clin skills exam #4--NG

these are examples of indications or complications of NG tube

1. sampling gastric contents

2. decompression GI tract

3. providing nutritional support for pt who cannot eat but have fxnal GI tract

4. provide meds

5. identification of esophagus and stomach on imaging

indications

what are some other indications for NG tube placement

1. severe diverticulitis

2. GOO

3. GI bleeding

4. intestinal obstruction

5. drowning

6. vomiting

7. surgery

8. burns

9. pancreatitis

10. dysphagia

T/F: you do not need to check the tube placement to verify it is in the stomach and not the lungs

false, must always check

what can happen if NG tube is passed forcefully into lungs

pneumothorax or aspiration pneumonia

what is the area of trauma that may cause issues with NG tube placement

area of triangle on face that includes nose and mouth

turbinates and nasopharynx issues are _ with NG tibes

complications

T/F: gastric erosion w/ hemorrhage is a potential complication of NG tube placement

true

T/F: sinusitis or erosion/necrosis of nasal mucosa is possible w/ NG tube placement

true

if an NG tube is placed in a pt w/ a severe head, neck, thoracic, or abd trauma what can happen

traverse and break into nasopharynx, larynx, esophagus, stomach and cause severe damage to brain, lungs, peritoneal cavity

what is the gold standard to know if NG tube is placed correctly

radiographic confirmation w/ x-ray

how can you test is the tube is in the lungs when x-ray not available

after passing tube through, place NG tube into glass of water and if tube is in lungs then bubbles occur during exhalation

how can you determine if there is insufflation of the tube with air

listen to stomach with stethoscope

should you place a tube in a pt w/ altered mental status

no, it is contraindicated

what surgery do you need to be careful with if NG tube must be placed

gastrectomy or bariatric surgery and surgery on esophagus/stomach

what is the order in which NG passes starting with Nares

nares—> nasopharynx—> posterior oropharynx—> larynx—> trachea—> esophagus—> stomach

T/F: NG tube placement is a sterile procedure

no, it is a clean procedure

what are 3 parts to include when explaining and discussing NG tube placement procedure

• flex neck until tube is in esophagus

• pt sipping water

  • swallowing—> helps facilitate passage of tube

what irrigation syringe size should you use for NG tube placement

60mL

what is the purpose of tincture of benzoin with NG tube placement

helps secure tube to skin, esp w/ tape, to create sticky layer and protects skin from adhesive

which NG tube is a firm straight non-radiopaque single lumen

Levin tube

what is the Levin tube used for

diagnostic aspiration or instill material into stomach

which NG tube is a radiopaque double lumen tube, 2nd lumen has vent and is smaller than main lumen

Salem Sump

what is the Salem Sump used for

provides continuous air flow when suction applied

which tube is a small-bore and flexible that is more comfortable

Dobhoff

what is special about the Dobhoff tube

uses wire and can be removed after correct placement is confirmed

what are some things that nG tube size depends on

pt size, age, length of time tube required, viscosity of fluids being instilled/evacuated, dz process of pt

what is the size of the Levin tube for an adult

10-18 Fr

what is the size of the Salem-sump tube for an adult

16-18 Fr

what is a French (Fr)

unit of measurement

0.33 mm diameter

smaller Fr # means __

smaller diameter

what is the size of the Dobhoff tube for an adult

8-12 Fr

what angle should pt be placed at for NG tube placement

45 degree angle

what must you check on the pt physically before putting in the NG tube

check nasal patency and examine nasal passageway

where do you measure from to determine length of NG tube and distance to push in

tip of nose to ear lobe and down to pt xiphoid process

why should the beveled opening of the tube be positioned toward the nasal septum

avoid trauma to turbinates

what degree angle do you insert tube when actually pushing the tube in

straight back at 90 degree angle to long axis of head

what quadrant of the abdomen do you listen and what should you hear after placement and air is pushed in

LUQ

should hear rush of air

what can you use to make the tube more firm before placing

putting the tube in ice

what are 3 comfort tricks for NG placement

lidocaine lube, afrin, Cetacaine spray

when is gastric lavage indicated

• pt w/ suspected serious poisoning who have decreased levels of consciousness and present to ER w/in 1 hour of ingestion

• upper GI hemorrhage

• poisoning w/ resultant large pill fragments

• severe hypothermia or hyperthermia

what is the preferred method of gastric decontamination

activated charcoal

who must you call if person has potentially ingested poisonous substance

poison control

what type of gastric lavage must you administer for hyperthermia

cold lavage

what is the #1 CI for gastric lavage

caustic ingestion

what are some other CI of gastric lavage

• unprotected airway

• increase risk severity of aspiration

• pt at risk for GI perforation or hemorrhage due to pathology, recent surgery, other med conditions

these are other complications with gastric lavage or NG tube

• pulmonary aspiration

• mucosal injury/perforation of upper GI tract

• fluid/electrolyte disturbance

• hypothermia

• hypoxemia

• laryngospasm

• cardiac dysrhythmias

gastric lavage

what is the orogastric tube size for adults

32-50 Fr

what is the orogastric tube size for children

24-28 Fr

what is the nasogastric tube size for gastric lavage

18 fr

what position must pt be placed in for gastric lavage

L lateral recumbant position and head lowered to approx 10 degrees

once confirmation of placement of gastric lavage is ensured, what must be checked fri

aspirate gastric contents and check pH and send for toxicology

how much fluid (NS or water) is pushed per cycle with lavage

200-300mL

how many liters of lavage must be at least utilized and return is clear

3 L

why is activated charcoal the best use for potential ingestion of poisonous substance

charcoal has good adsorptive properties that can bind to most poisons

what are some exceptions that charcoal cannot work well with

caustics, hydrocarbons, alcohols, iron, lithium, lead, fluoride, potassium

if the ingested dose of poison is known, how much charcoal is needed

give charcoal 10x the weight of the ingested poison; can give in divided doses if necessary

are completion of toxic ingestion how much of a slurry of activated charcoal should be used when indicated

50-100g — 1g/kg

why must you pinch/clamp the gastric tube during removal

prevent contaminating the lungs with charcoal or gastric contents

which gastric lavage system uses either an active (syringe/flush) or passive (gravity siphon) uses gravity to drain stomach content

open—less expensive

which gastric lavage system is used to provide more protection to the health care provider

closed—prepackaged

ex: EASI-LAV

what can poison control provide

• immediate assistance in selecting appropriate lab/toxicity tests

• recommended preferred methods of gut decontamination, pt specific care recommendations, use of antidotes

• advise on pt disposition