Medication Administration through a feeding tube

[lalexa15]

hi everyone!

this week was my first official med pass as a nursing student! my question regards one of my patients with a feeding tube. first, let me explain to you what happened. in lab we were taught if the patient is on several medications, you need to crush each one separately, put them in individual medicine cups and mix with 15 ml of warm water to let them dissolve. next you need to first flush with 30 ml of water to clear the tube and administer each medication separately, flushing with 15-30 ml of water in between each medication. well, on the first day, i had prepared all of my medications in their individual cups and turned to my instructor and asked her if she was ready to go into the patients room with me to administer the medications (it was my first time and assumed she was going to come with me). she replied "no". fine. i then said ok and explained to her that i have all the medications crushed, in separate cups and that i would administer each one separately with the 15-30 ml of water flush in between. she cut me off and told me not to administer them separately, just mix them all together and administer them all together at once. i was kind of surprised because of all the things we were taught about what could happen if you did not administer each medication separately (clogging the tube, adverse effects from mixing the medications together, etc.) well i did what she told me and put all the crushed medications into one cup and administered them. well yesterday after i finished my pharmacology final, my professor told me she needed to speak to me. apparently, one of my fellow clinical students had told the teacher that i was administering the medications incorrectly and that our clinical instructor was telling me to do so. i had to explain to her the whole situation and tell her other things that the instructor was telling us to do differently (like signing the mar before we give the medications and borrowing medications from other patients) my instructor told me that she was going to have to report this to the program manager and that she will have to make a decision on what happens next. i do not know what is going to happen next and i am horrified that i am going to get kicked out of my program. i feel extremely guilty for not administering the medications in a way that we were taught, but my instructor told me to.

my question to all of you is this: what would you have done? did i do the wrong thing? should i have ignored what my clinical instructor told me to do and administer them separatly like i was taught? how do you administer your medications through a feeding tube? do you administer them all separately? we always hear that what you learn in school will not always apply to the "real world".

thank you all so much for reading this long post and i'm looking forward to hearing your comments, replies and criticisms.

[lalexa15]

Wow, thank you everyone so much! You have eased my mind. To clarify, there were no Dr. Orders to NOT mix them together. And, as for the instructor telling us to sign the MAR before administration, we as a group expressed our concern about this (and the student that had to borrow the medication). TonyaM73, I too always prepare myself for the worst so I have already spoken to my group and I think we all have enough individual experiences with this instructor to bring to the table if need be.

Again, thank you everyone, so much!

[ZippyGBR, BSN, RN]

The real world way: Mix them up all together and administer at the same time.

it might be your real world way , but having to deal with the sequalae of tubes being clogged by inadequate tube care and slack medication administration - and the distress this causes patients and their rels / friends plus the hassle of getting tubes repassed - especially those who are difficulty to site NGs or required radiologically guided gastrostomies rather than easily replaced originally pegs

if meds want to coalese or clump they can do so in the stomach where they might well do that anyway - they aren't going to block the life line that is the feeding tube and will get sorted out by whichever phase of passing through the GI tract is meant to activate / dissolve them

[DemonWings]

Wow, I was never taught to mix each medication in a separate cup for administration through a g tube or ng. I do it as many other have stated, I crush them together, and pour the crushed pills into a 30 cc cup, mix with as little water as needed to dissolve the pills then I aspirate (I've already checked placement on my assessment, but like to make sure with each med pass) then I flush with a few cc to clear the tube, give the meds, thenflush with 30 cc. I give my liquid medications separately just bc its easier to do so.

[Isabelle49]

Really, some of my patients in home health swallow up to 10 pills and sometimes more at one time. Most important is to NEVER crush a time-released medication. Nurses on a med surg floor I prn'd on were crushing a time-relased morphine tablet and giving it to a patient who was go gorged she couldn't swallow her own saliva and best part is they were administering the meds orally. I refused to give the patient any of her meds and notified Doc that patient was not alert enough to swallow and didn't seem to have much of a gag reflex. Last time I worked there.

[supervisorhatchet]

ok...having worked in ltc and having lots of peg and g tubes...

wait...back up

#1 rule !!!!!!!!!!!!!!!!!!

always act in a way that you can defend in a court of law.

if you can't defend your actions at the end of the day....then you can't defend your actions at the end of the day...

i am an rn and i tell all nursing staff from care partners, techs, aides, lpns & rns...when in doubt do it by the book. if your actions come into question (in the real world nursing) it is you that has to answer for them. if nurse abc tells you to do it such&such a way, and that is the wrong way...nurse abc will not be the nurse in court...it will be you

now that being said....in real life, on the floor, nursing....

gtube meds are supposed to be done exactly the way you tried to do it.

if you are being observed, such as by state surveyor or horrible clinical instructors....do it the right way.

and some things that you did not mention...always check for placement, each and every time you administer meds or flushes. flush with water first, each med, then water and water to follow. flushes and meds are to be administered by gravity (no "pushing"), it is just supposed to flow freely. bolus feeding are also by gravity and are not supposed to be watered down

now in the real world with 35 -65 residents in a ltc or snf, 10-15 meds on each med pass, 3 or 4 tubes (if you're lucky)....i do mix the meds. and i have never seen or heard of a nurse that does not. i am careful not to mix potassium liquid with other meds because it does need to be administered slowly and the label specifically said do not mix. i do not mix promod liquid with any thing other than water because it tends to make things solidify (your liquid slurry turns to a brick). do not crush enteric coated or any long acting medications (er, ex, la, etc)

in nursing practice i have done things that i never "practiced" in nursing school. but as a general rule, if i have no experience or no prior knowledge, i don't do it.

and shame on your instructor!

[montecarlo64, ASN, BSN, LPN]

The medications should technically be separated with at least 5mL of water between. The rationale is that if the medications are all mixed together and the tube becomes clogged during the administration of these meds, there is no way to find out exactly which meds and how much of the meds they actually received before the tube became clogged. Even though the majority of the time the clog can be fixed, on occasion the tube will need to be replaced. I don't think you will be kicked out of the program, but you did learn a very valuable lesson: trust no one and never be afraid to question something that you think is wrong...You will need to be able to question other nurses and physicians many times throughout your career and a good health professional will never be offended if you catch & stop a potential med error or mistake:)

[MomRN0913]

The way i was taught in school was to do each med seperately. There is no reaction in PO meds. Pt's who actually do take them PO don't swallow one then drink water, then swallow another. usually they are swallowed at once.

We were taught to do meds individually incase we spill some. Atleast if you spill one, you can just replace that one med instead of 10 and if you spill half of all the meds in one cup, then you have no idea what the patient had already.

In the real world, when you have, say 8 pts on a med/surg floor, your going ot mix all those medications together for the sake of time.

Do it by the book in school.

I think the clinical instructor is in trouble, not you.

[NeoPediRN]

I have never flushed in between meds. 15-30ml of water for each med adds up quickly, and it's not uncommon for a pt with a gtube to have 10+ meds. By the time you've given them all their meds and flushed the tube you could end up giving them a half liter of free water. If you're doing that with a cardiac pt you're going to throw them into CHF by the end of your shift. Sometimes doctors will write how much water to bolus and you can divide it among the med passes, but if not I only give a 10-15cc flush at the end of the med pass, just enough to clear the tube. As far as adverse reactions from mess being mixed together, they are going to end up in the stomach together anyway. If a med isn't compatible with another med then the times of administration should be separate. I mix each med in about 5cc of warm water. Hope that helps.

[CapeCodMermaid, RN]

Standard practice in LTC, crush all meds or use liquid. Flush with 30cc water. Give each med separately and flush with 5 cc in between each med. Silly perhaps, but if you don't follow this, the DPH will cite you.

[clearblue3]

Hey!

We learned the same thing...never mix the meds. One of the big reasons is that if you mix them and some gets spilled you have no idea what meds the patient got and if they need more of one...etc. Also, in clinical on Friday someone gave all the meds mixed together and the g-tube got clogged and no one could get it unclogged. The DON had to come see what to do about it...we left before she got there, but there was the possibility that the patient would have to be sent out (this was in LTC) to get x-rays or have the tube redone by a surgeon.

Lastly, I was talking with my sister who is a nurse in a hospital. She said they used to all just mix the meds and dump them in, but then a memo went out about not doing it because there was an incident where a nurse mixed the meds and they started smoking in the cup! Crazy!

However, I don't think that you need to worry about getting in trouble!! How can they fault you when you followed your clinical instructors instructions? I am sure that you aren't going to be the one to be reprimanded...

[hecallsmeDuchess]

Well, in school I was thought to crush individual medications and mix them in individual cups never to mix meds. When I started working, the first time I had to do a g-tube med, I called another more experienced RN to come observe so I could be signed off, she came into the room and saw the multiple med cups I had assembled on the pt's table and she looked at me like I had two heads and told me they didn't do it that way on the unit and as I looked on, she poured everything into the syringe and let it go in to the tube.

One thing she told me though was that if ever JCAHO was in the building or some supervisor, to do it the way I was thought in school.

So OP, let this be a lesson learned, always do it by the book especially as long as you're a student. I hope they don't think of removing you from the program, it just wouldn't be fair.

[Double-Helix, BSN, RN]

I don't mix the medications together for three reasons:

1. Some meds require certain VS parameters (HR and BP being the most common. If I mix that med in with the others and the patient's VS is out of the parameters, I have to throw out all the meds.

2. I've had patients refuse certain medications when I bring the med to bedside. If the patient refuses a med that I've crushed and mixed, I have to throw them all away.

3. I like to double check what meds I am giving right before I give them. If I've mixed the meds, I can't be sure that I have the right dosages. Even if I keep the packages, it's not as good as being able to see the actual med and compare it with the MAR (what if I dropped a package, etc? And if I crush all the meds and then compare the package with the MAR and find a mistake, I have to throw them all out.

For those reasons, I draw up my medications in seperate cups and syringes. But 15 mLs of water? No way. 5 mLs is all you need.

But even though I don't mix them, I don't administer them seperately. By that I mean, I don't flush in between meds. Previous posters are correct that they all get mixed in the stomach anyway, so there is no risk of a reaction between medications. Also, if a medication is going to clog the tube, it's going to do it whether you give it alone or with other meds. Definately flush before and after giving the meds, but you don't need 30cc. You only need enough to clear the tube. For most standard G tubes and NG tubes, it's about 5-10cc. Less for smaller tubes. I work in Peds, and if you are giving several GT meds to an infant or fragile child and you flush in between each med with so much volume, you could give way too much water, throw off a fluid balance, cause gastric distention or vomiting. It's the same in a fluid restricted or cardiac compromised patient.

However, you will find that you will learn many techniques in nursing school that don't carry over to regular practice. Learn it the way you were taught and practice those techniques in your clincals. If a nurse of instructor tells you to do it differently, simply say "This is the way we learned in school so I'd like to practice this way." When you start working in the real world, you can learn the tricks of the trade.