Personal conflicts with orders

Published Aug 14, 2011

115 Posts

Specializes in Labor and Delivery, Newborn, Antepartum.

I've had this situation happen to me twice recently. I talked with my manager about the situation and her only advice was to talk to the physcian. I am wondering if anyone else would question the following situation? I am just out of my first year as a nurse, and this is the first time I've ever felt like the orders I were given regarding the care of my patients weren't appropriate. Here's the situation:

Both times this has occured on a term infant, with poor feeding in the first 24 and 48 hours, but has not lost more than 10% of their body weight. Both kiddos were 3-6 days old when this all took place. An NG was placed and orders were received to increase feeds by 5cc every other feed until the target amount was achieved. We also began fortifying the formula the babies were taking, to get 24 cal formula. The babies were both allowed to bottle feed, then NG the rest. In the first situation I had, the target amount was 75ccs, the second was 65ccs. In both cases, by the second day of the NG, the babies were taking 40+ccs by bottle. I would then NG the remaining amount to get ordered amount for that feed. With both babies, they each had very large regurgitations when we began getting to feeds around the 60cc range. When I talked to the physician with the first baby, he said "ok, he will probably want to eat sooner than the ordered 3 hour feed." I asked if we wanted to continue on with the same volume and he replied "yes, keep going as ordered." The mother of the first infant was a young, first time mom. She was very upset following the regurg and ended up refusing future NG feedings (the baby was taking 40+ ccs by bottle and was content). In the second instance, I got 17ccs of residual following a 48cc feed 3 hours prior. The infant was sound asleep, content, and giving NO hunger cues. The parents wanted to wait another hour before feeding to see if the residual would go down and to see if she would take more. I was ok with that option, but when I called the doctor, he said, "no, feed her now." I told him they were refusing and he told me "go talk to them and tell them that I'm trying to stretch her stomach. When they go home, if they want to feed their baby every 2-4 hours, that's fine. But here in the hospital, we need to feed her every 3 hours to stay on schedule." They fed her, then she puked.

The cases have really bothered me for a couple reasons. We educate our moms that they can bottle feed every 3-4 hours; then we don't allow them to do so. We also were fortifying the formula for these kids, which I didn't understand. And finally, why such large volumes?! We very very rarely see a kid going home taking more than 60ccs every 3 hours! Am I crazy to feel bad making these parents forcefeed their kids like this?