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?
Using a Foley was weird at first but, one I got used to it I think I might actually like it better. We've been using then for years so, when someone actually has a real peg tube in it seems awkward to use, lol. We have plugs we put in the end so they don't leak but, sometimes they will come out. I hate that their is no bumper on them though, they migrate in sometimes. I usually tape them to the stomach.
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.
Replacing an established Mic-key button on a kiddo in a home setting is a bit different. I know that when I did pediatric private duty, we weren't allowed to touch new tubes until a Mic-key could be established -- usually six to eight weeks after the initial tube placement on the kiddo.
I don't think that I've ever seen an adult with a Mic-Key, come to think of it.
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.[/quote']
The only time I've sent a resident to the ER for it was when the resident is NPO. Withholding any food and water for hours is not humane to me when there is no reason like a surgery.
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.
If enteral feedings are the patient's only source of fluids and nutrition, then they need that tube to be replaced ASAP. They can't wait overnight or through the weekend. Many of these folks are medically fragile and interruptions to their feeding puts them at risk. As long as facilities require radiographic confirmation rather than confirmation by air insufflation, the ED is really the only option for after hours and weekend tube replacements.
Juan de la Cruz, in fear of derailing this thread, I have to say that your posts on AN are incredibly informative and most certainly influence my nursing practice for the better. I have read completely the link you provided regarding the CA disciplinary action against the nurse and so many of the points included in the review of the case got me thinking. Thank you so much for your contributions to this website!
If enteral feedings are the patient's only source of fluids and nutrition, then they need that tube to be replaced ASAP. They can't wait overnight or through the weekend. Many of these folks are medically fragile and interruptions to their feeding puts them at risk. As long as facilities require radiographic confirmation rather than confirmation by air insufflation, the ED is really the only option for after hours and weekend tube replacements.
I also work at a LTC and use a Foley for enteral feeding frequently. Its been a common practice everywhere I've worked and the hospital sometimes sends us residents with a Foley already in place instead of a g-tube. In fact, I was once reprimanded for sending a resident to the ER for a dislodged peg tube after I was unable to place a Foley myself. My DON informed me that a displace PEG was not a good reason to send a resident to the ER and that I should have called her in from home to do it.
Hey-- weren't there any notes from the ER in the chart when he came back? From the RN or MD or PA saying something like, "We left it because it was fine and we don't stock PEG tubes here, deferred to PCP in the AM." Did you call them and ask? Why not?
It is my facilities policy to apply a dressing and send them to the ER which is exactly what I have done numerous times in the past 2 years. The nursing supervisor knows this but acted on her own, did not get an MD order for the foley and sent him out. I did not call the ER, probaly should have just to see why. This has never occured before so there is no policy specifically stating no feeding through a foley.
If enteral feedings are the patient's only source of fluids and nutrition, then they need that tube to be replaced ASAP. They can't wait overnight or through the weekend. Many of these folks are medically fragile and interruptions to their feeding puts them at risk. As long as facilities require radiographic confirmation rather than confirmation by air insufflation, the ED is really the only option for after hours and weekend tube replacements.
Yep, got it. But ... my ED does not replace tubes, and interventional radiology does not do this after hours. So a nursing home resident that arrives in the ED late afternoon/early evening/late at night ... can either be discharged back to the facility they came from with a totally wasted trip, or spend a very long time in the ED until IR can add them on to the day's already scheduled procedures the next day. The ED visit incurs time and expense that I find to be unnecessary & unreasonable.
My hospital's multiple ICUs are full of medically fragile patients with PEG tubes -- if they get pulled out after hours, they go without tube feeds until replaced the next day.
lindseylpn
420 Posts
Using a Foley was weird at first but, one I got used to it I think I might actually like it better. We've been using then for years so, when someone actually has a real peg tube in it seems awkward to use, lol. We have plugs we put in the end so they don't leak but, sometimes they will come out. I hate that their is no bumper on them though, they migrate in sometimes. I usually tape them to the stomach.