What would you do in this situation?

Specialties Geriatric

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We have a G tube lady who throws up alot. She is prescribed Dramamine prn and I give it to her right after I take the floor because she gets hooked up to her feeding at 3pm, after having it off all day (they give her a lunch tray during the day). The order reads to give her the feeding all evening and night shift at 45 cc/hr. Last night at last bedcheck before I was scheduled to leave, she had a large amount of emesis. Since the feeder bottle was low and needed changing, I unhooked her and because the bed was a total mess, my aides gave her a shower. The night nurse coming on told me to just leave it off and he would change the bottle etc. after he took the floor. I was finishing up some charting and one of the aides asked me did I want to hook her feeding back up...and I was thinking, if someone's stomach was really full, enough to make them vomit, do I still hook the pump back up and continue feeding, or leave it off for like 30 min?

What would you do in this situation? (Btw, her order states "continuous feeding"; wish we could get an order to leave be after she vomits.)

I want to know because the aides told me it depends on the nurse; some nurses will leave it off for 30 min. after a big vomiting spell, and some keep it going.

Blessings, Michelle

Specializes in Rehab, Infection, LTC.

What are her residuals? That will tell you if the rate should be slowed down or maybe the feeding changed to something she can absorb better. The problem with slowing down the rate is that the rate is set for a specific amount of calories for her to rcv. she might need some reglan q6 to help her absorb it too.

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Specializes in Geriatrics.
What are her residuals? That will tell you if the rate should be slowed down or maybe the feeding changed to something she can absorb better. The problem with slowing down the rate is that the rate is set for a specific amount of calories for her to rcv. she might need some reglan q6 to help her absorb it too.

The last time I worked, I remember her residual prior to me giving her her meds was only 5cc. Thanks for all the input everyone! I will be sure to read her chart and check her care plan.

Blessings, Michelle

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Specializes in Gerontology, Med surg, Home Health.
I totally agree but am only a weekend nurse; however, when I work next, I will take a look at her care plan to see if this has already been addressed. I know she has an order to keep HOB up to 45 degrees, but she scoots herself all around and we have to pull her up repeatedly during the shift. If no one has addressed it in the care plan, I will call the DON and see if I can have permission to go ahead and send a fax to her doctor. Thanks again!

Blessings, Michelle

Why in the world would you need the Director's permission to fax the doctor??? You have a license and are responsible for the care you give on your shift.

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I already posted in this thread, but I wanted to add that this resident is highly susceptible to aspiration problems. You said that even though the head of the bed is elevated she moves around all over the place and has to be pulled up in the bed. If she would vomit while in a less-than-upright position or if her neck is flexed, she could easily aspirate some of the regurg.

The long-term problem is having her keep enough down to have sufficient caloric intake. The short-term, and more critical, concern is making sure that she doesn't end up with aspiration asphyxia or pneumonia.

She is fortunate to have you caring for her.

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Specializes in Geriatrics.
Why in the world would you need the Director's permission to fax the doctor??? You have a license and are responsible for the care you give on your shift.

Because this may have already been attempted; I've only worked here a total of 6 days now and don't want to step on any toes; that is why I said I'd look at her chart and care plan. I suspect things have been mentioned before and that is why she is on Dramamine and has an actual order to keep her HOB up. I would sure hate to fax something if this has already been addressed in the past.

Blessings, Michelle

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Specializes in LTC, Hospice, Case Management.
I would sure hate to fax something if this has already been addressed in the past.

I am not trying to pick at you... but think... would that answer work in a court of law if your patient actually got aspiration pneumonia and died?

Even if it had been addressed, it must not have fixed the problem if she is still vomiting. The Dr. still needs to be called and made aware of the situation.

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I encounter that alot. I only work weekends and get report from the last few days. I try to skim the report book before shift starts to get a bit more background.

In situations like this, skim the docs notes and nurses notes. If you don't see a problem addressed.....CALL the doc....do not wait or pass it on. This is how issues get missed or passed on and never really addressed. What would happen if you call the doc and he already knew? He/she might yell or get crabby....so what? I'm a big girl. I apoligize (not that I need to) and remind them that I called because I ddin't see a progress not or nurses not or orders addressing xyz issue.

Most often...they didn't know a person was having a problem and are more than happy to address it.

Document like crazy when this happens. (nurses note and report sheet etc)

Might need q 6 hr dosing of reglan too. Does the dietician know about this problem? Might need a change in rate, formula feeding.........

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Specializes in Geriatrics.

Update: Ironically, right before my shift started yesterday, her Dr. came in to see her. I pored over her chart after finishing my work for the evening, and it has all been addressed in her careplan. The vomiting, risk for aspiration, possible nutritional deficit...it's all there. Everything that can be done has been done. I also noted an order for Compazine that I didn't see on the MAR/TAR...so good to know! She is also maintaining her weight and hasn't lost any in a really long time, so nutritionally she is good to go, despite the occasional vomiting.

Anyway, just thought you all might want to know!

Blessings, Michelle

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Specializes in acute care and geriatric.

What about bloodwork- are her protein/albumin levels holding their own?

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Specializes in LTC,Hospice/palliative care,acute care.
I am not trying to pick at you... but think... would that answer work in a court of law if your patient actually got aspiration pneumonia and died? - - QUOTE

QUOTE Why in the world would you need the Director's permission to fax the doctor??? You have a license and are responsible for the care you give on your shift. -QUOTE

These things are all true however in LTC we must follow our P and P-no staff nurses (rn or lpn) can just pick up the phone and call a doc.We have to go through our immediate supervisor first.I have a supe whose head will spin if someone makes a call without her actually coming to the floor and assessing the resident first.It's nice to have that support BUT I know the residents on my unit very well and have many years of experience-if she does not agree with me I am comfortable insisting on being a bit more pro-active-others may not be. As the OP noted many nurses float or work part time and may not be aware that things may have been previously addressed and proceed to notify the on-call doc and maybe get orders for something that was tried without success in the past and may cause discomfort to the resident. If my supe assesses the resident and does not agree with my opinion regarding notifying the doc I document very carefully exactly what the supe did and said. I could care less about this but another problem we have had is the on-call docs have complained in the past about getting numerous calls for "trivial" things....

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Specializes in acute care and geriatric.

I have never heard of that rule- "No staff nurse (rn or lpn) can just pick up the phone and call a doc- we have to go through our supervisor."

Is this a written policy by you? Does the doc know?

We have a great relationship with our docs and any nurse ( we don't make distinctions here ) can call one if needed. Their cellphone s and home phones are listed by the phone of every unit as well as their work schedule - so we know when they are in the house.

Our only policy is that we must take vitals before we call a the doc will ask for them. (including o2 sat%)

I think that policy is ridiculous- why would the supervisor want such a policy? I wonder if it covers the staff nurse legally?

BTW- getting calls for trivial things is the norm by the doc and ours said he'd rather that than not being informed for something important. Usually the trivial calls subside as the nurse grows professionally and matures.

Regarding charting what the supervisor said- will that hold water in court? or will it be your word against hers

Sorry for playing devils advocate here, I really empathize with what you have to go through- having your supervisor second guess you and dictate treatment (or not).

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Specializes in Geriatrics.
What about bloodwork- are her protein/albumin levels holding their own?

Sorry, didn't get a look at her labs...still getting used to how the charts are put together/set up. If it were me, I would put the most recent documentation at the beginning of nurses' notes etc...at this facility everything is bass ackwards. They put the most recent notes at the very ends of the charts. It will just take me a bit to get used to all of it. I'll look at her labs when I work again...thanks!

Blessings, Michelle

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