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

Nurses General Nursing

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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.

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.

the gerichairs i think of, are those God-awful mauve, vinyl bulky recliners.

but i see what you're saying about your perception of bedbound.

either way, to give this pt continuous feeds during waking hours, seems like a viable alternative...

unless they want his gut to get total rest most of the time.

leslie

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Specializes in ICU.
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.

I see, okay, thanks. :)

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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?????

They tried that. Also they tried keeping the head of his bed up but he would always scoot down in the bed and end up flat again. He was hospitalized twice for aspiration pneumonia. Bolus feedings in bed didn't help, either, because even though we would leave the head raised he would wiggle around until he was flat again. . The only other alternative was to get him out of bed sitting upright.

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Specializes in pedi, pedi psych,dd, school ,home health.

You can also run a feeding very quickly through a pump.. just put the rate very fast...ie 480cc/hr (that way the 240cc can would go in in 1/2 hour) and you dont have to stand there holding a syringe and worrying about it spilling all over you ( been there done that more than once) . It is also easier to stop if he is having difficulty. It is still considered a bolus as it is run in quickly but not as fast as if you just hang it by gravity. As far as the geri chair; perhaps it is more comfortable; as long as his head is up as ordered >45 ; or 90 degrees. He should still be up for the 2 hrs after the feeding

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Maybe things are different because I work in Peds, but we DO do bolus feedings over a pump, usually over half an hour. Kids with GTs tend not to tolerate gravity boluses well. However, we also put them in an infant seat or wheelchair or mom's lap if they need to be upright. Putting the feeding on a pump doesn't change the need to be upright after the feed. Many of our chronic kids have had to change to GJTs and have continuous feeds in the J-tube, simply because they cannot tolerate GT feeds at all. So nothing but meds go in the GT, and feeds in the JT.

Sounds like the nurse may have thought that putting the feed in longer would help prevent aspiration, but she should have followed the orders as written and asked the Dr if they thought feeding over a pump would help. I wonder if she's ever tried to eat or drink in the semi-fowler's position. Might give her a fresh perspective. But, like the OP, I wouldn't want to completely discourage her. She does need to be confronted about what she is doing that may harm the patient, just not in front of the patient or family. Part of how we learn is when people confront us about our mistakes. It can be done in a professional and caring manner, rather than being confrontational. Personally, I appreciate feedback directly from my fellow nurses than hearing it from the manager or nurse educator after everyone has discussed it at the nurses station, which is what often happens where I work. When I hear nurses complaining about others, always when that person is not present, btw, I ask them if they have talked to that nurse. If they say it hasn't worked, I ask if they have talked to the ANM, then the next person up the chain, etc. Talking about it at the nurses station is unprofessional and unproductive. This was happening in front of nursing students, and I felt I had to say something so the students wouldn't think this was okay.

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Specializes in Neuro ICU and Med Surg.
You can also run a feeding very quickly through a pump.. just put the rate very fast...ie 480cc/hr (that way the 240cc can would go in in 1/2 hour) and you dont have to stand there holding a syringe and worrying about it spilling all over you ( been there done that more than once) . It is also easier to stop if he is having difficulty. It is still considered a bolus as it is run in quickly but not as fast as if you just hang it by gravity. As far as the geri chair; perhaps it is more comfortable; as long as his head is up as ordered >45 ; or 90 degrees. He should still be up for the 2 hrs after the feeding

This is how I would do it. The max rate on our pump I think is 300ml/hr.

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Specializes in Neuro ICU and Med Surg.

easttexasnurse,

What you are thinking of is a stryker chair. We have those in our ICU too.

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Specializes in A little of this & a little of that.

I've seen boluses run on a pump over 30 minutes in adults and peds. I wouldn't think you would need a separate order for that. I've also seen it done by gravity from a bag with the bag close to the level of the abd so that it runs slowly. I've found that a lot of times with the piston syringe it tends to "gurgle" back on me towards the end.

If the orders say upright then a geri-chair was inappropriate. And 2 hrs after feeding obviously means after the feeding ends.

You were right to report it. It would be good if you can get up the nerve to talk to her about things. If you do it nicely, she will hopefully take it as "mentoring". Going to higherups should really be reserved for when talking to someone does no good. I know this is hard for some people to do, but your working relationships will be better for it.

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I've seen boluses run on a pump over 30 minutes in adults and peds. I wouldn't think you would need a separate order for that. I've also seen it done by gravity from a bag with the bag close to the level of the abd so that it runs slowly. I've found that a lot of times with the piston syringe it tends to "gurgle" back on me towards the end.

If the orders say upright then a geri-chair was inappropriate. And 2 hrs after feeding obviously means after the feeding ends.

You were right to report it. It would be good if you can get up the nerve to talk to her about things. If you do it nicely, she will hopefully take it as "mentoring". Going to higherups should really be reserved for when talking to someone does no good. I know this is hard for some people to do, but your working relationships will be better for it.

It's so hard for me to do (correct another) I'd rather change ten colostomy bags than do it, and colostomies make me sicker than sick.

So, like a big chicken I hid behind the ADON. It's nothing to get reprimanded for. She wasn't doing it to be destructive, she really thought she had found a better way. This isn't one of those cut throat facilities to work in, it's tight knit and everyone generally gets along. I'm hoping the ADON never mentions me, just puts a friendly reminder note up.

I still don't see how running the bolus over a pump for 30 minutes would even make it easier. It's also 30 minutes later he would have to be kept sitting up (his feeding is at 8pm) to be in the 2 hour time frame. And why waste a feeding bag? Why drag out a pump? A hand bolus is done in a couple of minutes by gravity. He has no problem getting it in.

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Running a bolus over a pump for 30 minutes gives him more time to digest the formula as it goes in. Feeding bags are generally good for 24 hours, so if everyone were bolusing him the same way, it really wouldn't be a waste of a feeding bag. Is it possible to start the feed 30 minutes early, with the same 30 minute time allowance we have for meds? Then he wouldn't be getting down so late, and the extra 30 minutes might help keep him from aspirating.

I understand being uncomfortable confronting someone about something you think they are doing wrong. Just think about how you would want someone to let you know, and follow that as a guideline. Just a friendly, hey, did you know the doctor ordered that pt to be upright for 2 hours post-feed might be all it takes. The ADON shouldn't mention you, that would be unprofessional. When I've seen someone doing something they shouldn't, I just pull out the order or policy/procedure manual and show them, assuming they didn't know. Most people are receptive.

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