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?
Our ED gets lots of pulled out gtubes after hours. We find out what size they had, the MD puts it in, then confirm placement. The pt never gets off of the ambulance stretcher. Then the pt (and the paramedic) wait in the hall for discharge papers and approval to bring the pt back to the home.
It just seems gross and kind of dehumanizing to use a Foley catheter, something meant to drain urine from the body when they have PEG tubes meant for it!
It just seems gross and kind of dehumanizing to use a Foley catheter, something meant to drain urine from the body when they have PEG tubes meant for it!
You probably shouldn't use a previously used foley for this purpose, although urine is typically sterile, but new foleys are sterile so I don't see how it could be gross. We often use foley's as pleural drains so it's not as though this is it's only other use.
In my facility we only use specialized tubes for jejunostomies, not for g-tubes. For all g-tubes we use foley's with an add-on external collar, made specifically for turning foley's into G-tubes.
You probably shouldn't use a previously used foley for this purpose, although urine is typically sterile, but new foleys are sterile so I don't see how it could be gross. We often use foley's as pleural drains so it's not as though this is it's only other use.
In my facility we only use specialized tubes for jejunostomies, not for g-tubes. For all g-tubes we use foley's with an add-on external collar, made specifically for turning foley's into G-tubes.
I understand that you wouldn't use a used Foley but it just seems awkward using something for urine in a stomach. I don't know maybe I'm weird. But if they make kits to convert them then I guess I'm in the wrong.
Regarding what happened in the OP's case. Be careful with PEG's. There is a case in California where a nurse replaced a freshly placed PEG on a patient who accidentally pulled it. The nurse thought she was doing the right thing, checked placement by auscultation alone, and the patient became sick and was taken to the ED later and died. The PEG tip was inadvertently reinserted to the peritoneal space. The case is found here if you want to read it: http://rn.ca.gov/public/rn533139.pdf
-I really felt bad about Ms.Apilado. Her intention is good, but she can't back up her claim here cos she missed accurate documentation. She failed to review the history of the patient and check the placement of the tube thru X-ray and just assumed that all is well. This story really made me want to review my own hospital policy on PEG tube page by page.
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.
In the ICU they can at least get dextrose containing fluids intravenously until the G Tube is replaced. I could be wrong, but I'm guessing that most LTC facilities do not have standing orders for this.
I agree with you, the situation you describe does not serve the patient well. Are the facilities in your area aware that your ED is unable to provide this service? Are there any other EDs in the area that can?
I work in LTC also. I have had residents dislodge them; I have just replaced them or used a foley. Attach a y-port connector to the foley and check placement and resume feeding. The facility I am at uses kangaroo tubes and we usually have one on hand. We also have a dtanding order to use a foley if need be.
Sometimes you have to be creative if you run low on supplies.
I do have a question though...Are PEG's stitched into place to prevent dislodging and are G-tubes secured with a balloon? I just want a clarification.
"G-Tube" just means "Gastric Tube", as in placed in the stomach. A PEG (Percutaneous Endoscopic Gastric) tube is just a G Tube. PEG tubes have an internal and external bumper that secures them into place. When using a Foley catheter as a G Tube, the balloon inside helps keep the tube in place, but it's not foolproof. The tube should also be secured on the outside with tape or a catheter stabilization device. When red rubber catheters are used as Jejunostomy tubes, they need to be taped in place as well, because there is no internal balloon, there are no bumpers, and it is not sutured into place. I have never seen an enteral device sutured into place, because sutures present an infection risk, and most of my folks with enteral devices are immune compromised.
Has your tongue ever gone thru your cheek?? loved your post.
You probably shouldn't use a previously used foley for this purpose, although urine is typically sterile, but new foleys are sterile so I don't see how it could be gross. We often use foley's as pleural drains so it's not as though this is it's only other use.
In my facility we only use specialized tubes for jejunostomies, not for g-tubes. For all g-tubes we use foley's with an add-on external collar, made specifically for turning foley's into G-tubes.
How do you check for placement? You either need radiographic check, or at least check to see that the return is an appropriate pH for stomache contents.
I work in LTC also. I have had residents dislodge them; I have just replaced them or used a foley. Attach a y-port connector to the foley and check placement and resume feeding. The facility I am at uses kangaroo tubes and we usually have one on hand. We also have a dtanding order to use a foley if need be.
Sometimes you have to be creative if you run low on supplies.
I do have a question though...Are PEG's stitched into place to prevent dislodging and are G-tubes secured with a balloon? I just want a clarification.
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.
Exactly^^^
At the facilities I have always worked at this is what we always have done. I know you are supposed to get an X-ray to confirm placement but, it is not always feasible. The first time I had a enteral feeding tube become dislodged I freaked out. I told the supervisor, and she was like just put another in no big deal. I have worked with some nurses who do not like replacing them and will send them out to the ED. Other nurses will just replace them. The residents I have dealt with have well established tubes, so they can go a few minutes before worrying about closing up. I have also seen tubes sutured into place. I have also seen also seen tubes have leaks near the top of the tube we just cut that part off and add a new y-port connector and drive on with our shift.
Long term care is different from hospital nursing because this is their home. Radiology is not always readily available. Most LTC facilities to set up an X-ray is usually done at another facility; transportation needs to be set up, usually with a 48 hr notice.And the whole what is their payer source also comes to play. The goal of LTC is to treat as much in house.
NICUmiiki, DNP, NP
1,775 Posts
Our ED gets lots of pulled out gtubes after hours. We find out what size they had, the MD puts it in, then confirm placement. The pt never gets off of the ambulance stretcher. Then the pt (and the paramedic) wait in the hall for discharge papers and approval to bring the pt back to the home.