GTube, med administration..HELP - page 4

by perksrn 31,258 Views | 38 Comments

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... Read More


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    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.ns...ocument#corner
  2. 1
    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:

    susan.moseley@vanderbilt.edu

    http://vumcpolicies.mc.vanderbilt.ed...256928007A6571
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    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/pha...004/04rxu.html

    http://216.239.39.104/search?q=cache...+Crushed&hl=en
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  5. 0
    Quote from hoolahan
    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.
  6. 0
    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.
  7. 0
    Quote from 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.

    yes in a perfect world, there would be backup for those pts. that have gtubes.

    actually there was never any problem with supplies until the DON decided that she and the ADON would be the only ones to order supplies via a secret pin #, which we weren't privy to. that's when all the problems began.

    and then there were 'some' that when a gtube was pulled out, nothing was placed in the stoma, thus it closed up. :stone
  8. 0
    Quote from LTC_LPN
    As a LTC nurse, I always check for placement before I do anything else. When giving meds through a g-tube, I crush the med powder fine, then mix with a little water (unless it's contraindicated). For liquids, I'll give them as-is, then follow up with the flush as ordered...usually 60 or 120 cc water. The best way to give the meds is by gravity, but we all know that some of these tubes just DON"T cooperate that way...you can stand there for 30 minutes and the syringe is still full! So a gentle push is all that's needed. I'm a firm believer in properly flushing these tubes....if one is ever found stopped up when I come on duty, it's a write up. Period. If flushed correctly and as ordered, they should never become stopped up. And I've un-stopped some whoppers in my time!:angryfire :angryfire :angryfire

    Edit: Also, I never intentionally push air into a resident. Although I've read of other nurses "unstopping" tubes by forcefully pushing air through the tube...which ends up giving the res a painful case of gas! And I've heard of nurses using soda pop to unstop tubes, too. Our facility uses de-cloggers but only as a last resort. I have save many from an unnecessary trip to the hosp for tube replacement because I was able to unclog the tubing. What's bad is when the lazy nurse sends the res to the ER with a stopped up tube and the ER flushes it and sends them right back...and the family gets the ambulance & hosp bill for $$$ and demands to know what happened...while the Er staff is laughing at us for being "those idiots at the nursing home"....
    Why not use "write up" as a last resort. Maybe re-education is in order. Fellow nurse may appreciate your tips and expertise.
  9. 0
    Quote from DANRN2000
    Why not use "write up" as a last resort. Maybe re-education is in order. Fellow nurse may appreciate your tips and expertise.
    It's no longer a "last resort" because I've worked with the same nurses at the same nursing home now almost 2 years...and we've been inserviced and inserviced on this subject repeatedly. Yet amazingly, we still have the same problems. Notes left in the med room about flushing tubes, notes left on the pumps as reminders. Some people are just plain lazy...and they don't care. But since we're so short staffed, our dept. heads are happy to have the nurses we do have.:angryfire


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