New nurse on the floor

[Tinkers33]

Good evening

So I am a new nurse and am training at my new job. Since I will be a float I'm spending two days on each hall, four halls total. We are a skilled nursing rehab with one hall devoted to long term skilled nursing. My question is this: I know there is by the book school nursing and real life nursing, regardless I do do everything I can to be by the book. Today I was on the long term hall and had two PEG tube patients. All of their meds needed to be crushed, then mixed with water to give via tube. I was told you never mix meds, you give them separately. The nurse I was training with mixes them all together. Cough meds, BP meds, fiber and so on. When I went to give the meds I was separating them and was told "you don't have time for that. You will never get meds done on this hall if you separate them." To make matters worse, our med aid was also irritated that I was doing this because i was taking too long. My long story question is this, what is ok to do?

Thanks all

[NurseOnAMotorcycle, ASN, RN]

Yes it's ok to do them all separately. If they are compatible meds, it's probably a time management issue. Also, who exactly said that it was never ok? It may be a matter of being a broad blanket statement by an instructor to avoid new nurse medication errors rather than a hard rule.

On the flip side, cutting corners to save time is a common problem across nursing. They could be rushing too fast in order to try to care for many patients and be causing an increased likelihood of error.

If you have any pharmacy friends, just ask them what their opinion is. I'd be more likely to trust that than an overly meticulous instructor or corner cutting coworkers.

/yay for alliteration!

[Tinkers33]

My NCLEX prep study questions and my instuctors said to never mix so of course I thought this was a set in stone rule. I'm not confident on med compatibility so that is something I need to look further into

[westieluv]

You're right, you're not supposed to mix them, both for potential incompatibility and because the more medication, the less likely they will all dissolve effectively and the more likely you will be to clog the PEG tube. A clogged PEG tube is a royal pain in the neck for everyone. However, the nurse you are working with is probably right too, not in how she is administering the meds, but that if she doesn't do it that way she will never get through her med pass.

It's a tough situation: do things the right way and take eons to do your med pass, thus pushing your treatments, admissions, etc., back even further, or take shortcuts so that you can get all your work done. Some choice, isn't it?

[Tinkers33]

What medications are incompatible? Just wondering

[CardiacDork, MSN, RN]

Dude seriously? You are an RN now! Take practice into your own hands and use your judgement. Weigh the pros and cons. Sometimes you have to mix all the medications together to save time in order to see all your patients.

I certainly don't have time to mix all the medications and administer them ONE by ONE. I work in critical care - so ALL my patients have an NGT or OGT (prevent aspiration and give PO meds). Do you think giving each PO med is worth time taken away from more important tasks?

Yes the book says this - but the reality is you are too busy to worry about that.

Book nursing is acceptable for somethings, I can tell you it is not for this.

[AMN74]

What is the difference in swallowing a med cup of pills at once or putting the pills in the tube all at once? Be aware of the meds that are DO NOT CRUSH, of course. They are all going to the same place (if it's a g tube) at the same time. I'm an OLD nurse and was honestly NEVER taught not to mix the meds.

[Cowboyardee]

What medications are incompatible? Just wondering

There are more things than I can list really.

Here's a table listing medications that should be taken on an empty stomach vs meds that should be taken with food:

Drug-Food interactions: what medications should be taken on an empty

stomach or with food. Includes newer agents as well

Then there are medications when inhibit each other's actions. For example, calcium inhibits the absorption of iron, as do H2 blockers and PPIs. Iron, antacids, and phosphate binders inhibit the absorption of synthroid.

Dilantin, notoriously, should have tube feeds stopped before and after administration, and may be ill-suited to co-administration with some other medications for this reason.

I'm sure I'm forgetting much more than I'm remembering to include here.

[NotAllWhoWandeRN, ASN, RN]

Do you have access to a pharmacist or pharmacy reference through the employer? I was never taught that you must administer every med separately, but that you must check compatibility.

They're all going to the same place, but first they're all crushed and swimming together with little dilution and no stomach acid. It's not the same as a person swallowing those tablets at the same time.

I don't remember any specific contraindications, though, and I've personally never seen or heard of an adverse event from mixed g-tube administration.

[Alex_RN, BSN]

Every new grad has this very same experience at my LTAC. I remember being very anxious about it. I recently learned the tip of carefully crushing very small pills while still in their foil capsule instead of in the plastic crushing sheath. Less wasted/lost pill dust.

[Kitiger, RN]

There are more things than I can list really.

Here's a table listing medications that should be taken on an empty stomach vs meds that should be taken with food:

Drug-Food interactions: what medications should be taken on an empty

stomach or with food. Includes newer agents as well

Then there are medications when inhibit each other's actions. For example, calcium inhibits the absorption of iron, as do H2 blockers and PPIs. Iron, antacids, and phosphate binders inhibit the absorption of synthroid.

Dilantin, notoriously, should have tube feeds stopped before and after administration, and may be ill-suited to co-administration with some other medications for this reason.

I'm sure I'm forgetting much more than I'm remembering to include here.

Those meds that inhibit each other should be given at different times. And, of course, you don't crush long-acting or enteric coated meds: ask the doctor to order the correct form for GT administration.

It important to flush the tube with a little bit of water first, to be sure the tube is clear, and to do a good flush after all the meds are in.