GT Mic-key Bolus feedings to a 2 yr old

[letitride123]

Hello,

I recently picked up a pediatric 2 yr old patient that the family is asking us to give Nutren Jr. feedings via a GT Mic-key. The father is adamant about what he wants and has no medical background other than he "knows nutrition and is a body builder." Apparently the father has been giving the feedings as per his knowledge and doing this for the past year and a half. We are to give 135 cc at 8 am, 160 cc at 12 noon, 160 cc at 4 pm and 160 cc at 8 pm. Then at night 11 pm the child gets 55 cc an hour of the feeding until 5 am.

Prior to today (and per recent MD order) we were checking for stomach residual prior to giving the first bolus. We were giving the feeding in increments of 60 cc. If the stomach had > 60 cc we were told to hold that dose, check in 15 minutes and give unless still > 60 cc residual. We were to do this checking for residual until the stomach had

On my last shift I checked the child's residual for the 12 noon feeding and gave the first 60 cc. For over the next hour and one half each time I checked residual I found that the child had > 60cc of stomach contents. So the feedings did not progress. The mother came in and found that we were still waiting for the stomach to have 60 cc and went ahead and gave him the remainder 100 cc bolus in 15 minutes.

Today the supervisor called and said that now the father wants us to do the following: Only check for residual at the beginning of the feeding. If the child has > 60 cc stomach residual then wait for 30 minutes then proceed and give all of the 160 cc over 45 minutes in increments of 60, 60, 60. Not to check again for any stomach residual

The problem is that this child has projectile vomiting every morning after the first feeding of 135cc - even if it is given over 2 hours. Rarely he vomits in the afternoon but has on occasion and on rare occasion will vomit during the night. The supervisor said that she would get the child's pediatrician to sign this order that the father wants.

I just don't want anything to happen to this child who has Connatal Pelizaues-Merzbacher Disease, FTT, vocal cord paralysis, hypotonia and a trache. He also had a brain stem transplant last year and weighs 25 pounds

Please advise. Thank you very much

LIR

[caliotter3]

In my opinion you are providing the correct nursing judgement regarding this situation. The supervisor is appeasing the parents. She is not there when the child is projectile vomiting. She will not be there when the child aspirates. I had a relative expire as the result of aspiration and they were a healthy adult. I think this is atrocious. If I were you I would send a written communication note directly to the doctor relating what you have said with some of the verbiage shortened, with a copy to the nursing supervisor. Better yet talk to the doctor on the phone (while you are not in the house). If everyone insists, it might be wise to seek another case or another agency to work for. If you choose to work under these circumstances you had better get down your emergency procedures pat, because it is only a matter of time.

[letitride123]

Thank you for your quick response. I have felt sick about this all day and feel that I am making the right judgement call. It's not about being right, but what is best for the child. Plus I do need to protect myself professionally as well. I am not comfortable with this at all.

My question, is how much liquid can a 2 yr old's stomach really hold at one time. I have tried to search on the internet but have not been able to get an accurate answer. I don't think it is possible to perforate a stomach with too much fluid but I certainly do not want him aspirating which I'm sure you are right... it will happen. Thank you so much!

[NotReady4PrimeTime, RN]

Be very careful about going over your supervisor's head. The one time I attempted to do that I was threatened with termination. But I do agree that this child's feeds should be managed by a pediatric home nutrition expert, not a body-building know-it-all dad. The volume, 785 mL/day contributes 785 kCal per day or about 31 kCal/pound, which is appropriate, but with the projectile vomiting, how much is the child actually absorbing? Perhaps this child would benefit from continuous feeds at 34 mL/hr. Or to have his GT Mic-Key changed to a GJ Mic-Key. You can't vomit from past the pylorus after all. That would of course entail continuous feeds anyway.

He also had a brain stem transplant last year.

Do you mean a brain stem cell transplant?

[noreenl]

I run into this problem in school nursing quite frequently where the parent verbally tries to override a written dr's order. I remind my nurses taht in order to keep the licenses they worked so hard to get you follow DR's orders only and you eplain it calmly but firmly to the parent. If the parent is adamant then you need to call the dr and have him/her come and consult with you and the parent together so that everyone hears the same answer. If the dr and parent decide to only check residuals as the parent requested, make sure MD is aware that the child has frequent episodes of projectile vomiting. Maybe a GI Consult is needed. As far as nursing care I have always checked residual prior to initiate feedings and if there is more than 30 cc i hold the feed & call MD and recheck in 30 min.

[letitride123]

Thank you all for your response. I dismissed myself from the case and am looking at another agency to meet my employment needs.

[caliotter3]

I think you made a wise decision. It is better to find employment elsewhere with an intact license. I am sorry the patient is in this position but the adults are very well aware of their actions, especially that "supervisor".

[NeoPediRN]

I'm late on this, but if the parents continued to push faor n order that was different from what the physician wrote for and was detrimental to the pt, then I would withdraw from that case.

[NeoPediRN]

I just saw that you did exactly that. I commend you for it. The point of homecare is for nursing and families to work together to optimize the care of the patient. A family that won't support you and an agency that won't back you is a recipe for disaster for sure.