Neb treatments

[txredheadnurse, BSN, RN]

Technically you are required to monitor the resident during the entire time of the neb administration. However as others have mentioned there is a viable work around which is to use a standardized assessment tool to determine resident ability to participate actively in using a neb, care plan that resident is capable of doing the neb treatment without constant nursing oversight and get the appropriately worded order. Given the "getcha" attitude prevalent this year among both state and Federal surveyors it is best to have all of this lined up or face possible negative consquences. The rationale for the constant nursing oversight that I have been informed about during neb treatments is that if a resident requires skilled nursing services they can't self medicate or self treat or they aren't appropriate for skilled care. I am not saying I agree with this mindset but the folks that monitor and reimburse use it as their guideline.

I would also suggest that you ask your pharmacy consultant to review all the nebs/inhalers, etc and see if there are any that can be eliminated or changed from routine to PRN. Many times the orders that a resident arrives with are based off their care needs when in an acute setting such as the hospital and really don't need to be continued after admission to a SNF. CapeCodMermaid mentioned this with stopping qshift I & O's, per shift charting, getting an order to "cocktail" crushable meds for G tubes, etc.

[BrandonLPN, LPN]

I'm stunned some facilities apparently have to get "orders" to crush/mix all the meds together for PEG pts. State could actually cite nurses for doing so without an official order?? Give me a break. We all know it would be incredibly UNSAFE for a nurse to give all the

pills/liquids one at a time to all his tube feeders. In LTC we have at least 30 other pts! Nurses who waste time doing this (if there actually are any) do so at the expense of all their other pts.

The fact that we have to get an "order" to NOT do an unsafe practice boggles the mind. Why why why is "the state" (and nursing instructors) so out of touch with reality?

If I have start initialing some bull s*** box that says "nurse may leave room after initiating nebulizer", I may lose it.

[txredheadnurse, BSN, RN]

One of the reasons for getting an order to permit cocktailing all crushable meds is to ensure that nothing that is incompatible when mixed together is given simulataneously. In addition even with consent to cocktail all crushable meds liquid meds still need to be given separately and flushed after each one. And before you get agitated with my response I was an ADON at a facility with an average of 35 G tubes on any given day so I am very well aware of the time frame required to do everything involved with G tubes and po passes. Even if you disagree with the guidelines, in general, they are based on documented outcomes and optimum dosing parameters. Those neb treatments are useless if the resident doesn't keep the mask on for the entire time required or just holds it close to their face. These are things that I have seen repeatedly happen when I am doing my QA assessments so each resident does need to be assessed objectively for their ability to comply consistently with the process. Otherwise a lot of expensive inhalants are being blown into the air and not down the lungs.

[BrandonLPN, LPN]

We'll have to agree to disagree about the meds in a g tube thing. I get that some meds may be "optimal" to be given separately, but whatever minimal benefit there is would be outweighed by the time lost. If my residents weren't getting the therapeutic effects of the meds, wouldn't that have been apparent a long, long time ago? After all, almost all g tube residents in all LTCs everywhere get their meds in a "cocktail". Wouldn't any negative effects worth writing home about have surfaced by now?

[ClearBlueOctoberSky]

Brandon, it's not about you, it's about your patient.

If your facility protocols state you need to give meds one at a time with 30 ml flush between each one, and you're not doing it, you will get tagged in survey, and it won't be a pretty tag either.

[BrandonLPN, LPN]

I'm not sure what our official policy is, to be honest. As a state facility, we are overseen by a federal agency. They are actually much more lenient.

And I realize it's not about the nurse, but if I (the only nurse on the floor) am spending 15 minutes administering g tube meds and 15 minutes sitting with each pt getting a neb tx, then I'm neglecting my other pts. We ALL know that to give meds the way state wants is asinine. I've never heard of a resident being shipped out for getting their senna and Dilantin in a g tube cocktail or for their neb mask falling off with a little albuterol left. I HAVE seen plenty of residents shipped out because the nurse was too anal about her med pass to actually ASSESS the residents.

[tokebi]

I agree with you Brandon for the most part, but have a minor nitpick:

Dilantin CANNOT be mixed. It already has a very poor absorption in the stomach, which is why it should be given in empty stomach (hold the feeds before and after), and separately from other meds. It may not have happened to you, but there's a possibility that the drug level falls and your patient ends up having a seizure.

Back to the original topic, requiring a nurse to remain at bedside during nebulizer tx sounds ridiculous. RTs at hospitals don't do that either unless it's a critical patient. They go around room to room, setting it up, putting on the masks. Then, they repeat the rounds by the time tx would finish, taking off the masks. It doesn't make sense to begin with, to require neb tx to be administered by nurses, when it really is a separate RT job.

[wooh, BSN, RN]

Dilantin CANNOT be mixed.

Unless the drug levels have been balanced during a time when it WAS mixed, in which case you're going to overdose the patient by suddenly changing to not mixing it. :)

[BrandonLPN, LPN]

As Wooh said, if we were doing any harm by giving Dilantin with other meds, it would be reflected in the blood work. Are you honestly telling me you have a separate med time for Dilantin?? Even the pills??! That just seems like a dangerous waste of time to me.

Reminds me of the facilities that wake up all the poor 80 year olds to give them a synthroid at 6am....

[bubblejet50]

The facility I used to work at had the ADON tell me (while I was orienting as a new grad) to cocktail g-tube meds and that she has done this in front of state and never got dinged. The facility I worked at before as a cna had the nurses cocktail them and 19/30 residents had a g-tube. No problems were ever noted.

For the neb tx's....i would stay only with the residents who would be non compliant with their tx. It would usually be a dementia pt on a prn neb or one for 10days because of a uri.

When I would work tge med cart and we were at full census I would have literally 50 residents to give meds to in a 2 hour window. The other med cart would have 20 residents at full census. My residents would be both on a second level floor and first level floor. The DON would not let us even the carts even when the other med nurse would offer to take extra. We presumed this was for when the DON and ADON had to work on the carts because we were short staffed. They would always take the "easier" cart. There was no way that I could stay with all the neb residents. Even staying with the noncompliant ones put me over on time for meds. I left this facility and never looked back. They did not care for patient safety for a number of reasons that I am not going into right now.

[tokebi]

As Wooh said, if we were doing any harm by giving Dilantin with other meds, it would be reflected in the blood work. Are you honestly telling me you have a separate med time for Dilantin?? Even the pills??! That just seems like a dangerous waste of time to me.

Reminds me of the facilities that wake up all the poor 80 year olds to give them a synthroid at 6am....

Unless there's a specific drug-drug interaction, there's no "harm" in mixing except the fact that less Dilantin will be absorbed, and the blood work will show sub-therapeutic level, in which case the MD will have ordered increasing doses until a therapeutic level is reached. If that is the case, suddenly NOT mixing the drug would predispose the patient to get overdose, as wooh pointed out. No problem, as long as there's a consistency -- which is scarce in LTC.

I don't think extended release pills come with such instructions since they get absorbed further down in GI tract with better rate.

[CoffeeRTC, BSN, RN]

As Wooh said, if we were doing any harm by giving Dilantin with other meds, it would be reflected in the blood work. Are you honestly telling me you have a separate med time for Dilantin?? Even the pills??! That just seems like a dangerous waste of time to me.

Reminds me of the facilities that wake up all the poor 80 year olds to give them a synthroid at 6am....

Umm...Yes, I have seen this happen to two of our long term residents. The one of the tube feeding had some really bad levels and seizure activity. The down times were adjusted so that the med was given one hr after. presto...theraputic levels!