The following is a link to a recent article from the October 2009 issue of AJN about tube feeding, and how it should be performed. I know that we aren't supposed to mix meds or combine meds with feeding. Plus, we should flush between each med. However, I was surprised to see that it states sterile water should be used for flushing and diluting through a G-tube, not tap water:
A few questions: do any of you use sterile water for tube feeding medications? If tap water is bad for tube feeding meds, then shouldn't it also be bad for oral medications? Or to have patients/residents drinking it, in general? (Or us, for that matter?!) I was never taught to use sterile water in school for tube medications.
I think sterile water should be used after the PEG has been placed initially, however if the PEG has been in for years, why use sterile water? The gut isn't sterile. boiled tap water would suffice.
Having recently taken chemistry, I can understand the rationale for not using tap water to mix meds in, and not crushing different meds together.
Remember precipitation reactions that occur when certain substances are mixed together in a test tube?
Think about it. When pills that are swallowed dissolve in the stomach, they don't mix together to the same extent that they do when crushed and mixed before administration. They aren't crushed, so they also don't have the same exposure to the impurities in tap water before they are metabolized.
When you're pulverizing different drugs together into powder, there's more chance for a reaction between the drugs to occur. Same goes with reactions with the impurities in water. The drugs weren't tested in this form. I do agree that bioavailability of the drugs can be altered, but to what extent I am not sure. For some medications, it probably makes a big difference. Others, not so much.
That being said, in reality, separate crushing and administration with sterile water just isn't going to happen in practice, for all the reasons given above. But I am dismayed that so many professional nurses are so quick to dismiss this research and evidence-based practice. Can't we instead work with drug manufacturers to make drugs safe and compatible for easy g-tube administration?
Having recently taken chemistry, I can understand the rationale for not using tap water to mix meds in, and not crushing different meds together.
Remember precipitation reactions that occur when certain substances are mixed together in a test tube?
Think about it. When pills that are swallowed dissolve in the stomach, they don't mix together to the same extent that they do when crushed and mixed before administration. They aren't crushed, so they also don't have the same exposure to the impurities in tap water before they are metabolized.
When you're pulverizing different drugs together into powder, there's more chance for a reaction between the drugs to occur. Same goes with reactions with the impurities in water. The drugs weren't tested in this form. I do agree that bioavailability of the drugs can be altered, but to what extent I am not sure. For some medications, it probably makes a big difference. Others, not so much.
That being said, in reality, separate crushing and administration with sterile water just isn't going to happen in practice, for all the reasons given above. But I am dismayed that so many professional nurses are so quick to dismiss this research and evidence-based practice. Can't we instead work with drug manufacturers to make drugs safe and compatible for easy g-tube administration?
Yep those were the scientific arguments I mentioned before and on a chemical level they are sound arguments. BUT I really like your idea that the drug companies work to make the drugs themselves easier to administer with regular old tap water (again, on a chemical level, probably easier said than done as I'm sure contaminants in tap water are going to always be variable). Maybe one solution is to research using distilled water, which is much less expensive than sterile water.
I'm not dismissing the research, I'm dismissing its ability to be incorporated into practice.
I agree with you, Sue. But some of the replies were dismissive.
Sometimes when I'm at work, it's as if I really don't have time to think. There are too many tasks and too little time.
But if the drugs aren't going to have the desired effect if we're crushing them all together, why are we continuing to give them that way? Is it because we, as nurses, just don't have the power to change the way things are done? To improve staffing? To improve drug manufacturing and testing? To get these old people off the multiple drugs they are taking that they probably don't even need in the first place?
In nursing school we used both. Most times we used tap water for NG tube feedings. The exception to the rule was when I worked in pediatrics. We used sterile water only for peds.
If you consider first who you are giving the meds to I guess I can see the relevance of using sterile with some patients. Some patients may have just been on antibiotics, may be immune supressed, or are too young (infants) to have built up a good supply of normal flora. Not that I'm saying tap water is laced with C-diff but the faucet and sink might me. Just a thought...
I'd probably use sterile if patient has diarrhea, immunocompromised, or infant. Of course if its the policy I'd do it for everyone.
Oh yeah, and I guess if someone has an ulcer the chlorinated tap water might be slightly irritating??
I have a pediatric client with a G tube and we use tap water for everything. Because there is flouride in our drinking water it has helped maintain his teeth to a level that they are starting preventative therapy instead of monitoring deterioration
Sure - lets use sterile water. Who cares if it cost a kazillon times more than tap water! And lets give meds one at a time. Flushing before/after each med. Lets see - 10 meds, flush before, after, mix each one in its own medicine cup -(more expenese there - 10 cups instead of 1). Hmm - if I'm lucky, I'll get his meds through just in time for the next batch! and of course, I'll have to open a new container of sterile water, because after dipping my no longer sterile syrine into it to flush between those 10 meds, it will no long be sterile.!
Ya really have to wonder if the people that write these articles really work in the real world!
Sterile water meets United States Pharmacopeia standards. Tap water should not be used; it can and often does contain contaminants, including pathogenic microorganisms, pesticides, pharmaceuticals, and heavy metals that might interact with a drug and reduce its bioavailability.
How is this dfferent from swollowing medications with tap water (i.e. taking a pill)?
And as for not mixing them- as my Mom told me about my carrots and mashed potatoes touching- they are all going to end up in the same place. If you push them in succession, aren't they going to mix in what ever spot the tube is positioned? Gastric motility isn't THAT fast.
Specializes in ICU, PICC Nurse, Nursing Supervisor.
10 meds..... how about 10 vitamins then the regular meds....ive had patients take up to 30 meds....lol....crush- then in one cup-tap water and then in they go...
sure - lets use sterile water. who cares if it cost a kazillon times more than tap water! and lets give meds one at a time. flushing before/after each med. lets see - 10 meds, flush before, after, mix each one in its own medicine cup -(more expenese there - 10 cups instead of 1). hmm - if i'm lucky, i'll get his meds through just in time for the next batch! and of course, i'll have to open a new container of sterile water, because after dipping my no longer sterile syrine into it to flush between those 10 meds, it will no long be sterile.!
ya really have to wonder if the people that write these articles really work in the real world!
I just saw a HOUSE where the patient had Legionnaire's and and an amebic infection from stealing water from a roof cistern contaminated by pigeon poop. He died. I didn't even know cisterns were still in existance.
Spritenurse1210, BSN, RN
777 Posts
I think sterile water should be used after the PEG has been placed initially, however if the PEG has been in for years, why use sterile water? The gut isn't sterile. boiled tap water would suffice.