Medication via peg

HealthyRN · Jun 19, 2005

I'm still in nursing school and we learned to administer everything separately, because if the tube should become plugged, you must know what has went down and what hasn't. If you were to mix everything together, you wouldn't be able to tell which medications and how much of it the patient received. If you do them separately (which is really not practical and takes a lot more time, but is the correct way), you should at least be able to identify which meds the patient didn't get. I hope this helps!

Carlos Casteneda · Jun 20, 2005

I'm still in nursing school and we learned to administer everything separately, because if the tube should become plugged, you must know what has went down and what hasn't. If you were to mix everything together, you wouldn't be able to tell which medications and how much of it the patient received. If you do them separately (which is really not practical and takes a lot more time, but is the correct way), you should at least be able to identify which meds the patient didn't get. I hope this helps!

It makes a lot more sense when you look at it from that perspective

thank you

Julian

Carlos Casteneda · Jun 22, 2005

It makes a lot more sense when you look at it from that perspective
thank you
Julian

This is what i have ended up with i am posting it for criticism please feel free to comment.

New House best practice statement

RE:Administration of medication via PEG

Date: 20/06/2005

Patient safety is enhanced when those administering medicines understand and apply the principles of pharmacology, (Jordan 2003).

If prescribed medications are to realize their therapeutic potential, healthcare professionals need to focus on the details of drug administration, (Jordan 2003).

This statement is confined to enteral administration

Some drugs, for example, warfarin, phenytoin, sucralfate and syrup formulations, are known to interact with enteral feeds and/or gastric acid and should be administered following a cessation of feeding of at least two hours. Drugs whose absorption is decreased by food should also be administered following a cessation of feeding of at least two hours.

(1)Nurses should be aware of any reactions and plan medication administration accordingly.

Enteral feeding tubes can sometimes block. This can be due to medications being incompletely crushed or forming clumps when exposed to moisture Opening a capsule or crushing a tablet before administration will (in the majority of cases) make its use 'unlicensed'. Under the Medicines Act 1968 only medical and dental practitioners can authorise the use of 'unlicensed' medicines in people. It is, therefore, strictly illegal to open a capsule or crush a tablet before administration without prescriber authorisation. Chewing medication before swallowing must also be carefully considered because this practice can have the same effect as crushing tablets or opening capsules.(Wright 2002 b)

(2) Nurses should ensure that, wherever possible, medicines are translated to liquid form. If, for any reason a liquid alternative is not available, authorisation for unlicensed medication administration (crushing of tablets or opening of capsules) should always be obtained from the prescriber in writing and not accepted verbally. If there is no alternative, crush tablet or open capsule and mix with 10-15ml of freshly boiled and cooled water Draw up into 50ml syringe flush tube with 30ml of water before drug administration, administer each drug separately, flushing the tube with 5ml of water in between each medication. The syringe should also be flushed between each administration, flush the tube with 30ml of water after administration is complete. There are certain medications which should never be crushed, Wright D (2002a) provides a list of medications that should never be crushed or opened. It is based on lists published in the United States and Canada (Glustein 1984, Mitchell and Pawlicki 1992) and acts as a useful guide for healthcare practitioners in the UK, as there is currently no official list here.

In many clinical areas, the margin for error in drug administration is now very narrow. Unless administration issues are addressed, the amount of drug entering the body can fluctuate, resulting in either therapeutic failure or serious adverse effects. It is extremely important that nurses consider any factors which may affect drug bioavailability and employ strategies to deal with any problems which could arise. Food may bind to drugs, keeping them in the intestines and decreasing absorption, to a varying degree. Examples include frusemide/furosemide, calcium antagonists, erythromycin stearate, tetracyclines and iron preparations. Antacids and guar gum bind in a similar way to many drugs, particularly enteric-coated preparations (Stockley 1999) Some foods and herbs can interfere with metabolism and increase or decrease the effects of certain drugs. Re-timing administration of medicines may not prevent these drug/food interactions. When medications have to be administered through PEG tubes, they should be in liquid form, diluted if appropriate. However, it is important to seek advice as not all oral liquids are suitable for PEG tube administration, for example, co-amoxiclav and lansoprazole suspensions may form clumps; and diazepam, and possibly carbamazepine, adhere to plastic tubes (Naysmith and Nicholson 1998).Due to the fact that any failure to consider the details of formulation variables, drug interactions or administration schedules may compromise the efficacy of therapeutic regimens and even patient safety, pharmacists, doctors, patients and, if appropriate, carers should be consulted by nursing staff regarding medication regimens The following is given as an example of best practice as far as administration of medication via peg is concerned.(see Jordan 2003).

Handwashing will reduce the risk of infection.

To reduce the risk of tube blockage:

Administer medicines when the patient is not receiving enteral feeding, if possible. Alternatively, stop the feed for 15-60 minutes before drug administration. This is easier if drugs are only administered once or twice per day.

Administer each medicine separately, flush tube with 30ml (10ml-30ml in some guidelines) sterile (*) or boiled water cooled to body temperature before and after administering medicine, and with at least 10ml between medicines. Use 50ml syringes to avoid pressure damage to the feeding tube and breakage.

If patient is on restricted fluids record water administered on the fluid balance chart.

Drugs should be administered as liquids formulated for oral administration, if at all possible. However, not all these are suitable It may be necessary to dilute viscous (thick) or concentrated liquids with at least an equal volume of sterile(*) water .

Soluble/dispersible tablets thoroughly dissolved in sterile (*) water may be an alternative.

In consultation with doctors and pharmacists, it may be possible to use injectable forms of medication, short term, but doses will need to be adjusted. Some intravenous medicines, for example, diazepam, adhere to plastic tubes.

If it can be demonstrated that all professionals agree that there is no alternative (for example, warfarin), tablets should be finely crushed and administered as a dilute solution with sterile (*) water. Wear gloves to reduce exposure.

Enteric-coated, sustained release, modified release, sublingual, chewable tablets, nitrates, cytotoxics, hormones, steroids, prostaglandins and pancreatic enzymes should never be crushed.

Avoid bulk-forming laxatives as these will expand on contact with moisture and block the feeding tube.

Avoid antacids, as these may interact with the feed and block the tube.

Many medicines are incompatible with enteral feeds. Interactions can occur, which could block the feeding tube. Avoid co-administration, unless this has been approved by the manufacturer or pharmacist. No drugs should be administered with Fresenius Kabi feeds

To minimise adverse drug reactions:

Be aware that concentrated (hyperosmolar) medicines, particularly those containing sorbitol (in some sugar-free preparations) can cause diarrhoea when administered enterally.

Consider the emetic potential of all medications. PEG feeding, particularly if administered rapidly, can cause nausea. Co-administration of a medication that has nausea as a side effect is likely to exacerbate these problems

Constipation is a common problem in this client group. This is exacerbated by drugs which inhibit colonic motility, for example, tricyclic antidepressants and opioids.

Due to changes in bioavailability caused by change in route of drug administration, change from tablet to liquid formulation or possible interaction with the enteral feed, it is important to monitor patients for both adverse effects of medication and therapeutic failure.

(*) Some authorities consider boiled water cooled to body temperature an adequate substitute for sterile water in these circumstances. Manufacturers of the giving sets advise against use of tap water (Fresenius Kabi 2000). A few medicines, for example, ciprofloxacin suspension, interact with the ions in tap water and must be administered with sterile water (Thomson et al 2000). (BAPEN 2003, Chadwick and Forbes 1996, Fresenius Kabi 2000, Nutricia 1996, Nutricia clinical care team (2002), Pine 1999, Whitney et al 2001)

References

1.BAPEN (2003), British Association for Parenteral and Enteral Nutrition Administering Drugs via Enteral Feeding Tubes: A Practical Guide. London, BAPEN.

2.Chadwick C, Forbes A (1996) Pharmaceutical problems for the nutrition team pharmacist. The Hospital Pharmacist. 3, 6, 139-143.

3.Fresenius Kabi (2000) Gastrostomy Aftercare Booklet for Patients and Carers. Runcorn, Fresenius Kabi.

4.Glustein J (1984) To crush or not to crush: administering solid medication to the elderly patient. Perspectives. Winter, 12-14.

5.Mitchell J, Pawlicki K (1992) Oral dosage forms that should not be crushed. Hospital Pharmacy. 27, 690-699.

6.Howell 2000

7.Jordan S et al (2003) Administration of medicines part 2: pharmacology. Nursing Standard. 18, 3, 45-54.

8.The Medicines Act 1968 (Commencement No. 8) Order 1989, ISBN 0110961927. Medicines Act 1968. London HMSO

9.Naysmith M, Nicholson J (1998) Naso-gastric drug administration. Professional Nurse. 13, 7, 424-451

10.Nutricia (1996) The Flocare Gastrostomy range. Trowbridge, Nutricia Clinical Care.

11.Nutricia clinical care team (2002) Unpublished Personal communication. cited in Jordan S et al (2003)

12.Pine M (1999) Home enteral nutrition. In Van Way C (Ed) Nutrition Secrets. Philadelphia, Hanley & Belfus

13.Stockley I (1999) Drug Interactions. Fifth edition. Oxford, Blackwell Science.

14.Thomson F et al (2000) Managing drug therapy in patients receiving enteral and parenteral nutrition. Hospital Pharmacist. 7, 6, 155-

15. Thomson F et al (2000) Managing drug therapy in patients receiving enteral and parenteral nutrition. Hospital Pharmacist. 7, 6, 155-164

16.Wright D (2002a) Medication administration in nursing homes. Nursing Standard. 16, 42, 33-38.

17.Wright D (2002) Swallowing difficulties protocol: medication administration. Nursing Standard. 17, 14-15, 43-45.

JD

doliveri · Jul 9, 2005

I have been given the dubious honour of writing a best practice statement concerning the administration of medication via peg tube.
I have found a suggestion that we should administer each individual liquid medication seperately
Wright D (2002) Swallowing difficulties protocol: medication administration.
Nursing Standard. 17, 14-15, 43-45. Date of acceptance: September 28 2002.
This table has been designed to help minimise tube blockage
Action
Liquid (A) Steps Dispersible tablet (B) Tablet or capsule ©
1 (A)Shake the mixture or suspension
(B)Mix with 10-15ml of freshly boiled and
cooled water
©If there is no alternative, crush tablet or open capsule mix with 10-15ml of freshly boiled and cooled water
2 (ABC) Draw up into 50ml syringe
3 (ABC) Flush tube with 30ml of water before drug administration
4 (ABC) Administer each drug separately, flushing the tube with 5ml of water in between each medication. The syringe should also be flushed between
each administration
5 (ABC) Flush the tube with 30ml of water after administration is complete
The only problem is that it doesnt say why and my nurses are saying what is the diference betwween putting all meds in one beaker and flushing before and after (as everything will be mixed up when it is in the patients stomach anyway), can anyone shed some light

I believe that if you crush all the meds and flush down the tube at once, you run the very high risk of clogging the tube, and secondly, if your patient should have a reaction to something you just gave, you would not know what it was exactly, not how to treat it. It is very time consuming, but it is the correct way and the safest method for the patient.

Dee

cursenurse · Jul 9, 2005

i was told a long time ago that you didn't mix everything up together and give it because of the chemical composition of everything. the view was that you are not a pharmacist, you don't know what chemicals are compatible. perhaps it's the same rationale used to explain why one wouldn't just mix up a bunch of iv meds together-compatibility.

i just spoke with our pharmacist who says that the rationale is 1. absorption being adversely affected by mixing them all together. 2. that giving a bunch at a time can clog the tube, and as others posted-you don't quite know what got through, and what didn't.

MissJoRN, RN · Jul 9, 2005

opening a capsule or crushing a tablet before administration will (in the majority of cases) make its use 'unlicensed'. under the medicines act 1968 only medical and dental practitioners can authorise the use of 'unlicensed' medicines in people. it is, therefore, strictly illegal to open a capsule or crush a tablet before administration without prescriber authorisation. chewing medication before swallowing must also be carefully considered because this practice can have the same effect as crushing tablets or opening capsules.(wright 2002 b)

ok, so here's my legal loophole question... is a drs order for "2 ativan tablets...by gt" implicitly an order to crush/dissolve? i see a lot of tablets and capsules in homecare ordered to be given by gt, but never an explicit order to crush or open. in some cases, such as my kids on ketogenic diets, there is no other way. (and i'm not even going to touch other necessary practice deviations to take care of these kiddles)

Carlos Casteneda · Jul 9, 2005

opening a capsule or crushing a tablet before administration will (in the majority of cases) make its use 'unlicensed'. under the medicines act 1968 only medical and dental practitioners can authorise the use of 'unlicensed' medicines in people. it is, therefore, strictly illegal to open a capsule or crush a tablet before administration without prescriber authorisation. chewing medication before swallowing must also be carefully considered because this practice can have the same effect as crushing tablets or opening capsules.(wright 2002 b)
ok, so here's my legal loophole question... is a drs order for "2 ativan tablets...by gt" implicitly an order to crush/dissolve? i see a lot of tablets and capsules in homecare ordered to be given by gt, but never an explicit order to crush or open. in some cases, such as my kids on ketogenic diets, there is no other way. (and i'm not even going to touch other necessary practice deviations to take care of these kiddles)

we now ask doctors to actually give us written permision to crush tablets or open capsules if there is no alternative. in most cases they change the order, say from ativan to diazepam before they will put their name on the line .

can i thank everyone for the replies, most wellcome.

doliveri · Jul 10, 2005

Thank you for sharing this.

VickyRN, MSN, DNP, RN · Sep 7, 2005

This is great information. Thank you so much for sharing.

The area teaching hospital states this in their policy and procedure:

If medication is administered through the feeding tube, observe the following guidelines:
a. Obtain drugs in a liquid form if possible.
b. If the drug is not available in liquid form, consult the pharmacy.
c. Calculate equivalent liquid dose carefully as many liquid dosage forms are for pediatric use.
d. If crushed tablets or Solutabs are to be administered, crush to a fine powder and mix in water. Do not crush drugs with enteric coatings or sustained release action.
e. Administer drugs separately. Do not mix all medications for one dosing time in one container.
f. Adults: Flush the tube with 10 ml of water prior to giving the medication and before restarting the tube feeding.
Pediatrics: The volume of water to use for medication flushing is dependent upon the priming volume of the tube. Only 1-5 ml may be administered. For patients on water/fluid restriction, note physician's order for alternative method.
g. Drugs hypertonic or irritating to the gastric mucosa, e.g., potassium chloride, should be diluted in 60-90 m. of water or other clear liquid before administering.
h. If medication is to be added to a feeding, observe for any reaction or precipitation. Shake the solution thoroughly. Medications may be administered by gravity infusion via syringe rather than via pump.
Tube fed patients ordered to received phenytoin or ciprofloxacin should have these drugs scheduled to be administered at least 2 hours before or after the tube feeding is administered to avoid a drug/nutrient reaction.
Pediatric patients: The abdominal girth is measured on initial assessment, each shift, and with discretion, during the shift.

Concerning tube feedings and medications, the September, 2005 edition of Nurse-Advise-ERR (volume 3, issue 9) states:

Serious drug-nutrient interactions that alter the bioavailability of drugs may be poorly recognized with enteral feedings. The most notable interactions occur with phenytoin, quinolones, and warfarin (Finch C, Self T. Medication and enteral tube feedings: clinically significant interactions. J Crit Illness. 2001; 16:20-21). The administration of these drugs must be coordinated with schedules for withholding and restarting the feeding. For example, one drug reference (Micromedex) recommends holding the feeding for 2 hours before and after giving the drug. Ask a pharmacist for a list of the most serious interactions. If using computer-generated medication administration records, also ask the pharmacy to include a special warning about important drug-nutrient interactions with the drug entry.

Clarkster000 · Nov 15, 2009

Hi, I am a nursing student currently and on Monday is my return demonstration for medication administration via peg tube. We are told to administer one med at a d/t drug drug interactions. Example is what if the drugs started to melt the tube? Anyway this is what they told us when demonstrating the skill.