help?! PEG tube incident

[morningloryRN]

Hey all,

Let me preface by saying i'm a brand new RN. Just graduated in May and i'm working on a medsurg floor. The other day i had a patient with a PEG tube who was receiving continuous feedings. I told the charge nurse i had never had a patient with a PEG tube before and they assured me not to worry about it and told me what they thought i needed to know about it. Long story short, i ended up giving a medication through the feeding tube that was supposed to be given PO. I assumed that because the pt had a PEG tube that their medications were to be given through this, HUGE MISTAKE, i know. Regardless, the pills clogged the PEG tube and the tube would not flush. i had 2 experienced nurses come in to look at the tube and try to unclog it, they could not. Finally, the charge nurse tried flushing the tube, during the flush the PEG tube fractured. You could visibly see where there was a crack in the tube (the part coming out of the abdomen). Needless to say i cannot sleep because of this. I feel absolutley horrible, the patient needs to get a new PEG tube now because of my carelessness. I'm scared of the repercussions of my actions and i just need some advice. An incident report was filed out by the nurse who fractured the PEG tube, but i still feel responsible. Please help!

[nursemike, ASN, RN]

As you undoubtedly realize, assuming anything is risky. However, I often see patients with meds ordered PO that are to be given by g-tube. Are you sure it was meant to be given PO?

We usually get most meds that are to be given by g-tube in liquid form, but a lot aren't available. Anytime you crush a med and give it through a tube there's some risk of clogging it. You are as careful as you can be to flush before and after, and usually it's not a problem, but there's always a risk.

Replacing a PEG tube is a bigger deal than replacing an NG, but it really isn't a huge deal. So, when in doubt about the route, have the order clarified. If you are putting crushed meds down a tube, be careful to dissolve them completely, flush the tube completely before you put the meds in, and flush well before starting any tube feeds. This is an incident to learn from, not one to lose sleep over.

[SillyStudent, ASN, RN]

First, don't flip. You made a medication error. This happens to the best of us.

The patient has to have a new PEG tube placed. This is unfortunate, but you will NEVER make a mistake like this again. :) Placing the second PEG tube is way easier on the patient. I have had patients yank their PEGs out, and it's usually not a huge deal to put them back in if it is done pretty quickly.

Having said that, before someone calls you into the office, drag out your old 'potter and perry' or whatever textbook you used in nursing school. Make yourself familiar with all aspects of PEG care, including the policy your hospital probably has written down somewhere. Make sure your manager knows that you looked up the information.

Above all, do not beat yourself up.

[whipping girl in 07, RN]

First of all, quit beating yourself up. Mistakes happen and you didn't kill anyone. PEG tubes have to be replaced periodically as they break down from use, meds, and stomach acid. Always check with your pharmacist about whether a medication can be crushed to be given per tube. Was the patient able to swallow the pills? If not then it was not appropriate for the physician to prescribe a med that could not be crushed and given per tube.

In order to keep something like this from happening in the future, remember that water is your friend when it comes to feeding tubes, whether they are PEGs, Js or nasal feeding tubes. Always flush with at least 30 ml of water before you give meds. Give each med separately, crushed and mixed in a little water, usually about 30 ml is enough. Flush with water between medications and before you resume tube feedings. If you are doing bolus feedings, check whether the medications need to be given before or between boluses, and always flush before and after each bolus. Most patients need anywhere from 500 to 1500 ml of water outside of their tube feeding product for hydration (if they cannot drink water or are not on IV fluids), so you should have plenty of water to use for medication administration. Just subtract the amount you've used for meds and give the rest as a flush.

There are commercial products that work well to unclog feeding tubes. The Clog Zapper is the one our team uses and we've had quite a bit of success with it, especially with J tubes and PEG tubes.

http://www.corpakmedsystems.com/Supplement_Material/Enteral Devices/ClogZapper/Clog Zapper Brochure.pdf

You can also crush a bicarb pill and a viokase pill, mix them together in warm water, and use that to try to unclog the tube. It's much cheaper than the Clog Zapper and utilizes inexpensive medications that are likely already in your hospital pharmacy (sodium bicarbonate and pancreatic enzymes). I don't think it works quite as well though.

Some people will tell you to use Coke. That is not a good idea, as the carbonic acid and sugar is hard on the tube and can cause it to fracture, especially over time if the tube becomes clogged often and Coke is used to unclog it.

BTW, welcome to nursing!!

[SillyStudent, ASN, RN]

Great info, Mike and morninglory!

To make you giggle, whipping girl...

I recently gave myself a shower with orange Juven, because I pushed it a little too hard, and blew the cap off the flush port, which was not completely closed, it seems.

I wanted to scrub myself with brillo.

[carolina4]

We crush pills, dissolve pills, open up capsules and put all the junk down the PEG tube with a good water flush. no big deal. if they can't take things by mouth, then there's a reason that tube is there.

[whipping girl in 07, RN]

Great info, Mike and morninglory!

To make you giggle, whipping girl...

I recently gave myself a shower with orange Juven, because I pushed it a little too hard, and blew the cap off the flush port, which was not completely closed, it seems.

I wanted to scrub myself with brillo.

EEEWWW, no doubt! Juven is gross!! The first time I ever gave any medication through an NG, I gave myself, the patient, the curtain, the wall and my preceptor a liquid Tylenol shower!

[loriangel14, RN]

I currently have a regular pt that has a PEG tube and all his meds are via the tube because he cannot swallow.Everything is crushed, dissolved in warm water and delivered through the tube preceded and followed by a flush.

I have had about half a dozen pts with PEG tubes and all their meds were given this way.

[netglow, ASN, RN]

Note the warm water, stir well with wooden end of a swab (less splashing and you mix better than with say a tongue depressor or spoon handle or irrigation syringe nose.

[Steffers]

Wow, I'm surprised that in all your clinicals that you did while in school you NEVER had a patient with a PEG tube! . eh, maybe it's just me...I mean I'm a LVN and granted, we did do clinicals in a SNF for about 2 months, but were in Acute for alomst 8 months! I think I saw about the same amount of PEGS in each place! Anyways, like some others posted above I think the best thing is Warm water and crush,crush, crush those meds! You'll be fine though, everyone makes mistakes right?! Just curious though, did you crush the pills before you administered them?

[carluvscats]

I plugged a g-tube giving Prevacid one time. Thankfully, I was able to unclog it pretty easily with the little tool and some flushes. I learned from that point on to gently turn the syringe (up and down shaking motion) while giving the med. The continuous motion helps the med go in smoothly and evenly. I haven't had any problems since then.

Rest easy, OP...... you're doing fine. :)

[SuesquatchRN, BSN, RN]

Heck, we replaced a PEG tube with a Foley Sunday night. Patient ripped it out. Had to keep it patent. Kaka pasa.