Regulating Feeding Times When Pt has PO and Continuos Feeding

JustBeachyNurse, LPN · Oct 14, 2014

I thought you received excellent advice in your original thread and also from your clinical supervisor. What more do you wish to get advice on?

oncnursemsn · Oct 14, 2014

Wow- a lot of good questions and I hope you have a preceptor who is also able to assist. Before offering solutions/answers, you have raised some important questions that need to be addressed first:

Has the child had speech/swallow consult to determine ability to swallow safely?

Who ordered the corn starch for use as thickener? There are commercially prepared thickeners which allow you to thicken formula to specific thickness. (Nectar, honey, semi-solid etc thickness) A dietician should be involved.

What is the goal of oral feeding? For comfort/oral satisfaction or to try to wean from tube feed to oral nutrition?

As the child has CP, I would imagine physical therapy, occupational therapy etc etc are involved and so should speech and swallow.

Re: timing and quantity of offering oral feeds, ideally oral should be offered when the child's stomach would be least full (just prior to next G-tube feeding) and during the day when the child is more awake.

Hopefully this helps you prioritize actions and who to consult- good luck in your new journey, don't stop asking questions and seeking guidance from those you work with.

Jessie Brodbeck, RN, MSN, AOCNS (former pedi oncology nurse)

SDALPN · Oct 14, 2014

This is why new nurses don't belong in private duty (its not home health...home health means visits). Not trying to be harsh, just saying it like it is. You should be able to handle that on your own and know the resources available. A CP kid with only a GT is considered a basic case. That's as basic as it gets. I suggest you talk to your supervisor/clinical manager. Its important that they know what further education you need to do the job.

NURKeish · Oct 14, 2014

Justbeachy, I know that the approach to dealing with issues vary among patients. However, as a new nurse, I am curious as to how other nurses handle such issues on their PDN cases or facilities. I find this forum very informative to the point where it challenges one to look at issues from various stand points.

ONCnursemsn, the mom said that the MD told her she could do PO feeding for 'oral stimulation.' The child has PT and GI, but no speech and swallowing (as far as I know). Re cornstarch, I didn't ask mom if it was the recommended thickener. I did asked what exactly was used to prepare the feed. Even though mom is the one doing the actual PO feeding, I am still concerned as it does affect my actions post feeding. I spoke with my clinical supervisor, who said I could hold the feed for 30 mins. I told her I held it for 1 hr, then check residual and restart based on residual policy. She said that was ok. Now you have raised some vital questions, some of which I didn't think of. I love this forum and all the possibilities it challenges me to explore. I will definitely continue to ask more questions and seek guidance from the people I work with.

Thanks to everyone for the responses.

Alex Egan, LPN, EMT-B · Oct 14, 2014

This is why new nurses don't belong in private duty (its not home health...home health means visits). Not trying to be harsh, just saying it like it is. You should be able to handle that on your own and know the resources available. A CP kid with only a GT is considered a basic case. That's as basic as it gets. I suggest you talk to your supervisor/clinical manager. Its important that they know what further education you need to do the job.

I don't necessarily view this as a new nurse issue. It's more about where the parents authority starts and ends. As well as the fact that often we are placed in a position of taking instruction and care plan changes from non healthcare providers. A unique situation which requires sound judgement.

I use my phone, to type, I work at night, and I'm a bad speller. Pick any reason you want for my misspellings

SDALPN · Oct 14, 2014

I don't necessarily view this as a new nurse issue. It's more about where the parents authority starts and ends. As well as the fact that often we are placed in a position of taking instruction and care plan changes from non healthcare providers. A unique situation which requires sound judgement.
I use my phone, to type, I work at night, and I'm a bad speller. Pick any reason you want for my misspellings

In nursing school, its taught that we don't take orders from anyone other than licensed professionals. I couldn't count how many times a parent has lied to me about what a physician told them. Luckily, I have my license because I checked with the physician. Its also against most agencies policy to take orders from unlicensed people. The BON has a statement on this in some states. Just because a parent gives us "orders" doesn't mean we can legally follow it without a physician order. And if the parent lies to suit their needs and we don't get the order correctly, we can lose our license. And I promise you, there are parents out there that would swear they never told us the order they gave us if something goes wrong. That's why we have/need a paper trail to cover our rears.

The parents can tell us to hold an order, but we document it and notify the Dr if necessary. They can ask us to get an order from a Dr or ask the Dr to send us an order. The parents can do things any way they like, but we are held to physician orders. And if the parents does what they want and it causes harm or has the potential for harm, we are required to report it.

Alex Egan, LPN, EMT-B · Oct 15, 2014

I work for two agencies, they're both nationwide. Both, allow parents to relay order changes from physicians visits. So long as those are verified within seven days, they are carried out in the interim by the field nurses. Obviously so long as they are safe for the patient, and in line with standard practices, using sound nursing judgment. In eight years, I've never once had a parent lie to me about orders. We definitely seem to be having different experiences, have different policies to follow.

I use my phone, to type, I work at night, and I'm a bad speller. Pick any reason you want for my misspellings

caliotter3 · Oct 15, 2014

As I stated in my previous post, I would do up the documentation for a 'parent communicated' V.O., but I would not carry out the order until I had the signature of the doctor or had it from the doctor himself/herself. This was in spite of the agency policy. And some agencies that I have worked for would not even allow for that action in the first place. You go with what you need to do in order to get the job done and to protect yourself. One time a parent complained about my stance and I "politely" made it known that had they taken me along to the MD appointment, none of this added inconvenience would have been necessary. They didn't like that reminder either.

CloudySue · Oct 17, 2014

The big red flag I see here is that the parent is doing the PO feed, not the nurses. Why is that? Is there an actual order on the MAR permitting the child to take formula PO, and the mom administers that feeding for quality bonding time? Or else is the child NPO, and mom is just feeding PO because she wants to, and thinks it will be fine? I worked on a case where the latter occurred- the child was NPO due to inability to swallow without aspirating. Mom felt bad and wanted her child to sample flavors, so she'd slip him some traces of pudding or honey-thickened juice. The child ended up with aspiration pneumonia and ended up in the hospital for two weeks, followed by 4 weeks in a step-down facility. He was never the same after that.

caliotter3 · Oct 17, 2014

I have had parents go against the care plan and the physician's orders like in the previous post. They lie or don't lie about it, usually through a lie of omission, and when I have started to find out about this type of stuff happening when I am not around, it comes to the point where I have to decide whether it is safe for me to practice in that setting or not. By the time I was up against the wall, it seems for some reason or another, I end up off the case. Typically the parents do not want to communicate appropriately, and then it is time to look for the next victim nurse. Poor patient.

NightNurseRN13 · Oct 17, 2014

I'm sorry, but my first job was PDN and I've found it to be generally a great learning experience. I would base it off residual. There should be an order on when to hold and when not to. Also, I&O is a good thing to watch.