Good day fellow nurses! I just got off work and had a long shift (orange juice splashed all over me by a combative and arrgumentative patient) as well as a fall and a long med pass!
Some background on me: I have been an LPN for 2 1/2 years and just recieved my RN (asn). I have 2 years full time expierence at my current job - LTC as well as 3 summers of sleep away camp nursing.
Today as I was preparing to start a tube feed on a non-verbal pt I discovered his peg dislogded with the ballon deflated. Not a big deal- happens every once in a while. What I normally do is clean the site apply a dressing and send them to the ER for peg replacement. Well my supervisor instead put a foley cath in the stoma to.keep it patent while he is in the ER waiting room. I thought this odd and vant imagine his stoma closing by the time he was seen. His original peg would not stay in place. He came back from the ER WITH THE SAME FOLEY IN HIS STOMACH like really did anyone even examine him?? How could you not tell the diff between a peg tube and a foley?? His paperwork saif peg conformation and that he had an xray. Well he came back at 11pm. New supervisor on shift said to not send him back he has been there all night with no feed and is prob starving. She said to start the feed. I had a feeling in the pit of my stomache that this was wrong to give a feed through a foley. I voiced my concern and she the supervisor said it was ok for the night. I check placement and patency. In the Am My unit manager Was FURIOUS she said it was not my fault but the supervisors. I feel horrible! Pt was not harmed. Any thoughts?
Think about it. The Foley is a two way valve. When used as a urinary catheter, the fluid comes out by gravity into the bag which is placed below the level of the bladder. When used as an enteral feeding device, the formula goes in using gravity via syringe bolus (held higher than the level of the stomach) or pump (pressure).
This is a huge pet peeve of mine, (but I do follow regulations and never replace them)! I just think its rediculous that a parent with no medical knowledge can change a feeding tube (I know I did it on my son every month, or whenever he pulled it out)... Yet RN's can not be trained to do it? It is really easy and you can check for placement with a stethoscope. If its safe for thousands of children to have parents changing them at home I really don't see why we as nurses can't do it?
Anyway, yes at my facity the policy is to put a foley in the hole so it doesn't close. Though if someone has had a tube for years it probably won't close on its own anyway, my son only had his tube for 1 yr and it had to be surgically closed because it wouldn't close completely on its own and I've heard of this happening a lot... So you probably have time but better safe than sorry. I'm very confused as to them sending him back with the foley still in, not trying to put the ER down but what's the point of sending them out then? Obviously they confirmed placement but it seriously is easier to put a g-tube in than a foley or supra pubic, it takes like 5 seconds once your field is set up... Maybe they didn't have that tube though? I personally would have called an on call or my DON before giving a feed through a catheter. But I know it's hard when your supervisor is telling you to do something (I'm charge but if my girls ever felt uncomfortable I would gladly let them call the DON) its still your license...
We are allowed to change g tubes at the nursing home I work at as long as we are trained properly. I have seen a resident with a foley in for two months while waiting for the proper tube to come in. The feed went in it fine and there were no issues.
I work for an agency in which we do not have orders to replace dislodged tubes. If the parent of the pediatric patient has been trained to replace an NGT, then they do. Otherwise, if the tube becomes dislodged or occluded, we (I) have to determine if the patient is dependent enough on the enteral feedings that they need to go to the ED immediately, or if they can take enough PO to wait until they can contact the appropriate doc in the morning. I do not have orders to go to the patient and replace the tube. It's not a matter of what I know how to do; it's a matter of what I have orders to be able to do.
It used to drive me nuts when I worked in the ED. Now I understand.
Thank you for all the replies! I was feeling horrible about the situation. My ADN called me today and I explained what happend. She said in the future if I am uncomfortable or have a bad feeling about something which I did and I voiced my concern to the supervisor regarding feeding through the foley that I should I should speak up and follow my gut. From my point of view I didnt want to come off as insubordanent. Also the supervisor has 20+ years of nursing expierence. She said it was not ok to feeding through the foley. I learned a lesson and will carry this through the future of my career. She also said it is the supervisors "fault" bc I notified her and did not attempt or start the feed until she directed me too. I'm not looking to pass blame. Just happy this situation is behind me.
Peg tubes are easily changed. I've done it in the home. Radiology? Doctors? Come on, it's a simple procedure. And it is alright to put a foley in until you can get the proper Mickey button.
At my facility we have went to using foleys as g-tubes because they are cheaper. We do all our own peg changes too, we can either replace it with a 18f Foley with a 10cc balloon or a peg tube, whatever we have in stock.
Whenever I have a kid pull out their gtube we immediately put in a foley so that it doesn't close up (assuming it is not a mickey button in which case I would just replace myself). If surgery can't take them that day then we start feeds through the foley. I've never had any issues with it. Given, my hospital policy clearly spells out all of this.
I can see from this thread that there is variation in what ED MDs are willing to do regarding PEG replacement. However, at my ED ... we do not do this. And so it is very frustrating to repeatedly get residents from area LTCs at say ... 6pm ... and have the patient incur a 15-18 hour ED visit just to have a radiologic procedure in the morning. Why can the LTC not contact the resident's provider and arrange for an outpatient radiology procedure? Adding the ED MD into the mix is unnecessary, costly, inconvenient and uncomfortable for the patient.
Thank you for all the replies! I was feeling horrible about the situation. My ADN called me today and I explained what happend. She said in the future if I am uncomfortable or have a bad feeling about something which I did and I voiced my concern to the supervisor regarding feeding through the foley that I should I should speak up and follow my gut. From my point of view I didnt want to come off as insubordanent. Also the supervisor has 20+ years of nursing expierence. She said it was not ok to feeding through the foley. I learned a lesson and will carry this through the future of my career. She also said it is the supervisors "fault" bc I notified her and did not attempt or start the feed until she directed me too. I'm not looking to pass blame. Just happy this situation is behind me.
Your supervisor is right to tell you to follow your gut. Your supervisor is Wrong, however, to freak out over this. It's perfectly acceptable to use a Foley for tube feeds as a temporary measure if placement is verified. I'd question her judgment that she seems so adamantly opposed to this. Where is your facility policy? Where's the MD in all this? You should be consulting the MD first before worrying about your ADON.
There should be a policy that spells this all out. Especially in a facility where you have patients who have PEGS.
If you send the patient to the ED, they would just check placement for you--and when confirmed, send the patient back.
Then follow up with patient's GI doc for proper tube.
I am confused about facilities that use strictly foleys. (Especially because it is a cost issue). I would think if difficult to give meds through a foley tube.
Anna Flaxis, BSN, RN
1 Article; 2,816 Posts
Think about it. The Foley is a two way valve. When used as a urinary catheter, the fluid comes out by gravity into the bag which is placed below the level of the bladder. When used as an enteral feeding device, the formula goes in using gravity via syringe bolus (held higher than the level of the stomach) or pump (pressure).