G-Tube fed and oral feeding

[beachynurse, ASN, BSN]

I have a student in my school that has both a private nurse with her, as well as a school division employed Teacher Assistant. This student is tube fed for nutrition and to regulate her weight. Mom is extremely hostile and difficult with all who interact with her child. Last year it had come to my attention that she has been fed cereal orally, which I had no orders for. I had the TA stop feeding him orally until I obtained an order from the MD, which took 2 days. We only did the tube feeding when her nurse was out, which was very rare.

This year, the clinic is not having anything to do with her tube feedings. Mom wants the student to still be fed cereal. I wanted to obtain an order for her, to cover the TA, who is still employed by the school division. Since Mom is a problem, my administrator is insistent that we don't need an order to feed him cereal because the tube feeding is only to maintain nutrition. I have tried to explain to her that being tube fed, is being tube fed, no matter what the reason is. My administrator is an educator, not a nurse. My coordinator, who is not my superior, had agreed with me about the order, and spoke to my Admin. The admin was so difficult, and is still demanding that no order is to be obtained for oral feedings.. 

Can I have some of your opinions please? Thank you in advance. 

[k1p1ssk, BSN, RN]

Does this student have a diagnosis that suggests they physically cannot have oral intake or is there documentation that says they can't or shouldn't for safety reasons? Or are you saying the oral feeding is happening INSTEAD of the tube feed? If the latter, then I guess yes, you would need clarification on the order in order to make sure you are in compliance, but I'm a little perplexed by the notion of "a tube feed is a tube feed"... I have known many kids who have tube feeds in addition to oral feeding. 

[beachynurse, ASN, BSN]

k1p1ssk said:

Does this student have a diagnosis that suggests they physically cannot have oral intake or is there documentation that says they can't or shouldn't for safety reasons? Or are you saying the oral feeding is happening INSTEAD of the tube feed? If the latter, then I guess yes, you would need clarification on the order in order to make sure you are in compliance, but I'm a little perplexed by the notion of "a tube feed is a tube feed"... I have known many kids who have tube feeds in addition to oral feeding. 

The student has several developmental delays, reflux with history of aspiration. He was in the hospital for aspiration pneumonia last year. The student has tube feedings 4 times a day, twice at school. I have seen tube feeders eat orally as well, but never without an order to do so. What I mean by a tube feed is a tube feed, there is always a higher risk of aspiration with tube feedings, and other complications, no matter what the reason for the tube feeding is. 

[Chitowngirl]

I was a school nurse for 20 years and have encountered similar issues with eduction administration (non medical) giving medical orders to health staff. Given the student's aspiration history, you are correct to question oral feedings. . Until you have medical clearance/ orders to orally feed you are to tube feed..Why would a parent or an administrator object to clarification? Neither the school district nor the administration hold a nursing license. You do. As a nurse, no matter what area of nursing you work in, you must follow the Nurse Practice Act and physician orders. You have a right and a responsibility to clarify or obtain any order that is not clear. That doesn't change in school nursing. If the parent gives oral food at home, that is fine. However, other rules apply when a student is in a school setting. You need a physician's order. Safety first. I would also suggest having a suction machine on stand by. In a school setting, it can feel like you are serving 2 masters. There will always be difficult and demanding parents that will try to intimidate you. Stand your ground. This may be an opportune time to review your district nursing policies and practices to address such issues in the future. Unfortunately, I have seen nurses taken to court and lost because they didn't follow the Nurse Practice Act in a school setting. Contact your local NASN state chapter they will support you. 
Good luck to you. 

[beachynurse, ASN, BSN]

Chitowngirl said:

I was a school nurse for 20 years and have encountered similar issues with eduction administration (non medical) giving medical orders to health staff. Given the student's aspiration history, you are correct to question oral feedings. . Until you have medical clearance/ orders to orally feed you are to tube feed..Why would a parent or an administrator object to clarification? Neither the school district nor the administration hold a nursing license. You do. As a nurse, no matter what area of nursing you work in, you must follow the Nurse Practice Act and physician orders. You have a right and a responsibility to clarify or obtain any order that is not clear. That doesn't change in school nursing. If the parent gives oral food at home, that is fine. However, other rules apply when a student is in a school setting. You need a physician's order. Safety first. I would also suggest having a suction machine on stand by. In a school setting, it can feel like you are serving 2 masters. There will always be difficult and demanding parents that will try to intimidate you. Stand your ground. This may be an opportune time to review your district nursing policies and practices to address such issues in the future. Unfortunately, I have seen nurses taken to court and lost because they didn't follow the Nurse Practice Act in a school setting. Contact your local NASN state chapter they will support you. 
Good luck to you. 

Sigh, thank you so much, and I agree with you. The Admin doesn't want to do anything because the parent is already suing the school division for something else, so they are afraid of her.  The Mom is extremely difficult, and there isn't a soul that has had to work with her that can find anything nice to say about her. As usual, the kid is adorable.. I'll PM you with other info.. 

[NutmeggeRN, BSN]

Three words.as noted above...Nurse.Practice.Act.

That is the standard  you hold yourself to. I would ask  to get a review by the district legal team...I bet the would agree with you. They should be smart enough to know the answer and that this may be another way for  mom to ding the district...

[payitforward]

This sounds like a law suit waiting to happen, especially when you say the mother is difficult with every one. I would make sure that there are ORDERS by an MD stating that the child can have both tube and oral feedings. My question is a teacher assistant is orally feeding the child? What happens if the child aspirates? Again, I would make sure that there are orders from the child's provider.

[beachynurse, ASN, BSN]

payitforward said:

This sounds like a law suit waiting to happen, especially when you say the mother is difficult with every one. I would make sure that there are ORDERS by an MD stating that the child can have both tube and oral feedings. My question is a teacher assistant is orally feeding the child? What happens if the child aspirates? Again, I would make sure that there are orders from the child's provider.

I totally agree with you. The TA, school division employed, has been specifically told by the admin that she is to continue feeding the student. The student does have an LPN with him that Medicaid pays for as well while he is in school.