Medication Administration through a feeding tube

Nurses General Nursing

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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.

Specializes in Gerontology, Med surg, Home Health.

It's always best to follow your facility's policy. Every facility I've worked in uses 30 cc after the meds.

I was taught in GI to do it the long way: aspirate, flush, med, flush, med, flush, med, flush, tube feed bolus, flush. I was taught in critical care to do it the short way: aspirate, meds all at once, tube feed bolus, then flush.

The GI rationale was that the patient needed the extra fluid for softened stools, or that it wouldn't harm them to have extra fluid. The critical care rationale was that fluid overload could do serious harm to delicate patients. So it really depends on the patients' needs.

In the role of a student nurse, though, do whatever the person who controls your grade tells you to do.

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.

Yep- definitely agree...

But sure when you have state surveyors in the building, you know what is expected in your state :) In TX, the last rules I knew were to separate the meds, and follow each with water. Which relates to a pp about knowing which meds were given if something gets stuck, and also gets enough fluid in the resident (in LTC, dehydration is always an issue- and state 'pet' tag to look for).

IRL, they get lumped together (and unless there's a fluid restriction and a very skinny tube, 5cc wouldn't work for a lot of places :))...but the surveyors don't care about IRL...they care about the rules.

CYA, and protect the patient from any possible interactions....

Just know your own state guidelines :)

The other big issue here that's not being talked about and could get the OP in big trouble is that she went to administer those meds alone. She stated that the instructor declined her request to watch her give the meds. A student nurse can not administer medications without the supervision of a licensed nurse, especially the first time they ever pass meds! Sorry OP, that could get you in trouble no matter how crummy your instructor is. Please don't ever forget this feeling of guilt over your actions, it will keep you safe in your nursing practice. And don't ever let some one pressure you into doing something in a manner that is less safe than you are comfortable with. Accuracy and safety is better then speed and regret.

I am a first year student but got to watch my co-assigned nurse give meds in a PEG tube in clinical this week and she said she never mixes meds - she gives each one separately - what she did was divide up the normal flush of the pt's PEG tube (she was on a 150cc flush q4h) and used half of that to give the crushed meds and the other half was a regular flush...she also stated she doesn't mix meds - this wasn't LTC though, it was med surg

There is a problem with giving all crushed meds at once. If, for any reason, you get interrupted before you have given the whole concoction - an emergency demands you tend to it, pt getting the meds has resp distress and you must deal with it, pt c/o abd pain and you need to investigate it before adding any more to the stomach, or whatever - you will not know what you've actually put down the tube.

You will have part of the mixture in the pt and part still in your cup.

I know that schools teach 1 thing and real life demands that we not spend so much time, use so much water and so many cups, etc. But there really is a good reason to give each med separately.

Your teacher needs to be horse-whipped.

So does her boss if you suffer for the teacher's incompetence.

I'd be thinking "lawyer" at this point. I wouldn't take action yet, but I'd be thinking it.

Just know your own state guidelines :)

And do what's right for the patient.

In the role of a student nurse, though, do whatever the person who controls your grade tells you to do.

I know what you're saying, but don't forget that students are still held legally accountable, can be sued, etc. They are expected to not do "whatever" in order to get good grades.

I know it's terrible to be between that rock and that hard place, but so much of Nursing, so much of Life is spent there. We have to fight sometimes, we have to respectfully question authority, gently but firmly raise objections and ask questions. We have to confront.

Just make sure to have some witnesses when we do. :lol2: Seriously, OP, don't do "whatever" blindly.

Specializes in LTC.
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

Shouldn't happen if the tube is flushed. Oh but we are just another lazy nursing home that doesn't do that and just gives the meds without flushes. Yep thats what it is. :uhoh3:

Specializes in LTC.
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.

I give 50ml flush before and after the med "cocktail". If I know I won't have a chance to give the meds for a few hours. I'll flush the tube with 50mls of water to keep it from clogging.

G-tube patients are on tons of meds which makes this whole 1 crushed med at a time and follow with 10ccs of water or whatever the amount is.. very impractical and time consuming. I also only have 2 hands. How am I going to carry all those cups of meds/water into the residents room? If I make two/three/four trips I'd be leaving meds in there at the bedside.

Ok lets say they are 10 meds, and 2 supplements that you mix with 8 oz of water (fiber and protein). 50ccs of flush to start with.. before each med 10mls and after each med 10mls.. and 10mls mixed with each med, thats 300mls right there with just the meds. The supplements have to be given with 240ccs of water each so thats 480mls in addition to the 300mls from the meds. That equals 780mls. In addition to the 2 flushes before and after (50ccs each) you are giving that patient an additional 880mls(estimated) of fluid. In addition to the water they are already getting from their tube feeding. If thats a cardiac patient thats not good.

Specializes in LTC, Sub-Acute, Hopsice.

What I was told years ago by a pharmacist from my state Department of Health during an annual survey was that you should never crush different medications in the same vessel as you can actually change the chemical composition of the medications due to the pressure of the crush and forcing the molecules of different medications together. But as a lot of other people here have said, there is no problem mixing all the crushed medications together in liquid to administer into the tube. If a medication should not be given whole with another medication (colace and iron, etc.) they should be separated by time, not by a different cup of water.

I know what you're saying, but don't forget that students are still held legally accountable, can be sued, etc. They are expected to not do "whatever" in order to get good grades.

I know it's terrible to be between that rock and that hard place, but so much of Nursing, so much of Life is spent there. We have to fight sometimes, we have to respectfully question authority, gently but firmly raise objections and ask questions. We have to confront.

Just make sure to have some witnesses when we do. :lol2: Seriously, OP, don't do "whatever" blindly.

Sorry, I tend to assume people understand that I mean "within reason".

What I should have said: Do whatever your instructor tells you as long is it isn't illegal, stupid, or harmful to the patient. :lol2:

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