Peg Tube Nightmare

[GoNightingale, BSN, RN]

Hi everyone out there in my all-nurses community! I thought the GI nursing would be a good specialty to get advice regarding the Peg Tube nightmare I had on last night's shift. I will begin by stating that I work in a very hostile environment where nobody wants to help the other. I started there 6 months ago, thought I would give it time, but have decided to start looking elsewhere.

Well, regarding the peg tube nightmare. I am a floor nurse and last night I had 4 stroke patients and 3 peg tube patients. Peg tube #1, get on report that it's running at 40ml's/hr from 1300 until 0900 the next morning. I'm a night nurse by the way. So when I go to give meds throught the tube at about 2200, I check for residual and I get 280 ml's of residual. Wow! Auscultated for placement, o.k. it's in the right place. Next I pushed my very,very, very well-crushed meds mixed with water throught the tube. Then I go to give it a flush with 50 cc's of water. Oops, Darn, Dang! Freekin thing doesn't flush! Clogged maybe? O.K. how do we usiually onclog a tube, coke, maybe sprite, cranberry juice. Tried all 3- still wouldn't flush. So I called the physician told him about the residual and the fact that the tube appears to be clogged. He says no worries stop the feeding and I'll deal with it in the am. I know this patient and his tube is always clogged. Allrighty then! By the way, I relay all this info. to my charge nurse.I always like to relay problems to the charge nurse either for new ideas and/or so she can pass it on report to the next charge nurse.

Peg tube #2- On report I'm told this tube gets a 250 cc bolus freewater flush q4hrs x4. 2 of those flushed had been done by prior shift. When I asked why he's getting these flushes, nurse didn't know why. Quite frankly, I had such a heavy patient load that night, that I didn't have time to ask why. I just followed doctor's order. Does anyone out there know why a doctor might order that. I work in such a hostile environment, that even if would have asked, I would not have received an answer. Anyway, I check the tube for residual, residual was minimal. I auscultate for placement, so far so good. I push through my finly crushed meds mixed with water. All good. I go to flush with the 250 cc bolus (the 3rd of the 4) and dang! No can do! Darn thing won't flush! Dang! O.K. let's do the coke and cranberry dance! Butthis little sucker just won't flush! So I stop the feeding. At this point I should have told the charge nurse. But I thought I would try unclogging it throughout the night- unless placement is off, usually coke and cranberry juice have worked for me in the past.

Peg tube #3- thank God..all good with that one!

Comes about 0600 and I couldn't get the tube unclogged. So I tell the charge nurse to see if she's got any ideas. She said she would try to unclog it. I asked her if she had any new ideas techniques that I could try other than what I had already done. She didn't answer. This is very typical with her-not only with me but with others. She is very well known for never making herself available to the nurses under her charge.

So now, about an hour later, we are into shift change and the Nurse Mgr. is at the nursing station. She I think overhears me relaying to the physician of patient of Peg #2 that the tube didn't flush throughout the night. That I tried everything. I explained to him that I had oberved that the patient uses accessories muscles to breath (bad COPD patient) and that every time he expired, stuff would come out of the tube. Yet I did not get residuals nor was I able to flush. This was very puzzling to me and to the physician. He said, no worries. I'll request a GI consult and let's see what GI wants to do. Obviously feeding had been stopped throughout the night.

While I'm giving report to the same nurse who had these peg tube patients the day before, I inform her about Peg tube #1. She appeared surprised to hear about the 280 ml residual, but was not surprised that the tube was clogged. She said it had clogged up on her as well. I told her I couldn't get it unclogged using coke and cranberry juice. She didn't offer the technique (if any) that she used to unclog when it happened to her. When I tell her what's happening to Peg #2, she was I'm not sure-surprised and I think she must have been thinking..."gee, what a hassle I'm gonna have on this shift!". Suddenly all hell breaks loose! My unfriendly nurse manager apparantly went to both Peg Tube patients and quite frankly I don't know what she did. In a very demoralizing tone-like implying that I didn't know what I was doing-but she is all-knowing- she stops me in the middle of report and directs me with her into Peg #2's room. She gives me the flush syringe with about 10cc's of water in it and she says o.k. flush slowly. I did, and the 10 cc's went in. I was impressed, surprised, happy! I asked her, what did you do to fix it? She never answered. Then she says Peg #1 was fixed also and to start the feeding!Never once volunteering the method or what she did to fix the Pegs. The intent here between the charge nurse (who never showed up to try to fix the problem) and the Nurse Mgr. was to make me feel stupid.

I was very upset with the attitude the Nurse Mgr.'s attitude as well as the charge nurse. Onde of the nurse's who heard and saw the whole thing said to me," You know they are just trying to make you feel stupid. I heard and saw the whole thing and she did nothing different han you did. It may just be that the coke/juice that you used may of taken time to work and when she went to flush she got lucky.

I have thought alot about this problem (since it really bothered me and is the final spin to get me looking for a new job) and I wonder.....when she gave me those 10ml's to flush into Peg #2, did she even attempt more than 10cc's before calling me over? On Peg #1..what did she do? Is it really unclogged because........ there was 280 cc's of residual early on to the shift. Was 280cc's partially in the stomach and partially stuck in the tube?

This is why I am seeking explanations from my allnurses family because Icouldn't get answers at work and...I am definiteky not a peg tube expert. Thanks in advance :heartbeat

[DixieRedHead, ASN, RN]

Once the residual in tube #1 was resolved one or more of the methods that you used may have worked. She may have "milked" the tube to get the clog out (or in, but this seldom works).

As for tube #2, the free water flushes are usually written to increase hydration and/or increase flow to the kidneys. The patient was having drainage from around the peg tube site because of his respirations. When he exhaled, the diaphram relaxed to the point that pressure was put on the abdomen, causing the drainage.

Yes, both of these nurses are jerks. But I urge you to think critically. Things don't "just happen." They have a cause. When you think about the problem, and the cause, they are easier to understand, and fix if they can be fixed. Hang tough. Remember how bad you wanted it. Hope this helps.

[poopprincess]

Sometimes I am able to unclog the tubes with air. My preceptor taught me to push air through and it gives more pressure than fluid does. It works 7/8 times. We also have the plastic things (don't know the name of them) that we can put up in the tube to unclog it. Sorry that you had a bad night. That exact scenerio has happened to me: 3 Pegs, 2 clogged, 1 worked. It is super frustrating and there was no reason for the charge and NM to act like that. Hang in there. That night is over and you can check that off of nights that you never want to have again. :)

[rcon]

The free water is also used to decrease serum sodium levels in someone who has high sodium on the morning chemistry.

[BelgianRN]

The free water is also used to decrease serum sodium levels in someone who has high sodium on the morning chemistry.

I was thinking exactly the same.

Things that I sometimes do is use SodiumBicarb solution or water with a N-acetylcystein soluble tablet in it. But since both these things are meds I guess you'd need orders for those. (In my unit we are free to administer these via NG-tubes and likes PRN via a standard order)

Keep in mind that syringes with a smaller area on their plunger create higher pressures. Physically presssure is force per m². So the same force applied to a 50 cc syringe generates a lower pressure than the same force applied to a 2 cc syringe. That's how I get most tubes open when my colleagues ask for help. They've tried only the 50 cc syringe.

Another trick that I've used requires a bit of McGuyvering. Create a system where there is a three-way tap attached to the beginning of your tube. one side of the tap is on the tube and two ends are free, tap the one your syringe won't fit on with a stopper to prevent it sucking air or letting the pressure out. Now use a two cc syringe and try injecting 2 cc of air or water in the line. I'll start out with water as fluids are less compressable than gas.

Once it is in, close your three way valve, refill your syringe and repeat. Now you are steadily building pressure until you hear/feel a pop and the clot has dislodged. Just pressurize your syringe before you turn the three way valve back open so it communicates with the syringe (otherwise the other effect will occur and you'll be shot at by your syringe).

With the above two methods we managed to save quite a lot of NG-tubes, postpyloric tubes and PEG tubes from having to be replaced.