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LPN Changing G-tube?

Home Health   (5,191 Views 10 Comments)
by SunnyPupRN SunnyPupRN (Member) Member

SunnyPupRN specializes in Psych.

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Hi Nurses, Lost post ahead!

I hoped to gain some clarification from some of you, as my agency is not very helpful, and I generally get the impression to keep my head down and stop approaching them with questionable procedures.

I am one of several nurses on duty for a peds pt who has complex medical issues. She has nursing care ordered 20 hours/day, and I am the only RN. I don't take this to mean that I have any charge over the case. We have a CCM, and we all share responsibility, although I have not been oriented well to all of the procedures for all of the shifts, so I only do trach care, suctioning, vitals/ g-tube meds, wound care. My primary experience has been in psych, so when I started, I was/am rusty with clinical skills, but I've been doing fine. Anyhow,

I questioned a few things:

1] we didn't have a written MD order for some meds, just the pharm label. I was told that in " home health we do things differently" and the label was fine to serve as an order. Is this true? How do we know that the pharm transcribed the order correctly? For example, one label said 10ccs PO q 6h until bottle finished, but the pt only takes meds via g-tube.

2] There is an order to change out the G-tube, i think q month...and I always thought that this was a doctor's office visit. A few weeks ago I was talking to the guardian who told me that XX, who is an LPN has always changed out the G-tube. I asked again if she meant the WHOLE thing, not just the Mickey xtension set, and the guardian said yes, the whole thing. I've ALWAYS thought nurses except ARNPs were prohibited from changing a G-tube. Is home health different in this respect also....maybe because of the frequency of the order?

I'm sorry for the long post. Appreciate any insight, and also any other procedures/treatments that you can think of that are different in HH from the hospital. People are telling me I need to chill out, and that's fine if this is all on the up and up, but I want to stay well within the Nurse Practice Act.

Thanks!

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71 Posts; 2,198 Profile Views

No, you're incorrect on the Gtube issue. Why would you go to a doctor's office when it is within an LPN's scope of practice and can easily be done at home? I was changing my son's out long before I was an LPN and immediately after school in a patient's home. An LPN can do a trach/gtube change with no issue. It's not an issue of home health being different-it is within my scope of practice as an LPN.

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Assigned nurses can change the G tube unless the order on the 485 specifies that it will be done by the physician. Once had a client though that was an extremely difficult change. Dad used to do it but finally reverted to having it done by the GI doctor and even he had problems.

As for the med labels? Sounds as if your agency is way off base. If there is a prescription label, then, by all means, call the doctor and take a telephonic order, unless you are confident of the label, then write up the order as "transcribed from prescription label" and send forward for the PCP's signature. All meds are to be placed on the 485 with a valid order, to include those where the entire prescription or most of it is given before someone can get a signed order.

As for the PO vs. via GT issue, even the doctor often forgets and writes the original prescription for PO instead of via GT. We always make the correct notation on the 485 and MAR without bothering to get a formal clarification of order only for that reason.

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SunnyPupRN specializes in Psych.

3 Articles; 289 Posts; 10,066 Profile Views

No, you're incorrect on the Gtube issue. Why would you go to a doctor's office when it is within an LPN's scope of practice and can easily be done at home? I was changing my son's out long before I was an LPN and immediately after school in a patient's home. An LPN can do a trach/gtube change with no issue. It's not an issue of home health being different-it is within my scope of practice as an LPN.[/quote

OK, I hear what you are saying. For the record I'm not referring to the trach at all here. And what you said, is exactly why I wondered if it WAS an area of practice - but in orientation and in school [a long time ago] they taught us that if the g-tube dislodged to use a foley in emergency and go to the ER until the doctor could place a new tube.

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SunnyPupRN specializes in Psych.

3 Articles; 289 Posts; 10,066 Profile Views

Assigned nurses can change the G tube unless the order on the 485 specifies that it will be done by the physician. Once had a client though that was an extremely difficult change. Dad used to do it but finally reverted to having it done by the GI doctor and even he had problems.

As for the med labels? Sounds as if your agency is way off base. If there is a prescription label, then, by all means, call the doctor and take a telephonic order, unless you are confident of the label, then write up the order as "transcribed from prescription label" and send forward for the PCP's signature. All meds are to be placed on the 485 with a valid order, to include those where the entire prescription or most of it is given before someone can get a signed order.

As for the PO vs. via GT issue, even the doctor often forgets and writes the original prescription for PO instead of via GT. We always make the correct notation on the 485 and MAR without bothering to get a formal clarification of order only for that reason.

​Thank you for this clarification!

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Placement of a foley is an intervention most encountered in facilities. I did it once in a LTC facility. In the home, usually the patient is already stable, with a G tube that is not new. The tract is healed, usually, and one does not have to worry about it closing, usually. The home patient will have at least one "spare" G tube for the next scheduled change or for placement when there is a malfunction that makes the present G tube not viable.

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SunnyPupRN specializes in Psych.

3 Articles; 289 Posts; 10,066 Profile Views

Placement of a foley is an intervention most encountered in facilities. I did it once in a LTC facility. In the home, usually the patient is already stable, with a G tube that is not new. The tract is healed, usually, and one does not have to worry about it closing, usually. The home patient will have at least one "spare" G tube for the next scheduled change or for placement when there is a malfunction that makes the present G tube not viable.

Makes sense. I know that the stoma is still usually patent once the tube is stable, but isn't it still possible for the internal tract to close fairly quickly? Also, is placement just verified by the bedside nurse by checking stomach contents? P.S. I did research the practice act and found that I was mistaken...I think that I was just confused by our agency's instruction to insert a foley and get the pt to the ER. They never clarified that this would be for a fresh tube, and I'm personally not trained to insert a G-tube, although I would like to! Thanks for your responses.

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3 Followers; 36,943 Posts; 98,038 Profile Views

The patient will not have foley catheters available for this purpose unless they are listed as supplies on the plan of care. The plan of care provides for a replacement G tube. The patient is allowed X number per year, based upon the ordered replacement schedule. Find the spare GT and look on the packaging. The instructions should be printed there. Or, you can find the instructions on the internet; try looking up the actual named product. It is not a difficult procedure. If possible, you should arrange to do the next change, (with the family member or your clinical supervisor or even the experienced nurse present), so that you can alleviate some of your present anxiety about the procedure. (Frankly, between the agency instructions about the foley ((just where do they expect you to get a foley for this purpose?)) and giving meds without reconciling valid orders with the plan of care, I would advise you to find a way to shore yourself up in the home or find an agency that has supervisors that are more on the ball. JMHO).

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85 Posts; 4,112 Profile Views

LPN's scope varies from state to state but it's definitely within our scope of practice to reinsert g tubes. We have a lot of tube feeders at my facility and I change them quite frequent. It's similar to inserting a foley catheter but i's not a sterile procedure. You may be thinking of j tubes. They have to go to interventional radiology to verify placement.

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FlufferNutter has 9 years experience as a ASN, RN and specializes in peds, geriatrics, geri-psych.

1 Article; 21 Posts; 12,214 Profile Views

I work with a little guy who has a gtube change order for every three months, or more frequently, if needed. Recently had to change it due to leakage in the balloon keeping it in place.....He squirms so much that it is a huge deal to do.

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