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Medications Mixing and Nasogastric Feeding Tubes

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kjeanw kjeanw (New) New Student

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I have a questions regarding medications and mixing of medications.  When giving multiple medications through a nasogastric feeding tube, you must crush and give separately and flush in between to prevent the medications from interacting with each other.  My question is, is there not a risk of them interacting with each other once they all end up in the stomach together?  Is this just much less likely to interact there, but still a possibility? while the feeding tube would be a guarantee to interact with each other if given together?  Also can uncrushed medications ever be given thru a nasogastric feeding tube, such as enteric coated or sustained release?  Or if they can't be crushed then you simply don't give them and try to find an alternative?

NightNerd, BSN, RN

Specializes in Med-surg/tele. Has 7 years experience.

I have honestly just mixed them all together and gave them, never had any issues.

You cannot give anything coated or sustained release through an NGT. If this is ordered, contact the provider to order an alternative. Some medications may be available in liquid or IV form; some may require a completely new substitute.

Kitiger, RN

Specializes in Private Duty Pediatrics. Has 42 years experience.

1 hour ago, kjeanw said:

I have a questions regarding medications and mixing of medications.  When giving multiple medications through a nasogastric feeding tube, you must crush and give separately and flush in between to prevent the medications from interacting with each other. 

I crush them all and dissolve them in water, all mixed together.  Check for residual and vent air, refeed residual, flush with 5 or 10ml water, give the meds, and again flush with water.

Some meds, like chewable vitamins or acidophilus, do not dissolve; they go into suspension. Using a 60ml syringe, I swirl and pour in about 10ml at a time. If it plugs, I lower the syringe and allow it to come back into the syringe, swirl and repeat.

The only time I don't mix them all together is when I have an oil-based med, like Valium. That can cause clumping. Also, I mix meds with water, not formula. Formula can make the mixture too thick.

Oh, and as NightNerd said, enteric coated and sustained released meds do not belong in a NG. The packaging clearly says, "Do not crush."

JBMmom, MSN

Specializes in Long term care; med-surg; critical care. Has 9 years experience.

I think this is one of the biggest nursing school world vs real world examples out there. Yes, in nursing school (or when the state is observing), medications are crushed separately and administered separately because theoretically, mixing two or more medications can alter the bioavailability or intermediates. I have not seen any publications that can point to specific examples but I guess the problem is you can't always be sure.  Other than not crushing extended release or coated medications, or giving sublingual or buccal medications, almost everyone puts all the meds together with G tube meds. 

 

Pepper The Cat, BSN, RN

Specializes in Gerontology. Has 35 years experience.

If I had to give each pill separately, flushing after each one I would never get done! Crush them altogether, mix well with water and give them. 

 

amoLucia

Specializes in LTC.

All depends - what does your facility P&P  require?

DavidFR, BSN, MSN, RN

Specializes in Oncology, ID, Hepatology, Occy Health. Has 35 years experience.

I look at it this way, I'm on multiple medications which I just take in one go and they all get swilled down together. They're all down there interacting in my stomach.  No issue.

I don't see any difference passing multiple meds via an NG tube. If they are normally taken together orally with no interaction, I don't see an issue. If you'd normally take them apart orally for whatever reason (for example, a homoeopathic medicine that shouldn't be taken with other mainstream meds) then don't pass them together down an NG. Otherwise OK. Never had a problem.

JadedCPN, BSN, RN

Specializes in Pediatrics, Pediatric Float, PICU, NICU. Has 15 years experience.

I agree with what other posters have said. Except for certain meds that can’t be given at the same time as other meds (I know there are some meds that have to be given at least an hour after Calcium, for example), it’s all going to mix in the stomach whether it’s swallowed or given via GT.

However know your facilities P&P about it so that, as another poster mentioned, you’ll know the technical way to do it if state or joint commission comes. A hospital I worked at in the past said that mixing several GT meds together in one syringe was considered compounding the med, which we weren’t technically allowed to do as it was outside of our nursing scope of practice.  Realistically though, that’s exactly what gets done.

FashionablyL8, CNA

Has 15 years experience.

I agree with the above posters- real world, I've never seen anyone give each med separately. I sure haven't- I would like to finish my med pass by the end of my shift! We always have several Gtubes at our place so I've given a lot of meds through them and never had a problem. As previous posters said, it all goes to the same place as PO meds eventually, just takes a little shortcut. Of course there are certain meds that don't mix well together, but generally they are fine. I never mix anything with formula, it's already thick enough. Also using really warm- not burning hot- water helps dissolve the meds and prevent clogging. 

I remember in nursing school how we should never ever use Coca-cola to unclog a Gtube. Of course I just sat there looking innocent but I was thinking that it may not be ideal, but it beats sending a resident to the ER in the middle of the night during COVID season 😁.

LibraNurse27, BSN, RN

Specializes in Community Health, Med/Surg, ICU Stepdown. Has 8 years experience.

3 hours ago, FashionablyL8 said:

I agree with the above posters- real world, I've never seen anyone give each med separately. I sure haven't- I would like to finish my med pass by the end of my shift! We always have several Gtubes at our place so I've given a lot of meds through them and never had a problem. As previous posters said, it all goes to the same place as PO meds eventually, just takes a little shortcut. Of course there are certain meds that don't mix well together, but generally they are fine. I never mix anything with formula, it's already thick enough. Also using really warm- not burning hot- water helps dissolve the meds and prevent clogging. 

I remember in nursing school how we should never ever use Coca-cola to unclog a Gtube. Of course I just sat there looking innocent but I was thinking that it may not be ideal, but it beats sending a resident to the ER in the middle of the night during COVID season 😁.

I remember being shocked when I saw a seasoned nurse unclog a g tube with orange soda LOL but it did work. I guess a g tube is not sterile...? is it the same as drinking orange soda? still on the fence LOL

amoLucia

Specializes in LTC.

Ginger ale for unclogging works well also.

I think it's just the carbonation fizz that helps.

Had a supervisor who used to pour a 2 litre Coke down her kitchen sink monthly. Said it declogged the pipes and she never had any plumbing problems.

JBMmom, MSN

Specializes in Long term care; med-surg; critical care. Has 9 years experience.

On 4/7/2021 at 6:46 PM, DavidFR said:

I look at it this way, I'm on multiple medications which I just take in one go and they all get swilled down together. They're all down there interacting in my stomach.  No issue.

This is true, however, each of those pills you take are coated and will be dissolved either in the stomach or small intestine as intended because their whole packing remains intact. Unless you crush them in food or something and then it's the same issue. However, when meds are crushed and the excipients and active ingredients can mix with ingredients from other medications, you could precipitate a chemical reaction that changes the ways in which those medications will be digested, and potentially their reactivity. Again, not much specific information out there because there are millions of potential mixtures, but it is something to be aware of WHY it's not recommended. Which in the interest of time, and the small likelihood of negative outcomes, we all go ahead and do anyway. 

My facility’s policy is to crush them individually, so I do that.  The reason is that mixing crushed meds together is considered compounding medication which is out of our scope of practice.  It’s not about it ending up all in the same place.

Also mixing multiple meds together clogs the tubes.  One of my biggest pet peeves is a feeding tube that is not flushed properly and clogs.  So, I’m a stickler for keeping those feeding tubes flowing properly.

I know people think I’m crazy that I do them individually.  It doesn’t take me a ton of time to do each med individually.  After 9 years, I’m pretty fast.  

amoLucia

Specializes in LTC.

1 hour ago, LovingLife123 said:

Also mixing multiple meds together clogs the tubes.  One of my biggest pet peeves is a feeding tube that is not flushed properly and clogs.  So, I’m a stickler for keeping those feeding tubes flowing properly.

 

You are a nurse after my own heart!!

Clogged GTs = grrrrrrr!! And you always knew which other nurses didn't flush their GTs.

10 hours ago, amoLucia said:

You are a nurse after my own heart!!

Clogged GTs = grrrrrrr!! And you always knew which other nurses didn't flush their GTs.

Oh you know I do!  

CalicoKitty, BSN, RN

Specializes in Med-Surg, Geriatrics, Wound Care. Has 9 years experience.

On 4/7/2021 at 11:23 AM, JBMmom said:

I think this is one of the biggest nursing school world vs real world examples out there. Yes, in nursing school (or when the state is observing), medications are crushed separately and administered separately because theoretically, mixing two or more medications can alter the bioavailability or intermediates. I have not seen any publications that can point to specific examples but I guess the problem is you can't always be sure.  Other than not crushing extended release or coated medications, or giving sublingual or buccal medications, almost everyone puts all the meds together with G tube meds. 

 

I just watched a poor student nurse giving the 1 pill at a time crushed to a patient. I had a hard time not looking confused and asking why he wasn't just giving them all at once.. 😄

LibraNurse27, BSN, RN

Specializes in Community Health, Med/Surg, ICU Stepdown. Has 8 years experience.

I always gave them each separately because my instructor made such a big deal out of it in school! Plus what if the state walks by 😂