A bunch of questions!

[NurseyPoo7]

pegs:

i know when someone has a new peg, their drsg needs to be changed at least q day, but what about someone who doesnt have a new peg? and when is a peg considered not "new" anymore?

i'm used to having pegs drain by gravity (esp with bolus feeds) but ive seen a lot of nurses push meds and such thru the peg... esp if they have to give crushed tablets (or that horrible mvi powder... that orange crap that stains everything), which often "settle" and end up clogged up the tube if they arent drained quickly. is this acceptable?

is it really necessary to check placement of a peg tube? i know if it had been dislodged you'd often see signs of infection/rigid abd... i understand with ngt you def. need to check placement, but what about a peg since its surgically placed?

i have a little notebook called rn notes and under the feeding tube section written in red it says do not instill meat tenderizer - can cause metabolic complications or allergic rxns. what is this all about?

pulling piccs:

ive heard some nurses say when pulling a picc to tell the pt either to:

1) bear down like a bm

2) cough

3) hold their breath

whats correct?

can anyone run down chest tubes with me? ive never had to deal with one. a gentle bubbling is good right? and if the ct becomes dislodged, you are supposed to put petroleum gauze over it correct?

i had a pt who had a large diabetic ulcer on the bottom of their foot and the rx'd drsg change said to pack it with xeroform, which is basically like pet. gauze. was the purpose of that to keep the ulcer moist or is am i not understanding the function of xeroform?

when giving kcl and mag runs, i monitor their bp at least q 15 since they can both cause hypotension... but ive had other nurses tell me i'm wasting my time. what do you do?

[carol72]

I have no answers for you, but will follow this thread like a hawk.

Thank-you.

[rn-jane]

So many questions but I will answer them the best I can. Please someone else jump in if i miss something.

"PEGs:

I know when someone has a new PEG, their drsg needs to be changed at least Q Day, but what about someone who doesnt have a new PEG? and when is a PEG considered not "new" anymore? "

Peg tubes when new I usually change daily or per shift depending on if if needs changed. When I do my assessment I check the pegtube area and do a good cleaning around the site such as normal saline or whatever the doc has written on the dressing change areas. I find with good cleaning the peg tube does not come down with infection or become tender at the site. I also check placement at the time of assessment or when I start a feeding. Please remember to elevate hob 30 degrees or higher.

"II have a little notebook called RN NOTES and under the Feeding Tube section written in red it says DO NOT INSTILL MEAT TENDERIZER - CAN CAUSE METABOLIC COMPLICATIONS OR ALLERGIC RXNS. What is this all about? "

Meat tenderizer is an old remedy for cleaning a clogged pegtube. When the pegtube becomes clogged our docs allow us to put about 30cc of diet coke down a tube or another cola but honestly coke works best because it is very carbonated compared to other colas.

"Pulling PICCS:

Ive heard some nurses say when pulling a PICC to tell the pt either to:

1) bear down like a BM

2) cough

3) hold their breath

Whats correct? "

In our hospital only certified iv picc line nurses can pull the picc lines so can't help with that question.

Now chest tubes

We do alot of chest tubes on our unit but here are the basics

Pre Insertion

I. Assessment

Immediately after insertion and q 4 hours while chest tube is in place assess drainage collection system for:

A. fluctuations in the air leak indicator

B. air bubbles in the air leak indicator

You should hear a soft consistent bubbling in the chamber, check the order for the amount of cm of h20, common is 20cm.

Assess your patients lungs, if it appears severley diminished order a xray to confirm placement or notify your pulmonary care doctor.

C. suction set at ordered level.

Immediately after insertion, q 4 hours while chest tube is in place, and immediately after removal of chest tube assess:

A. comfort level

B. breath sounds, heart rate, blood pressure, temperature, respiratory rate and rhythm and O saturation

C. drainage for amount, color and consistency

D. dressing for occlusiveness and drainage from insertion site

E. chest wall at insertion site for subcutaneous emphysema (this is like little airbubble beneath the skin, commonly felt like rice krispies underneath the skin) Repot to the md immediately, this means somewhere there is a air leak.

While chest tube is in place and drainage collection system is in use

A. Mark volume of drainage (date, time and initial) qs

II. Interventions

Assure chest x-ray is obtained after insertion and after removal

Position the drainage system in upright position, below level of the heart at all times.

Place emergency equipment in patient's room (bottle of sterile NS, 4 x 4, Vaseline gauze, tape & padded clamps)

[mpccrn, BSN, RN]

WOW.......slow down a bit......lol :heartbeat

1. PEGS. no you don't have to check placement. yes you can push meds through them, in fact, it's better to as you can confirm you have given the dose at the prescribed time. i'm not sure that anyone i know would add meds to a feeding bag and assume they went in, but always flush the tube afterwards....clogging it would be very bad. yes you can put a drain sponge around the insertion site when fresh but it should be changed q shift and the site cleansed. when healed, a dsg. is no longer required. bolus feeds can be pushed in with a srynge if they are not a new feeding regimend, again, flush with water afterward.

2. PICS. betedine oint should be placed at the insertion site before pulling the line to immediately occlude the hole and avoid introducing air to the system. nothing is usually required of the patient although if you can coordinate it with exhalation its helpful but not required.

3. CT. Petroleum gauze is placed around the CT insertion site and then dressed. all connection sites are taped so that you can inspect the connections easily. a line of clear tape is slid along the connection posteriorly connecting the 3 points of connection, then tabbed tape is place at either end of the christmas tree. yes, gentle bubbling is good but the amount of suction is dictated by the water level of the pleural vac. always have 2 CT clamps handy as well as vaseline gauze....just in case.

3. KCL and Mag.......yes, wasting your time.

you know this stuff.......trust yourself!

[Penelope_Pitstop, BSN, RN]

meat tenderizer is an old remedy for cleaning a clogged pegtube.

this time two years ago, i was working at a facility that still used it. i'll add that to my mental list of reasons why i'm glad i don't work there anymore!

jess

[crissrn27, RN]

A small amt of meat tenderizer in a peg is not a big deal. We eat it, remember? Now, I wouldn't put more than you would normally consume in a meal in the peg. It really does work, along with coke, it is my fav way to dislodge tube feeding. It won't work on crushed meds, but is great for the caked on tube feeding.

ETA: not that I use coke and meat tenderizer together....although it might work, lol.

[KaliNurse]

These are good questions, and I will try to answer you to the ones I know for sure. Here it goes.....

PEG tubes: You are checking the RESIDUAL of what may come back out of it after the patient's feeds are going in. You are not checking placement per say...In fact, I believe PEGs are sewn into the stomach. Whereas NGT's are guided into the stomach by passing the tube through the nose and then it just sits in the stomach. There is no surgical attachment with the NGT. For a PEG, you are checking the residual to see if what is going into the stomach is infact getting absorbed. If you pull back too much tube feeding into your syringe when checking the residual, then there may be a problem with the patient being able to absorb whatever you are feeding him/her. The goal is for you to have little (less than 100ccs) or no residual from the PEG tube. To unclog your PEG tube, check with your pharmacist! There is a common remedy which includes bicarb and carafate (I think) which is a sure cure for unclogging the tube. We use carbonated sodas too, just until the pharmacy gives us the better solution for unclogging.

PICC lines : I would recommend holding their breath, NOT coughing. I think coughing allows air to come back in. For the few seconds it takes to pull a PICC line, I would tell patients to hold their breath. Bearing down (valsalva), is also another good option. I usually say to my patients..."When I tell you, please do not talk and hold your breath". That works well.

Chest Tubes: The most important thing I can tell you to remember with chest tubes is this.....IT DOESN't MATTER HOW MUCH YOU CRANK UP THE SUCTION ON THE WALL. WHAT MATTERS IS THE AMOUNT OF WATER IN THE SUCTION CONTROL CHAMBER!!!! If you are to set the Pleur-Evac at 20 cm of suction, then make sure the suction control chamber is filled to 20 with water. This should be checked every shift. However, you and I know that just doesn't happen! If there is bubbling in the water seal chamber, then there is a leak. Always keep an occlusive dressing (vasoline gauze) at the bedside in case the CT comes out. If it comes out, slap the dressing on there and tape it on 3 sides. Call the MD. Also, always feel around the chest tube dressing for the "Rice Krispies" feeling. This feeling is crepitus. Air is leaking into the sub Q tissue. Notify the MD if it happens. If your patient is in any kind of respiratory distress, YOU WILL KNOW IT! The patient will be symptomatic (short of breath, unequal chest expansion...etc)Make sure the tube doesn't get kinked either. Some patients will accidentally lay on the tubing.

K and Mag: I have never had to monitor vitals q 15 minutes for that. However, you do need to understand what Mag and K are doing to the cells in the body, specifically the CARDIAC cells! If anything, you should be monitoring for changes on the tele monitor while infusing the riders. For example tall, peaked T-waves are symbolic of hyperkalemia. Just keep a close eye on your patient, and run the riders as directed on the bags.

Xeroform: I think this is typically used on burns. Anyway, it is like vasoline gauze and should be cut to the specific size of the patient's wound.

I'm no expert, but I do have alot of experience with exactly the things you are talking about. Let me know if this helps! ~ Kali

[NurseyPoo7]

thanks!!

[Daytonite, BSN, RN]

pulling piccs:

i've heard some nurses say when pulling a picc to tell the pt either to:

1) bear down like a bm

2) cough

3) hold their breath

what's correct?

#3 hold their breath. this prevents air from being sucked into the track of the picc line when it comes out and accidentally introducing an air bubble into the patient's heart.

there are weblinks about picc lines on post #6 of this sticky thread of the nursing student assistant forum

https://allnurses.com/forums/f205/any-good-iv-therapy-nursing-procedure-web-sites-127657.html

-

any good iv therapy or nursing procedure web sites

can anyone run down chest tubes with me? i've never had to deal with one. a gentle bubbling is good right? and if the ct becomes dislodged, you are supposed to put petroleum gauze over it correct?

see

http://www.icufaqs.org/chesttubes.doc

[marachne]

While coke can do a really good job with clogged feeding tubes, it should only be used as a last resort s it can also eat through the tubing (another source stated that it denatures proteins leading to more clogs later. We were told to use enzymes. This seems to be a case of "an ounce of prevention is worth a pound of cure." Regular flushing, particularly after administration of medications can make a big difference in keeping a PEG from occluding....and if you have to administer oral mag++ try to get it in liquid form, it never dissolves and leaves a nasty mess in the tube that could contribute to clogging. This was kind of interesting: http://rn.modernmedicine.com/rnweb/article/articleDetail.jsp?id=142656

[iluvivt, BSN, RN]

When discontinuing PICCS......take a deep breath and hold it and discontinue while they are holding their breath. If patient can not cooperate to do this you can DC upon respiratory expiration. The risk of air embolus is there but is more common when inserting or discontinuing a CVC placed in the IJ or subclavian. Make sure to seal the site with ung or sterile vaseline and apply an occlusive dressing. For air embolus rectify source of air....turn pt on left side with their head down.

[tillie1]

Dissolving crushed meds in warm water makes them dissolve easier. Don't crush Carafate..drop the whole pill in a capsule and it will dissolve on it's own. I have known nurses to put syrup-y meds in the TF bag only to have to start over with new set up because the syrup made the formula curdle.