Usually, nurses manage to do this with no problem. It is unusual for them to call you. However, if the nurses request your assistance with this procedure, do the following:
- Tell the patient what you are going to do.
- Sit the patient upright.
- Cover the end of the nasogastric tube lightly with lubricating jelly.
- Insert the tube into one nostril horizontally, and pass it down slowly.
- Ask the patient to start swallowing, and push the NG tube down more quickly. If the patient starts to choke, stop immediately. A glass of water can help them swallow, although usually it will be unsafe for most patients in whom you want to place an NG tube to swallow water or they will be designated as "nil by mouth."
- The patient should swallow the tube down. Check the position. There are different local policies regarding checking NG tube positioning, so find out the policy of your hospital. The following are possible local policies:
– aspirating slowly on the end of the NG tube and checking the secretions with litmus paper
– injecting 20 ml of air and auscultating for "bubbling" over the stomach
– obtaining a chest x-ray to confirm the position. Specify on the x-ray request that it is for NG tube positioning because the x-rays used are of different penetration to highlight the tube.
- On the chest x-ray, look for the NG tube sitting in or toward the stomach bubble, beneath the diaphragm. If it deviates to the right or, less commonly, to the left, it is in a bronchus and needs to be removed and re-sited.
Note: Do not attempt to pass an NG tube if there is any possibility of a skull fracture (e.g., CSF from the ear). A skull x-ray might be helpful, although this will not exclude a base-of-skull fracture.
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If you cannot get into the epidural space, make sure you are at a 90° angle to the skin in all planes. Sometimes you will find you have aimed skyward.
If you still have no success or have hit bone, go up a space to L2–L3.
If you still have no success, sit the patient upright to perform the procedure. Again, mark out landmarks using the iliac crests and aim the needle at a 90° angle. You cannot measure the pressure but will get your samples using this method.
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