Reported for this?

[smartnurse1982]

So I work Pdn.

Mom makes the formula.

Child has order for Elecare 10 scoops mixed with 1860 water at 80ml/hr via k pump continuous(gtube)

Mom uses a 2000ml plastic container,no label.

The nurses usually just pour the formula into the feeding bag.

Well,it turns out that the new nursing supervisor found out Mom was using Elecare,but also mixing it with regular whole milk instead of water.

Nursing supervisor says every nurse on case is getting written up and reported to BON.

She said nurses should know what they are giving at all times and feeds are no exception.

She said anytime you pour formula(or meds) from an unknown source,and you give it,you take responsibility for whatever is given.

Mom doesn't want us to make the formula.

She said we have to tell mom to pour the formula she made in the bag,doesn't matter if its 3am.

We are not to sign for it either on the feeding schedule sheet.

[smartnurse1982]

So I am on another case with a different agency tonight.

On this case,another nurse from another agency makes the formula.

I've been with this case for 3 yrs.

It cannot be prepared any other way....its Pediasure 800ml mixed with 180 ml plus 1 tsp salt at 60ml/hr for 14 hrs 6pm-8am.

The differences?

This agency doesn't have feedings on the MAR.

The only place I see it is on the 485 and on the Physician orders.

[smartnurse1982]

This is what I would do, too.

I recall a situation with an adult client when I needed to replace the Foley and was told to use petroleum jelly as a lubricant, and "every other nurse I've had in years does it that way". I had no reason to doubt that statement, I wouldn't immediately assume they were all bad nurses in general. I refused to use petroleum jelly nevertheless. Using formula prepared by someone else is something I likewise wouldn't do, but the situation you describe doesn't sound much different from other conflicts I'm aware of in PDN.

I recall another situation when someone wanted to use sea kelp extract powder or some other weird dietary supplement (patient on regular diet) I got a stern talking to by another nurse who said we needed an order for that. I thought that excessive at the time, but later realized she was right.

I've had nursing supervisors who are accepting of habits private duty families develop over the years, and some who are "strictly by the book". Families can threaten to switch agencies, so there is some pressure on supervisors to "look the other way" as well. I have not seen a supervisor report all the nurses on a case to the BON, but I imagine there will be some repercussions in terms of the family continuing with that agency.

Most times,the feed is already running.

I can't just discard the formula.

Not sure what to do.

[smartnurse1982]

The math for my PDN case was simpler, LOL! The fact remains that you DID give a "medication" prepared by somebody else, even though you said you never ever do that.

How many nurses stand to be affected by this cutthroat decree?

about 45,including 3 past nursing supervisors.

She is getting nurses who have worked only 1 day on this case too.

From the "gossip" I am hearing,the regional administrator fired her.

She had only been working for 2 weeks.

[caliotter3]

If the feeding is already running when you start your shift, you don't just stop and dump the feeding. You indicate on your shift summary that such and such feeding was running at so and so ml/hr, whatever. The little label on the bag is supposed to be accurate per the initials of the nurse starting that feeding cycle and what she wrote that she placed in the bag, just like in the hospital. If you distrust the previous nurse and want to start a new feeding, then that would be on you; but wasting the feeding in that circumstance would cause its own set of problems.

[JustBeachyNurse, LPN]

Most times,the feed is already running.

I can't just discard the formula.

Not sure what to do.

In that case you document rate and route and note in report/narrative who started/prepared feed. Upon arrival, parent reports prepared feed as per orders (specify orders or whatever parent states) , parent reports enteral feed volume 700mL at 70mL/he via GT at 22:00. Approx 620 mL remains, rate verified at 70mL/HR.

[PacoUSA, BSN, RN]

I agree with the other commentators above. How do you know the mother was not mixing a shot of tequila into the feed when she prepares it? Just wondering. I would not sign off on giving anything to a patient that I did not have complete chain of custody from original opening to administration.

[Alex Egan, LPN, EMT-B]

I have been in home are for eight years. Pouring formula prepared by other persons (parents or nurses) is not avoidable in most of my cases. It is common practice, that doesn't make it correct, but like OP I can't always see a way to avoid it. I ran this by my supervisors who have a combined 50 years in nursing and they were stumped by your situation. We have kids who get speciality formulas that really can't be wasted, and yes parents who are untrusting of nurses not to mess it up.

OP Im sorry this happened to you, I'm sorry that our jobs put us in these imperfect situations. I'm sorry that what I said will appall other nurses who aren't in these situations. It's not as easy as just saying you won't administer something you haven't prepared, it just not possible sometimes. Parents are not nurses they don't label everything to the nth degree and have often been burned by nurses who prep formula wrong costing them money out of pocket.

PDN is tough because there are so many gray spots, the choice is often do it this way or don't work, and you have to pick you battles. Frankly formula mixing is not the hill I want to die on. I busy fighting parents put the pulse ox on, or actually apply the ventalator to their child as ordered. Or not suddenly stop benzodiazepines on their freshly NICU discharged baby.

Please keep me updated on what comes of the BON report, if you don't want to post please PM me.

[smartnurse1982]

If the feeding is already running when you start your shift, you don't just stop and dump the feeding. You indicate on your shift summary that such and such feeding was running at so and so ml/hr, whatever. The little label on the bag is supposed to be accurate per the initials of the nurse starting that feeding cycle and what she wrote that she placed in the bag, just like in the hospital. If you distrust the previous nurse and want to start a new feeding, then that would be on you; but wasting the feeding in that circumstance would cause its own set of problems.

We were doing that,but once the feed runs low we have to refill it.

We did that by using the already made formula in the plastic container.

[smartnurse1982]

I agree with the other commentators above. How do you know the mother was not mixing a shot of tequila into the feed when she prepares it? Just wondering. I would not sign off on giving anything to a patient that I did not have complete chain of custody from original opening to administration.

I guess I could say in my notes"Mom made formula" but somebody still has to refill it at 4am.

[smartnurse1982]

In that case you document rate and route and note in report/narrative who started/prepared feed. Upon arrival, parent reports prepared feed as per orders (specify orders or whatever parent states) , parent reports enteral feed volume 700mL at 70mL/he via GT at 22:00. Approx 620 mL remains, rate verified at 70mL/HR.

k pump bag only holds 500 ml.

Plus,we were told we can no longer add more than 4 hrs of volume,due to bacterial growth.

So we can only add 280ml every 4 hrs to the bag.

[caliotter3]

I would say "formula provided by Mom" because you didn't see what she did to it. She might have mixed it, she might have poured in a can of Carnation evaporated milk with a teaspoon of this and a teaspoon of that, you did not observe. You realize, of course, none of this would have become an issue if the supervisor had not taken what the mom said and ran with it. That is another reason why I always go over the entire 485 from one letter to the next, whether or not I am the designated primary nurse. If things are not according to Hoyle, or I can not come up with a satisfactory way of covering my own 'splanations', then I remove myself from the case. You can't always insulate yourself from what others do or fail to do, even with the most meticulous of documentation.

[nursel56]

I guess I could say in my notes"Mom made formula" but somebody still has to refill it at 4am.

I would want to know if the child's provider is apprised of how the mother makes up the formula and proceed from there, getting an order for it if necessary. No order then don't do it. As we know they often have a stack of recert 485s to sign and not going through it line by line before signing. Communication breaks down in a number of ways as we often hear "We saw the doc today and he said it was fine".