GTube, med administration..HELP

[perksrn]

I am looking for some info on med administration through G tubes. I have seen some nurses administer meds by gravity (which takes a long time, even with dilute meds) and others use gentle push with bulb or syringe. What's the nursing standard? If "pushing" with syringe, what's the best way to draw up to avoid the instillation of air and pt distention? Also on G tubes, what is the standard for aspirating, measuring and documenting residual. Some say only if ordered, some say q4.

If you have info or a good website regarding this, I would love it.

Thanks!!!

[cannoli]

We have a special tube feeding order sheet, done by dietician or nutrition nurse, something like that. It's preprinted and has the protocol on it, how often to check residual, how much residual to hold the feeding for and how long, etc.

Some meds will dissolve completely in HOT water, (that don't in warm) just make sure to cool it down before administration.

Feedings and meds are so much safer via G tube, than NG or dobhoff, I wish all were done by G tube.

[imnmk_rn]

Okay, so this doesn't have as much to do with procedures as far as giving meds, but confirming placement of NG tubes. It's our policy to do xray confirmation of placement of NGs/Keofeeds before using them to put anything down (if it's an NG to suction, we don't need an xray, unless we are going to be giving meds). Anyway, the other day one of my coworkers (in a Med-surg-Neuro ICU) got a pt from the floor with liver failure/unresponsive with a high ammonia level. They were supposed to be giving hourly lactulose until he woke up... nurse from the floor told her in report that "according to the xray, the NG is in the esophagus, but since the GI doc put it in, we've been using it anyway." AAACK!!!! Okay, so first thing we do is advance the NG -even though it looked awfully far in for a relatively short guy - and get another xray. Listening to the dictation of the xray - the radiologist commented that the NG remained coiled in the stomach and pointing upwards with the tip in the esophagus. Going back to listen to the previous xray, yep, it was in too far and pointing up the esophagus then.

Anyway, lessons learned??? GI docs don't have any special sense as far as placing NGs. Check it out yourself when in doubt. My guess is this guy has a whopping pneumonia from having gotten who knows how many doses of lactulose pushed up his esophagus.

Here were the other crazy things this nurse said in her report - "he sounds like he needs to be suctioned - but we couldn't..." why not??? the next thing we did after he got to us was put a nasal trumpet in - took care of his obstructing his airway, as well as allowed us to suction all kinds of junk from his lungs. All the color of lactulose. and "I think he's got a bowel obstruction... he hasn't stooled yet." Take off the attends you've got on him! It's full of stool! We all smelled it the minute he got to the unit. As we told the resident who came by to check on him, it was just a therapeutic transfer to the unit.... :)

[cannoli]

Okay, so this doesn't have as much to do with procedures as far as giving meds, but confirming placement of NG tubes. It's our policy to do xray confirmation of placement of NGs/Keofeeds before using them to put anything down (if it's an NG to suction, we don't need an xray, unless we are going to be giving meds). Anyway, the other day one of my coworkers (in a Med-surg-Neuro ICU) got a pt from the floor with liver failure/unresponsive with a high ammonia level. They were supposed to be giving hourly lactulose until he woke up... nurse from the floor told her in report that "according to the xray, the NG is in the esophagus, but since the GI doc put it in, we've been using it anyway." AAACK!!!! Okay, so first thing we do is advance the NG -even though it looked awfully far in for a relatively short guy - and get another xray. Listening to the dictation of the xray - the radiologist commented that the NG remained coiled in the stomach and pointing upwards with the tip in the esophagus. Going back to listen to the previous xray, yep, it was in too far and pointing up the esophagus then.

Anyway, lessons learned??? GI docs don't have any special sense as far as placing NGs. Check it out yourself when in doubt. My guess is this guy has a whopping pneumonia from having gotten who knows how many doses of lactulose pushed up his esophagus.

Here were the other crazy things this nurse said in her report - "he sounds like he needs to be suctioned - but we couldn't..." why not??? the next thing we did after he got to us was put a nasal trumpet in - took care of his obstructing his airway, as well as allowed us to suction all kinds of junk from his lungs. All the color of lactulose. and "I think he's got a bowel obstruction... he hasn't stooled yet." Take off the attends you've got on him! It's full of stool! We all smelled it the minute he got to the unit. As we told the resident who came by to check on him, it was just a therapeutic transfer to the unit.... :)

Okay, so why didn't somebody see about having it repositioned and rexrayed after the first xray was done showing it was in the esophagus? What was the radiologist's recommendation or was there one?, such as pull back so many inches, whatever.

[nurseygrrl, LPN]

When a GT is clogged, I usually just roll the tubing between my fingers all the way down to the pts belly to loosen the feeding stuck in there (left from the irresponsible nurse on shift before me, who didn't flush it!) then I flush with water. If it's really bad, I use the wooden end of a long sterile q-tip to roto rooter it out (this has to be done VERY carefully so it doesn't break inside the tubing.

[cannoli]

When a GT is clogged, I usually just roll the tubing between my fingers all the way down to the pts belly to loosen the feeding stuck in there (left from the irresponsible nurse on shift before me, who didn't flush it!) then I flush with water. If it's really bad, I use the wooden end of a long sterile q-tip to roto rooter it out (this has to be done VERY carefully so it doesn't break inside the tubing.

That's interesting. Is there something else that could be used that wouldn't break, I wonder?

[NRSKarenRN, BSN, RN]

mechanical complications in long-term feeding tubes --

peggi guenter, rn, phd, cnsn

http://nsweb.nursingspectrum.com/ce/ce201.htm

percutaneous endoscopic gastrostomy: clinical care of peg tubes in older adults - long-term care

http://www.findarticles.com/p/articles/mi_m2578/is_11_58/ai_110928381

pediatric gastrostomy

http://pediatric.um-surgery.org/new_070198/new/library/gastrostomytubeplmt.htm

infofact - gastrostomy may 2004

clinical nutrition: enteral nutrition

[hoolahan, ASN, RN]

AACN News AACN News Home

DECEMBER 2000 - VOL 17 - NO 12

Research Corner: Myth vs. Reality Checking Feeding Tube Placement

Grants Fund Research Relevant to Critical Care Nursing

How Do Religion and Spirituality Guide Our Practices?

Practice Resource Network: Frequently Asked Questions

Geriatric Corner: AACN Honored for Excellence in Promoting Best Practices

X

Research Corner: Myth vs. Reality Checking Feeding Tube Placement

Editor's note: Welcome to the "Research Corner," a new AACN News feature devoted to research and evidence-based practice issues. These articles, many of which will be written by members of AACN's 2000-01 Research Work Group, are designed to help nurses move away from ritual in practice. The "Myth vs. Reality" that is introduced here will not only address commonly held practice myths, but also provide data to support evidence-based practice. The following article was written by Kristine J. Peterson, RN, MS, CCRN, who was a member of the 1999-2000 Research Work Group.

By Kristine J. Peterson, RN, MS, CCRN

Mr. Dodge is a 62 year-old patient, who has been in the ICU for eight days with pneumonia and acute respiratory distress syndrome. He is receiving feedings via a gastric, small-bore feeding tube, which he has tolerated at 65cc/hour for several days. When I add feeding for the next four hours, I use a large syringe to inject 30 cc of air into the feeding tube. I hear a loud rushing sound in the upper left quadrant as I inject the air, and assume that the tip of the feeding tube is in the correct position. Am I correct in my assumption?

Myth: Air insufflation gives a reliable indication of the location of the tip of the feeding tube.

Reality: Research has shown that air insufflation is an unreliable indicator of placement. It does not distinguish between respiratory and gastric placement, nor does it distinguish location within the gastrointestinal tract. In a series of studies,1-5 Metheny and colleagues described the false reassurance air insufflation gives regarding placement. In one study, air was heard in the epigastrium 100% of the time. However, 18 tubes were found to be in the stomach, 11 in the duodenum, three in the jejunum and two in the esophagus. In another study, nurses correctly identified tube location via air insufflation 34% of the time, the same rate one would expect by chance. In yet another study, nurses reported hearing air in the epigastrium in nine of 10 patients whose tubes were found to be in the respiratory tract.

The recommended practice for checking feeding tube placement is whenever feeding is added and whenever placement is questioned.

How would I check placement? There are a number of alternatives to air insufflation.

* Immediately after placement confirmation by x-ray, measure the tube from the nares to the proximal end of the

tube. Track and note this measurement.

* Mark the tube at the nares with indelible marker and track the location of the mark, as well as the length of the

tube.

* Visually examine aspirate for bile color. Because the color may vary, this method is less accurate. Generally,

stomach contents would be the color of feeding, or yellow to green; intestinal contents would be yellow; and

respiratory secretions would be white.

* Check the pH of aspirates. This method requires that the feeding be stopped for one hour before

measurement. Measuring pH is usually not recommended when a patient is on continuous feedings, because

doing so would interfere with adequate caloric intake. Other variables that interfere with pH of stomach

contents are H2-receptor antagonists, antacids, HIV infection, pernicious anemia, medications given orally

within the last hour and advancing age.

To measure the pH accurately, the following conditions must be met:

a. No feedings or medications given orally for one hour prior to test

b. No antacids within last hour

c. Flush tube with 30-mL air before aspirating contents for pH testing

The range for stomach contents if above conditions are met is pH 4 to 5. Only 1% of intestinal secretions and no respiratory secretions is 4; 94% of intestinal and 99% of respiratory secretions are pH 7. With H2-receptor blockers, the range of pH for stomach contents may expand to pH 6.

References

1. Metheny NA, Spies MA, Eisenberg P. Measures to test placement of nasoenteral feeding tubes. West J Nurs Res. 1988;10:367-383.

2. Metheny NA, McSweeney M, Wehrle MA, Wiersema L. Effectiveness of the auscultatory method in predicting feeding tube location. Nurs Res. 1990;39:262-267.

3. Metheny NA, Dettenmeier P, Hampton K, Wiersema L, Williams P. Detection of inadvertent respiratory placement of small-0bore feeding tubes: A report of 10 cases. Heart Lung. 1990;19:631-638.

4. Metheny NA, Williams P, Wiersema L, Wehrle MA, Eisenberg P, McSweeney M. Effectiveness of pH measurements in predicting feeding tube placement. Nurs Res. 1989;38:280-285.

5. Metheny NA, Wehrle MA, Wiersema L, Clark J. Testing feeding tube placement: Auscultation vs. pH method. Am J Nurs. 1998;5:37-42.

http://www.aacn.org/AACN/aacnnews.nsf/0/1c37d868f691ae86882569d000047c36?OpenDocument#corner

[hoolahan, ASN, RN]

Even better, more comprehensive, and cites excellent references...

Tube Feeding Care Administration Guidelines, CL 30-14.01

manual: Clinical Policy Manual

categories Gastrointestinal

section: none listed

review responsibility: Clinical Practice Committee

effective date: March, 1983

last revised date: March, 2004

team members performing: RN, LPN, Care Partner/Patient Care Technician

guidelines applicable to: All patient care Areas*, VUH, VCH, VMG

Exceptions: Neontal ICU and Intermediate Nursery

(*VMG includes satellite sites unless otherwise noted)

specific education requirements: none listed

Physician Order requirements: Yes

REDLINE / BLUELINE VERSIONS OF THIS POLICY:

Version Date: 7/31/2003

Version Date: 3/31/2004

--------------------------------------------------------------------------------

Tube Feeding Care Administration Guidelines

Outcome Goal:

To provide for safe enteral nutrition and hydration.

Policy:

The following guidelines and procedures will be followed unless otherwise ordered per physician or contraindicated based on the patient's diagnosis or condition.

Protocol:

General Patient Considerations

Tube feeding is a clean procedure.

Elevate head of bed (HOB) at least 30 degrees at all times when tube feedings are infusing unless contraindicated by medical condition.

Do not administer medications via small bore feeding tubes (e.g., jejunostomy tubes) without a specific physician's order. If medications are ordered to be given through feeding tube,

flush/irrigate before and after drug administration; and

refer to appendix for "Drugs Which Should Not Be Crushed"

If questions arise, check with Pharmacy to determine the following:

drug absorption when mixed with tube feeding,

drug compatibility with feeding solution;

if drug available in liquid form.

if drug is known to coagulate the formula

The addition of blue dye is contraindicated in tube feeding. Addition of dye requires a physician's order.

Minimize air flow into the feeding tube. Do not allow feeding syringe to completely empty.

Weights on admission and then per physician order.

Placement Checks

Verify transpyloric feeding tube placement via X-ray before instillation of initial feeding or medication and as needed for suspicion of inadvertent tube misplacement (e.g., after coughing or vomiting episode).

Verify nasogastric tube placement by withdrawing gastric contents as follows:

INTERMITTENT USE; prior to each bolus feeding or each medication administration;

CONTINUOUS USE; every 4 hours

If unable to withdraw gastric contents, inject air via tube (ADULTS 15-30ml/PEDS 3-5ml) and auscultate with stethoscope for air movement at gastric region (left upper quadrant).

If correct placement is doubtful, hold feeding and notify MD.

Irrigation

Irrigate before and after each intermittent feeding.

Irrigate at least every 8 hours for continuous feeding.

Unless otherwise ordered, use warm water for the irrigant

Use sterile water for infants less than 3 months of age and immune compromised patients.

Amount of fluid used is determined by type of feeding tube and patient's ability to tolerate supplemental fluid volumes. Suggested amounts are:

Adult Tubes 20-50 ml

Pediatric Tubes 10-20 ml

If tube becomes progressively difficult to irrigate or becomes occluded, refer to "Clearing Obstructed Feeding Tubes." See section IV E.

Do not irrigate with smaller than 50-60 ml syringe for adults, 20 ml for PEDS without specific physician's order. With small bore feeding tubes can use 20 to 30 ml syringe.

Formula Considerations:

Shake product well before measuring amount.

If the entire contents of the container are not used at one feeding, label with date and time and refrigerate.

Hang no more than 4 hours of feeding at a time.

Discard remaining formula at the end of each 24 hours.

Change bag every 24 hours.

Procedures:

Continuous Tube Feeding

Equipment:

Continuous Feeding Pump

Pump Administration Set

Feeding Product

Syringe for flushing

Measuring Container

Feeding Tube (see separate procedure for inserting)

IV Pole

Maintain the patient with the head of bed elevated 30 degrees.

If formula is canned, wipe off can with a clean towel before opening.

Close control clamp completely.

Fill feeding flask with desired amount of formula.

Close flask according to instructions on bag.

Hang bag of IV pole.

Remove cover from the pump set connector.

Slowly open the roller clamp to allow formula to fill the tubing completely, inverting drip chamber until half full.

FILL DRIP CHAMBER NO MORE THAN HALF FULL. Pump's electric eye monitors the drip. Overfilling drip chamber will cause occlusion alarm to sound.

Close clamp

Attach pump set connector to feeding tube according to manufacturer's recommendations.

Insert bottom of drip chamber into pump. Grasp silicone tubing and gently stretch around roller on pump.

Insert retainer into pump, set positioning bar, and thread tubing through tubing guide.

Open roller clamp.

Turn pump on. Set rate in ml/hr.

Connect pump set to feeding tube and press "start."

Intermittent Tube Feeding

For pediatrics, the syringe method is preferred. For adults, when intermittent or "bolus" feedings are ordered, the gravity drip method using the feeding bag is the method of choice for providing controlled infusion time.

Gravity Drip Method

Equipment/Supplies:

60ml syringe

cup of water

catheter plug and cover

feeding product

clean towel

stethoscope

emesis basin

feeding set

IV pole

Prepare supplies, measuring required amount of formula and recommended amount of water for irrigation.

Position patient with the head of bed elevated 30 degrees or on right side.

Check gastric residual (or tube placement, where applicable), observe character of aspirate (see procedure, below).

Close roller clamp on feeding set and pour measured amount of formula into bag. Close bag securely.

Prime tubing, and hang feeding set on IV pole.

Remove feeding tube cap and insert tubing adapter.

Begin feeding, adjusting roller clamp to deliver feeding over 15-30 minutes (minimum).

When feeding complete, flush either by pouring water into feeding set or by slow, direct flush with syringe.

Pinch feeding tube, remove feeding set, and plug tube.

Immediately wash all equipment and store in clean area at patient bedside.

Leave patient in feeding position for 30 minutes.

Syringe Method

Equipment/supplies

60ml syringe

cup of water

catheter plug and cover

feeding product

clean towel

stethoscope

emesis basin

Prepare supplies, measuring required amount of formula and recommended amount of water for irrigation.

Position patient with the head of bed elevated 30 degrees or on right side.

Check residual (or tube placement, where applicable), observing character of aspirate (see procedure below).

Pinch feeding tube and attach syringe without plunger.

Pour feeding into barrel of syringe.

Holding the syringe so that formula will flow slowly by gravity (Adults: 18 to 24 inches above the stomach) release tubing and allow feeding to flow in slowly by gravity.

NEVER force feeding with plunger

Holding syringe too high or using force to instill feeding causes rapid distension and will likely result in cramping. nausea, vomiting, and diarrhea.

Encourage infants to suck a pacifier during feedings.

Refill syringe barrel as necessary, ensuring no air enters feeding tube. Delivering total volume over minimum time or more:

ADULTS: 30 minutes;

PEDS: 15 minutes;

INFANTS less than 3.5Kg; 5ml per 5 to 10 minutes

When formula is complete, flush by following formula with prescribed fluid and/or water.

When flush complete (i.e., fluid is at tip of syringe), pinch tubing, remove syringe over emesis basin and plug tube.

Immediately wash all equipment and store in clean area at patient bedside.

Leave patient in feeding position for 30 minutes.

Gastrosomy Button Feedings

To identify the type of button, see diagrams in attachments.

Equipment

Bard Button

Feeding extension set: Specify French size of button and if continuous or bolus feeding set:

Twist the button in a full circle. If it does not turn easily, do not give the feeding and notify physician.

Open the tab/plug from the button.

Insert the feeding extension set.

The Mic-key extension has the ability to lock when inserted into the button. Once the extension is inserted, turn the tube in the direction of the arrow until locked. This will prevent disconnection.

Follow procedures for delivering continuous or intermittent (syringe method) tube feeding.

When delivering medications, always use extension set and 60 ml syringe.

Connect extension set to button, attach syringe to open end of tube, and place medication into syringe.

Directly inserting small syringes into buttons may damage the anti-reflux valves.

When feeding is completed, remove the feeding extension set and close the tab/plug on the button.

Rinse feeding extension set after every use.

Assessing for Signs of Gastric Intolerance

Assess for clinical signs of intolerance at least every 8 hours.

Assess abdomen for distention/cramping - tense abdomen, guarding, rebound, or rigidity on exam.

Assess for presence of aspiration/regurgitation - food in lungs/food in oropharynx or nasopharynx on routine oral care.

Assess for presence of vomiting.

Assess for presence of diarrhea - greater than 3 liquid BM's per day.

Assess for presence of constipation.

Assess gastric residuals.

If shows signs of intolerance, then increase frequency of assessment to every four hours.

Checking for Gastric Residual

Frequency:

Continuous feedings: perform at least every eight hours.

Intermittent feedings: perform before each feeding.

Exceptions: transpyloric/jejunostomy feeding tubes (cannot check gastric residual).

Equipment:

60 ml syringe

Graduated measuring container

Towel

Disconnet feeding set from tube (continuous) or unplug tube (intermittent).

Insert syringe into end of tube, assuring it is secure.

Utilize syringe no smaller than 50 - 60 ml in size for adults, 20 ml for PEDS.

Pull back on syringe barrel until no more gastric contents can be aspirated. May need to empty syringe into clean measuring container and aspirate more than once if residual is over 60 ml.

Is aspirate appears coffee ground or bleeding is suspected, check for occult blood and notify physician.

If aspirate appears curdled or undigested, notify physician.

Note volume and return aspirated contents.

ADULTS (use guidelines if no specific order):

If the residual is less than 300 ml, return aspirate and continue feeding.

If the residual is greater than 300 ml, return 300 ml of aspirate, irrigate tube, and hold feeding. Unless otherwise ordered, re-check residual in two hours.

Residual check two hours after holding feeding if less than 300 ml resume tube feeds. If greater than 300 ml notify the physician and return 300 ml of aspirate.

PEDS: The physician may specify the amount of residual for which s/he should be notified. If there is no order, stop the feeding and notify the physician when a residual is greater than 2 times hourly rate for continuous and greater than 1/3 feeding volume for bolus.

Clearing Obstructed Feeding Tubes (Adults)

NOTE: for Pediatrics, notify MD.

Equipment

Declogging solution from Pharmacy

(one tablet pancrease mixed with 5 ml sodium bicarbonate in solution)

Syringe (greater than 20 ml unless specified otherwise by MD)

Water for flush

Check for known allergy to pork protein or hypersensitivity to pancrealipase trypsin or pancreatin.

Obtain physician's order to "declog obstructed feeding tube with pancrealipase/bicarbonate solution per guidelines."

NOTE: other solutions, though recommended in certain nursing literature, are rarely successful. (See References)

Obtain declogging solution from Pharmacy.

Immediately upon receipt draw up solution in 20 ml or greater syringe and manually flush and clamp tube.

NOTE: To insure proper pH solution must be used within 60 minutes of mixing.

Wait 10 to 30 minutes and attempt to flush tube with water.

If tube flushes, proceed with use.

If tube remains obstructed, repeat steps 2 through 5 once. If tube remains obstructed, notify physician.

Care & Dressing of Percutaneous Tube Site:

Equipment:

Split gauze 4 x 4's

Tape

Cotton swabs

Mild soap and water

Remove soiled dressing from tube site. Observe for erythema, granulation tissue, or copious drainage from tube site.

Cleanse around tube site and/or sutures with cotton swabs and mild soap and water.

Cover tube site with 2 layers of split gauze.

Tape dressing securely and label with date, time, and initials.

Tape the tube securely to the skin so that it is not hanging freely, putting stress on the sutures holding it in and stablilizing the tube.

Should be performed at least every other day unless otherwise ordered.

Nursing Implications:

If the following signs of intolerance are present; discontinue feeding and call physician.

Change is respiratory rate, rhythm, or breath sounds;

coughing;

swallowing or gagging;

vomiting.

Suction the patient, if necessary.

If patient exhibits distention, cramps, constipation, diarrhea, or signs of thirst, notify physician.

When a patient has a cuffed tracheostomy, the cuff must be inflated during feeding and for 30 minutes following feedings unless otherwise ordered.

Monitor tube site for signs of infection (erythema, pain, purulent drainage) or tube malfunction (copious drainage, skin breakdown).

Patient/Family Education:

Purpose of tube and feeding.

Feeding schedule and procedure.

Circumstances for which to notify health care team.

Home care procedures, where applicable.

Need for keeping site clean and procedure for cleaning.

Documentation:

Procedures are documented on the patient care flowsheet applicable to the practice area.Document education in Notes or Teaching Record, as applicable to area.

Cross References:

Clinical Policy Manual

30-08.11 Gastric Occult Blood and pH Point of Care Testing

PATIENT EDUCATION MATERIALS:

EZTV Video "Home Tube Feeding, Continuous/Intermittent"

TEACHING BOOKLETS:

"Mastering the Technique of Tube Feeding at Home by Gastrostomy or Jejunostomy." (1991), Ross Laboratories, Inc. (Free: available from The Learning Center).

"Mastering the Technique of Tube Feeding at Home by Nasogastric, Nasoduodenal, or Nasojejunal Tube." (1988), Ross Laboratories, Inc., (Free: available from The Learning Center).

PATIENT EDUCATION INDEX (THE LEARNING CENTER):

"Home Care Instructions: Gastrostomy Tube" DN# 0006-HC-87

"Home Tube Feeding: Intermittent Gravity Drip" DN# 0003-HC-86

"Home Tube Feeding: Continuous Drip with Pump" DN# 0004-HC-86

"Home Care Instructions: Gastrostomy Button" DN# 0141-HC-93

VIDEOS IN FAMILY RESOURCE CENTER

"Making That Important Decision: Parents' Perspectives on a G-Tube."

"Life After Your Child's G-Tube Placement."

References:

McClave SA, Sexton LK, Spain DA, Adams JL, et al (1999) Enteral Tube Feeding in the Intensive Care Unit: Factors impeding adequate delivery. Critical Care Medicine. 27(7): 1252-1256.

Spain DA, McClave SA, Sexton LK, Adams JL, et. al. (1999) Infusion Protocol Improves Delivery of Enteral Tube Feeding in the Critical Care Unit. JPEN: Journal of Pareneteral and Enteral Nutrition. 23 (5): 288-292.

Mallampalli A, McClave SA, and Snider HL. (2000) Defining Tolerance to Enteral Feeding in the Intensive Care Unit. Clinical Nutrition. 19(4):213-215.

Maloney, J. P., et al. Food Dye Use in Enteral Feedings: (2002) a Review and a Call for a Moratorium. Invited Review. Nutrition in Clinical Practice. 17:169-181. June 2002.

ASPEN Board of Directors and the Clinical Guidelines Task Force. (2002) Guidelines for the use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients. JPEN: Journal of Parenteral and Enteral Nutrition. 26(1suppl): ISA - 138 SA.

Roberts S. R., Kennerly D. A., Keane D., George C., (2003) Nutrition Support in the Intensive Care Unit. Adequacy, timeliness, and outcomes. Critical Care Nurse. 23 (6): 49 - 57.

Endorsement: Clinical Practice Committee - January 2004

APPROVED:

/s/ MARILYN DUBREE, Director, Patient Care Services & Chief Nursing Officer Date 3-16-04

/s/ Jim Shmerling, Chief Executive Officer, Vanderbilt Children's Hospital Date: 3-19-04

Copyright/Reprint Permission

This policy ©2004 by Vanderbilt University. All rights reserved. Requests for republication should be directed to:

Department of Accreditation & Standards

1161 21st Avenue South

A-1223 MCN

Nashville, TN 37232-2183

or email to:

[email protected]

http://vumcpolicies.mc.vanderbilt.edu/E-Manual/Hpolicy.nsf/AllDocs/65D3362B2E527EE986256928007A6571

[hoolahan, ASN, RN]

Medications That Should Not Be Crushed

Joan Murhammer, R.Ph., Mary Ross, R.Ph., M.B.A., Kevin Bebout, R.Ph.

Peer Review Status: Internally Reviewed

--------------------------------------------------------------------------------

If a liquid formulation of a medication is not available, it is sometimes desirable to crush a medication for a patient who is experiencing difficulty swallowing tablets/capsules or has a nasogastric tube placed. However, due to special pharmaceutical formulations of some medications, crushing the tablet/capsule may be an unsafe practice. Some reasons why certain medications should not be crushed before administration include:

Crushing a sublingual or buccal tablet may cause the drug to be ineffective.

When enteric-coated tablets are crushed, the drug is released too early and may be destroyed by stomach acid or irritate the stomach lining.

Extended-release formulations should not be crushed because they may cause an increased risk of adverse effects or potentially deliver a toxic dose of the active ingredient. Many extended-release formulations have abbreviations affixed to their name (e.g., CR, LA, SR, XL, XR) to identify them as extended-release.

Crushing products with carcinogenic/teratogenic potential may expose handlers to health risks through aerosolization of the product.

Fragility, bitter taste, local anesthetic effect, the ability to stain teeth, and irritation of the mouth or esophageal mucosa.

A partial list of medications that should not be crushed includes:

Enteric-coated:

Bisacodyl (Dulcolax®), enteric-coated aspirin (Ecotrin®), lansoprazole (Prevacid®), omeprazole (Prilosec®), pancrelipase (Pancrease®), divalproex sodium (Depakote®), many erythromycin products

Extended-release:

Diltiazem controlled-dissolution (Cardizem CD®), fexofenadine/pseudoephedrine (Allegra-D®), mesalamine (Asacol®, Pentasa®), verapamil sustained-release (Calan SR®, Isoptin SR®), oxybutynin extended-release (Ditropan XL®), propranolol long-acting (Inderal LA®), tamsulosin (Flomax®), divalproex sodium extended-release (Depakote ER®), many theophylline products

Bitter taste:

Cefuroxime (Ceftin®), ciprofloxacin (Cipro®), docusate (Colace®), ibuprofen (Motrin®)

Irritant:

Alendronate (Fosamax®), atomoxetine (Strattera®), diflunisal (Dolobid®), isotretinoin (Accutane®), piroxicam (Feldene®), risedronate (Actonel®), valproic acid (Depakene®)

Safety:

Finasteride (Proscar®), mycophenolate (Cellcept®), other cancer chemotherapy agents

Anesthetizes local mucosa:

Benzonatate (Tessalon Perles®)

Fragility:

Mirtazapine (Remeron SolTab®), olanzapine (Zyprexa Zydis®)

Ability to stain teeth:

Amoxicillin/clavulanate (Augmentin®), linezolid (Zyvox®), iron products

If you need a liquid formulation of a medication or if there are any questions regarding the acceptability of crushing certain medications, please contact the Pharmacy serving your area or the Drug Information Center (6-2600).

-------------------

Adapted from:

Mitchell JE. Oral Dosage Forms That Should Not Be Crushed: 2000 Update. Hospital Pharmacy. 2000; 35:553-7.

Miller H, Miller D. To Crush or Not to Crush. Nursing. 2000; 30:50-2.

http://www.vh.org/adult/provider/pharmacyservices/RXUpdate/2004/04rxu.html

http://216.239.39.104/search?q=cache:780Uc6rYZ2sJ:www.hospital.uic.edu/hosppharmacy/donotcrushlist.pdf+Drugs+Which+Should+Not+Be+Crushed&hl=en

[hoolahan, ASN, RN]

http://www.ross.com/productHandbook/devices.asp

[zacarias, ASN, RN]

Reality: Research has shown that air insufflation is an unreliable indicator of placement. It does not distinguish between respiratory and gastric placement, nor does it distinguish location within the gastrointestinal tract. In a series of studies,1-5 Metheny and colleagues described the false reassurance air insufflation gives regarding placement. In one study, air was heard in the epigastrium 100% of the time. However, 18 tubes were found to be in the stomach, 11 in the duodenum, three in the jejunum and two in the esophagus. In another study, nurses correctly identified tube location via air insufflation 34% of the time, the same rate one would expect by chance. In yet another study, nurses reported hearing air in the epigastrium in nine of 10 patients whose tubes were found to be in the respiratory tract.

]

Thanks hoolahan for posting these articles. I wonder how many nurses know the above. EVERYONE does air insufflation. A major shift in practice needs to occur and inservices.

[Dixiedi]

LTC LPN - Don't you change tubes? I was suprised when I read they have to go to hosp for tube replacement.

Earle 58 - We always keep spare g-tubes or buttons just for replacement for damage or age. Usually damage, they never seem to last long enough to have to be replaced because of age with all the pulling and tugging so many kids seem to be able to "give" their tubes.