PEG Tubes: when is a "bolus" not a bolus?

[Jo Dirt]

We have a PEG tube patient who strangles and aspirates very easily. So, we received orders to sit the patient straight upright with each bolus feeding and leave up 2 hours after the feeding. There is a new nurse who has said she's found a better way than the way I was doing it, which is I get him up in a wheelchair and run the feeding through a piston syringe by hand (takes a couple of minutes) and then I leave him up in his wheelchair for 2 hours.

Her method is to put him in a geri-recliner (so he can relax) and "bolus" the feeding on a pump so this frees her to take care of other things while he is getting his feeding. This takes an hour and a half, and then she puts him to bed 30 minutes later.

I'm not a confrontational person so I don't say anything to her, and I might well be wrong, but this doesn't seem like a bolus feeding to me. He strangles even when he is sitting straight upright. He was her patient last night when I worked and it seemed he was strangling a lot worse, but that may have just been me.

I just wondered what you all thought.

[DeepFriedRN]

Sounds to me like she's just not following the orders as they are written. I'm not really too sure on the pump thing, although an hour and a half seems like a reeealllly long bolus. But if the order reads up for 2 hrs post feeding, then he should be up for 2 hours post feeding, not half an hour. And upright means upright. It amazes me that there are nurses out there that still do the "but he won't be comfortable like that" in these situations. Umm, he'll be way less comfortable with aspiration pneumonia, or on a vent. Its cool to make your job less difficult when and where it possible, but unfortunately we have one of those jobs where it just isn't possible a lot of times. This is one of those times. You probably ought to say something to her. Maybe being a new nurse (and I'm not slamming her, just pointing out) she just hasn't really considered it from another point of view, or see that the patient could suffer.

[Jo Dirt]

I couldn't stand it anymore and called the ADON. She says that putting a feeding on a pump is not a bolus and he's not supposed to be in a geri-recliner, either.

[leslie :-D]

you did the right thing.

putting him to bed 30 minutes s/p fdg, is dangerous.

there's a reason they wanted his stomach to rest x 2 hrs...

and remain upright.

was this nurse keeping the gerichair totally upright or in the normal, semi fowler's position?

(these folks tend to slide out of gerichairs when fully upright and unrestrained).

i'm glad you called the adon.

leslie

[Jo Dirt]

you did the right thing.

putting him to bed 30 minutes s/p fdg, is dangerous.

there's a reason they wanted his stomach to rest x 2 hrs...

and remain upright.

was this nurse keeping the gerichair totally upright or in the normal, semi fowler's position?

(these folks tend to slide out of gerichairs when fully upright and unrestrained).

i'm glad you called the adon.

leslie

Semi Fowlers. I know she thought she was making it easier on herself, but to me it was way more trouble to drag out that pump and break out a feeding bag and go through all that instead of hand feeding him. I kind of got offended because one of the other nurses I work with (who is a fairly new nurse also) said to her it looked like this pump was a much better and easier way. I didn't say anything but when she said this I was thinking no it isn't. I threw a tantrum in my mind and wanted to jump up and down like Rumplestiltskin and tell them, no! no! this isn't the way you're supposed to do it at all!!! But I kept my mouth shut.

The nurse doing the PEG tube feeding is a little too confident in herself. I'm the type to always guess myself over and over so cockiness really gets on my nerves, especially when I feel like I'm right. She has made a lot of mistakes (nothing immediately life-threatening) and still needs to learn a lot but I don't want to be the one to bring it up. I also hear her telling patients and families things that she shouldn't be telling them (and giving them information that isn't necessarily correct, either.) And her charting is sloppy (I thought mine was bad until I saw her's.) In spite of it I like this nurse and don't want to see the wind let out of her sails. I don't like telling people they're wrong. At the same time I'm like damnit I'm right and you'll see!She promised she won't single anyone out but will leave a note on the MAR.

Anyway, thank you for the back up.

[jmgrn65, RN]

You may not like telling people they are wrong but if it is effecting the patient then you need to do it.

The patient should have been up for 2 hours after that so called bolus, not 30 minutes. She placed that patient at a higher risk for aspiration.

[leslie :-D]

golytely, i know you struggle w/asserting yourself (unless you're riled up;)), but as nurses, we need to be defending the safety and well being of our pts...

even if that entails 'educating' a nurse who is doing it incorrectly.

putting this pt to bed 30 minutes after fdg, was indeed, endangering him.

and honestly, there would have been nothing wrong w/you calling her on it.

but at least you reported it, so hopefully it will stop.:)

leslie

[Magsulfate, BSN, RN]

Okay, so, maybe I'm in the dark here, or maybe I've just been an icu nurse for too long,, but why not just have this guy on slow continous feedings since he seems to be bed bound anyways and is having trouble with large amts of feeding in his stomach at once. Why not try a formula that can be fed at 40cc an hour?????

[CoffeeRTC, BSN, RN]

orders are orders. (yeah...we question them when they are wrong or weird, etc) Putting the resident in a geri chair could be considered a restraint too and the positioning is much different than in a w/c. Why does she even use a pump? Why not just let is free flow from a bag?

Is that something you can do when he is in a w/c? Sometimes cutting corners isn't the best thing and yes....You are right, she is wrong.

[leslie :-D]

Okay, so, maybe I'm in the dark here, or maybe I've just been an icu nurse for too long,, but why not just have this guy on slow continous feedings since he seems to be bed bound anyways and is having trouble with large amts of feeding in his stomach at once. Why not try a formula that can be fed at 40cc an hour?????

i agree about continuous feeds, but am not seeing where pt is bedbound?

leslie

[Magsulfate, BSN, RN]

i agree about continuous feeds, but am not seeing where pt is bedbound?

leslie

The geri recliner thing, if it is what I've always used, it is layed flat (like a stretcher)so you can slide the patient over on top of it and then sit them up in a chair position. Otherwise, wouldn't they just walk him to a regular chair/recliner? That is how I am thinking he is bed bound.

[CoffeeRTC, BSN, RN]

He probably does better sitting up at a 90 degree angle or he could be one of those that are all over the bed scooting around so being attached to a tube and machine won't work????

Bed bound (unless severly contracted etc) doesn't always mean geri chair. We have to fight tooth and nail to get them ordered for some of our residents...heck, wouldn't you rather recline in a recliner type chair.