Tube Feeding Question

LPN1974, LPN · Dec 12, 2004

I am an RN in LTC. Residents with tube feeding have the HOB up 45 degrees. The NAC needs to take care of this person every 2 hours to do peri care and change their brief. In order for them to this, the tube feeding needs to be turned off to allow the resident's bed to be put down to turn them. I delegate the task for the NAC to turn off the T.F. machine, but that I will be coming in a few minutes to make sure all is well and that the machine is turned back on properly. Sometimes I am with them to turn it off myself depending if I am right in that area of the facility. I have had no problems with delegating this task. But, another NAC claims that I am wrong for delegating this task and would like to turn me in. She states it is illegal for me to do this. Am I wrong for delegating this task?

HMMMM.....I never thought about it. I think you're handling it well.

When I worked in a LTC the aides turned the machines off sometimes, and I would go turn it back on, making sure everything was ok.

Sometimes, tho, at the beginning of my shift I would go check my tubefeeders, and find the machine turned off, and it was obvious from the date/time on the bag, that they hadn't received their feeding all day.

I would try to tell the other nurses about it, but no one listened.

It was very frustrating. If the feeding continues as it was supposed to, I would be the one on the night shift to hang new bags and tubes, but when I had to do it at the beginning of my shift it slowed me down getting started with my med pass. ANOTHER reason I quit LTC.

BTW.....what does NAC stand for? Nurse aide....what?

webblarsk · Dec 12, 2004

Hmmm.............good question. My opinion is its out of the NA's scope of practice. But the NA dosen't need to be so rude!

acgemt · Dec 12, 2004

Hmmm...tough question. I think it is out of the nursing assistants scope of practice, since it isn't covered in the class. At the same time though, I feel that she should have said right from the get-go that she would not do it. Why did she wait until now to say that she would turn you in for it. It seems to me that there might be an alternative motive for turning you in that you need to investigate. Either that, or she is just plain rude.

RNPATL, DNP, RN · Dec 13, 2004

First of all ... it is important to review the nurse practice act for your State. Most States provide guidance for the delegation of a task to a lessor skilled individual. For example, a nurse would not delegate a complex dressing change to a nursing assistant. If you, as the RN, are going to delegate this task, we first have to explore the critical thinking behind why a licensed person needs to perform this duty and what could happen if the nursing assistant thought he/she turned the pump off and then lowered the HOB to provide hyigene care. The patient would be at a significantly higher risk of aspiration and might even aspirate.

I also think about how I can support or respond to an attorney if they are asking me a question as to why I make a certain clinical judgement or decision. In this case, if the attorney said to me, "you delegated this task to the CNA despite the fact that there is no competency that this individual could perform such a procedure." "You delegated this task despite the fact that your licensure requires that you perform this procedure."

See, regardless of how it goes down, the action of the nursing assistant is still and forever your responsibility. As an RN, you hold the ultimate accountability for this patient's care. The nursing assistant is NOT licensed and therefore is not expected to have any related competency or knowledge for this type of procedure.

Sorry my response is so long, but in relaity, if I were the RN, I would not delegate this task to anyone and would perform it myself, unless there was another licensed nurse available to perform the procedure. And, yes, turning off the feeding pump is viewed as a procedure.

Good luck with your decision in this area.

lovingtheunloved, ASN, RN · Dec 14, 2004

I'm a CNA, and in AZ, we're not allowed to mess with tube feedings. However, I wouldn't be threatening to turn a nurse in for delegating the task to me. I would refuse and explain that it is out of my scope of practice. The only reason I'd turn the nurse in would be if s/he threatended me with disciplinary action for refusing. Unless you did that, there's no reason for that person to get all hyper like that.

CoffeeRTC, BSN, RN · Dec 14, 2004

Good question! The CNAs always turn off the pumps while doing care and will turn it back on. Actually they press the hold button which will beep after a few minutes propting them to turn the pump back on. Never really considered this wasn't in their scope.

KrisV27 · Jan 23, 2005

CNA's are not allowed to touch the pumps where I work. They will be fired and the nurse will be fired for asking the CNA to do this. It is not in their scope of practice. I don't turn off the pumps during care. The order says 45 degrees at all times, that means at all times. It is possible to turn and change residents while they are sitting up. It's a pain, but it can be done. I don't allow them to be rolled down, I've seen residents start aspirating when this was done. Just because the pump is off doesn't mean there isn't 300cc of residual in their stomach waiting to be aspirated on.

SharkLPN · Jan 23, 2005

Just because the pump is off doesn't mean there isn't 300cc of residual in their stomach waiting to be aspirated on.

Good point, but if my pt has that much residual, their TF was already halted until a residual check shows that it's moving through the GI tract. I hold them if it's at or over 100cc, regardless of the MD order. I'm not about to find out how much their stomach can hold, or if they have a SBO!

Sondra Cash · Jan 23, 2005

I worked in LTC over 30 years and here in Tennessee, you can not ask a CNA to do anything that has to do with TF.It is your responsiblitiy to make sure they are off and on.I agree also a pt.should never be rolled down.As to her turning you in maybe she was not rude but, did not want you to know she was uncomfortable and did not know how to tell you.Sometimes when a person is unsure of themselves they take the defence.LTC can be very stressful for everyone who works it because of the rules and demand OF TAKING CARE OF THE PTS.I also believe cna's have the hardest job there and can either break you or make you as a LTC nurse.

Sondra

meownsmile, BSN, RN · Jan 23, 2005

It is a good question. We had a couple CNA's recently that felt they didnt have to do anything they werent taught in school. Well that isnt necissarily right either. I think letting them turn the pump off isnt a problem. They should know and have the common sense to know where the off switch is. If there was an emergency(ie.choking etc) with this patient would they leave it running and go find the nurse? I would hope not. Its the turning the pump back on that shouldnt be their responsiblity. It should be done by the nurse to assure the settings havent cleared and it is still patent and running. However, just because the CNA's arent taught about the specific type of bed scale in school doesnt mean its not their job to find out and be taught how to safely use it. Maybe your facility needs to address the tube feeding question in their policy if its not already. Since there is a question at your facility and people dont really seem to know, the DON needs to put policy in place for everyone to follow. Pass this buck to the higher ups and then tell the CNA who wants to write it up address her concerns to the DON as you already have.

Timberwolf · Jan 23, 2005

So here we all are discussing how to satisfy requirements that are impossible to satisfy.

And no it is not possible to adequately clean and dry someone who is at a 45 degree angle -- without enough CNAs and there are never enough. What a fantasy land nursing is.