Is this considered change of route?

[Marijane]

Hi everyone. I am a nursing student that just finished the first semester of nursing school. During clinicals, I had a patient with a gastric feeding tube and the doctor's order was to give meds through the feeding tube. So for morning meds pass, I crushed the medication and gave it through the feeding tube. For the afternoon meds pass, the patient insisted on taking the medication orally. I gave the pills over to the patient and he swallowed it without any problems. My question is this changing the route of administering the medication? Thanks.

[P_RN, ADN, RN]

Technically yes it is a change. NEt time get the doc to specify may swallow, if unable then give through tube. I assume it was a gastric and not a small bore duodenal tube? Those tiny ones clog easily.

[TazziRN, RN]

Yes, it is. Some pts with tubes are NPO for different reasons. Pts often do not think they're as sick as they are....."I can swallow them, I'm fine." Then come to find out there's a reason the doc wants the pt NPO.

[suzanne4, RN]

There are usually specific reasons that the patient still has the feeding tube in place. A big one is because of aspiration, meaning that the meds could end up in their lungs and not their stomach. Not a good thing. Definitely giving it orally when it is ordered down a feeding tube is a change in route and needs an order for that.

Not to blame you, but where was your instructor or preceptor? As a first semester student, you should not be passing medications on your own as you do not have a license as of yet. You were passing medications under another nurse's license.

Never, never give meds in a route that was not specified by the provider. There is a reason why they were ordered that way.

[CritterLover, BSN, RN]

i went to school with a girl who made this mistake. (it also happened to happen on the unit where i worked).

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[color=#483d8b]patient had a peg tube, and she gave him the pills by mouth, rather than through the tube.

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[color=#483d8b]i can still remember my instructor saying to her the next week "have you thought more about what happened and why it was wrong?" (this was supposed to have been a private comment; i wasn't meant to overhear it. as her peer, i hadn't heard about the mistake. i only know because i worked on that unit, and other nurses told me about it.)

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[color=#483d8b]however, i'm going to say that it depend on why the patient has the feeding tube.

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[color=#483d8b]if they arn't able to take in adequate nutrtion by mouth, and have the feeding tube to assure adequate calories, and are able to eat/drink when they want to, then it is fine to give them their meds by mouth if they ask.

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[color=#483d8b]if, on the other hand, they have a peg because they failed their swallow eval due to aspiration, then no, absoultely no meds by mouth.

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[color=#483d8b]to me, that is more "nursing judgement" than something a physician needs to order. (mostly because almost all of the peg patients i have taken care of, the med sheet says "po" rather than "per tube" for all of their meds, even if they can't swallow -- the docs are in the habit of writing "po." to me, it is within my nursing assessment/knowledge to give that po med via peg tube unless contraindicated by the particular drug.)

[TazziRN, RN]

Critter, you're right, but it sounds like the OP did not know if the pt could swallow anything. And even if the pt could, if the meds are ordered via tube, giving them PO is changing the route.

[loriangel14, RN]

I agree with Suzanne, where was your preceptor? I am in my final consolidation and I can still not pass meds on my own because I have no license. Giving them PO is changing the route and should not be done without an order.

[anne74]

Let this be a lesson to not let pts manipulate you, or talk you into changing orders for them. Most pts don't have medical knowledge and aren't aware of the dangers they can put themselves in. That's why they rely on nurses, with medical expertise, to serve as a guardian of their health. This won't be the last time a pt tries to get something past you, or tries to negotiate something. Pts have a right to refuse any treatment/med, but as the nurse, it's your duty to educate the pt regarding their choices. Explain the rationale behind doctor's orders. Often if they learn the reasons behind the orders, they easily submit. This is also true for pt's family members who try to change orders.

Any time that comes up again, you need to stop and go get your instructor. Maybe the request can be granted, but not without a new order written by a doctor. Pts often ask one nurse for something, get denied, and then when they see a new face - especially someone in a student's uniform - they try again. As much as you want to please a pt, you have to think of your license first - and as a student, you're putting someone else's license on the line.

[VegRN]

There are usually specific reasons that the patient still has the feeding tube in place. A big one is because of aspiration, meaning that the meds could end up in their lungs and not their stomach. Not a good thing. Definitely giving it orally when it is ordered down a feeding tube is a change in route and needs an order for that.

Not to blame you, but where was your instructor or preceptor? As a first semester student, you should not be passing medications on your own as you do not have a license as of yet. You were passing medications under another nurse's license.

Never, never give meds in a route that was not specified by the provider. There is a reason why they were ordered that way.

:yeahthat:

[caliotter3]

I agree with everything anne74 and suzanne4 said. I would not have given the meds PO without having first called the MD and would have explained to the pt. I work in home hlth and frequently encounter pts/family members who try to change things to suit their current whims. They know their rights and often play the nurses off against each other. I always tell them politely that I will follow the MD's orders or I will speak to the MD about the situation. When they insist, I have a family member follow their request and document everything. Some people would rather argue about everything rather than be compliant with their orders or simply express their wishes to their MD. At any rate, any time that you do not follow the order as written, you must justify your actions in your documentation. Even by doing something at the patient's request, you are jeopardizing yourself by not following the order or taking steps to get the order changed.

[Marijane]

Thank you for all the replies. To answer some questions and clear things up. My clinical instructor was not with me but asked another student to come with me to make sure I did the five rights while administering medication. I can see where I went wrong on one of the five rights. The patient was not NPO and was able to eat and drink without any problems, just wasn't getting enough nutrients and calories.

Thank you anne74 for the warning to not let patients manipulate me. From now on I will definitely be more careful and follow the doctor's orders.

[nursemike, ASN, RN]

Patients definitely will try to manipulate you, and they can be very persuasive. One of the orders I dread seeing is: "Absolutely no narcotics." You know you're going to be answering a lot of call lights.

With experience, there come to be some orders which docs who know you may expect you to put in on your own judgement and they'll sign off on them in the morning. Ice bag for swelling/pain, K-pad for muscle pain, etc. The thing not to forget is that doing so is illegal. Not to say we don't ever do it--just that you shouldn't get nonchalant about it. A nurse I followed recently stopped a patient's heparin because the CT tech spotted a brain bleed. They probably saved the patient's life, because it took a good while to get a doc to read the CT, but, technically, techs don't read films, and nurses don't change orders. On the other hand, nurses are expected to question inapproriate orders and not give inappropriate meds, so I'd say the nurse was covered. I received the patient just long enough to get her sent to ICU, where she was doing okay, last I heard, but that process took almost two hours. If it had taken that long to get the heparin stopped, who knows what the outcome might have been.

I know nurses with decades of experience whose collaboration with docs goes well beyond anything I would dare and well beyond their scope of practice. Sometimes, it's a matter of not "bothering" the doctor with "small stuff," which is kind of dumb. Usually, it's a matter of getting the right thing done in a timely manner, but, boy, you'd better know you're right, because it's going pretty far out on a limb.