NG in on a little one (babies and toddlers) swaddling them is essential before you begin. I place my stethoscope over their stomach first, then wrap them as tight as I can with my steth in place. That way their little arms and legs can't flail around and I don't have to scramble to check placement once the tube is in. You can't always aspirate stomach contents with little tubes (the 5 and 6 Fr. ones), so you have to rely more on auscultation. And always remember to adjust the amount of air you inject to the size of your patient ... I've had a couple nursing students come from an adult clinical to the PICU and go to put a good 20ml of air into a 5 kilo baby's little belly.

elizabells, BSN, RN · Nov 15, 2007

I've had a couple nursing students come from an adult clinical to the PICU and go to put a good 20ml of air into a 5 kilo baby's little belly.

:eek: We use 2cc for our little ones!

AliRae · Nov 15, 2007

We use 2cc for our little ones!

Yeah ... I was kind and gentle though as I explained that the tiny tummy couldn't quite handle that much and that 2-4 ml was a little more appropriate. =)