Withheld meds

[demo24]

Hi all,

I was just curious about the legality of a particular situation. One morning I come into work and the night shift nurse leaves a note stating that the pts peg tube was clogged and to call for a GI consult which I did. The problem being is that i was unable to pass meds that were to be administered via peg due to the clogging of the peg tube. I called the GI dr twice to come and hopefully look at it in hopes of fixing it, but no response all day. I at some point had to state that meds and feeding were held due to no access pretty much all day. The pt still remained stable and i was able to give iv meds, but in the mar i had no choice but to put med not given via peg due to no access. I also wrote in my notes that the dr was notified twice, and no response. Is this a red flag and considered a med error and will and can there be legality issues because of this? I guess what im asking is did i chart properly? Thank you

[Horseshoe, BSN, RN]

Never tried coke, but it is constantly recommended here for clogged feeding tubes. At my facility, we were absolutely forbidden to use it, rationale being that any good result is short lived as it causes more and worse clogging subsequently.

This article gives some do's and don'ts:

Research clearly supports water as the best choice for initial declogging efforts, as carbonated beverages,juices, and meat tenderizer have been shown to be ineffective.5,8,9 In fact, because of their acidic pH, juices and carbonated beverages may even cause formula protein precipitation within the tube, making the clog worse or leading to more clogging later on.

http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/Parrish%20March%2014.pdf

[JustBeachyNurse, LPN]

Coke can make the clog worse depending on the cause (curdled for us, clumped meds). I was told either a clog kit (the one I have for a patient is a syringe of baking powder to be mixed with nearly hot water.) coke and other acidic carbonated beverages are contraindicated in many cases as it can make the clog worse or erode the tube

[NurseGirl525, ASN, RN]

Please don't follow this advice. Sorry, amzyRN. Follow your facilities policy and procedure. If they have a standard for declogging, use that. It is best to use manufacturer suggestions. It is a bad idea to use unapproved methods to declog a PEG as they can compromise the integrity of the tube, even with something as innocuous as Coke (which I use to clean the terminals of my car battery - it is very corrosive). Also, using a smaller bore syringe can backfire and blow out the side of the tube above the clog, necessitating the replacement of the whole apparatus.

You did the best you could and you documented it. The only things I would suggest are:

1) Try aspirating back the clog. Sometimes this works better than trying to push it through.

2) Manually palpate the tube and see if you can feel the clog and try to "mash it out" GENTLY.

3) Instill warm (not hot) water while agitating it and letting it dwell, then trying to aspirate back the clog

4) Page the doc q30 min until he returns the call.

We were actually taught to use coke in nursing school to unclog a tube if other methods did not work. It's a pretty common practice.

[Horseshoe, BSN, RN]

We were actually taught to use coke in nursing school to unclog a tube if other methods did not work. It's a pretty common practice.

It seems that evidence based practice has shown this to be an inferior method and is no longer recommended when compared with other methods.

http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/Parrish%20March%2014.pdf

Drug Information Group

http://c.ymcdn.com/sites/www.apsna.org/resource/resmgr/compendium/university_of_iowa_decloggin.pdf

[toomuchbaloney]

Maybe I am too old.

Is it really possible that RNs are putting CocaCola into clogged tubes without an order or direction to do so in P&P manuals?

I think the OP did okay and may augment practice slightly in similar situations in the future based upon some of the comments and suggestions.

Steps I believe I would have taken:

1) Review P&P for guidance relative to declogging tube.

2) Notify primary MD of clogged feeding tube/PEG/GT (whatever the device).

This call would include a request for an order to hold or change route of delivery for affected meds.

3) Notification of charge nurse of change of status of patient and device. If he/she provides any guidance document that.

4) Documentation of situation, medical contact/orders, plan, response of patient to plan.

[MunoRN, RN]

if you did not get one, you needed a specific order from the PCP to hold ALL meds that would ordinarily be given through the feeding tube, and the feeding, if there was one.

I don't know that you really need an order, although writing a clarification in the chart can be helpful (prescribing MD aware PEG is obstructed, no alternate route/tube ). But you don't really need an order, what happens if you don't get the order?

[loriangel14, RN]

Has anyone used Viokase?

[cardiacfreak, ADN]

Could be against policy to use Coke, though.

I learned this recently in our Policy and Procedure committee. Coke is a no-no at our facility. Who knew? Obviously not me and I've been there > 15 years.

[armyicurn]

Chart all your actions and make sure your shift leader is aware along with the unit manager. Cover your bases with accurate charting to include the times you called the doc and left so and so msg....

Good luck!

[KelRN215, BSN, RN]

Hi all. Thank you so much for responding. I did tell my manager about the peg and the response was to check the patency and call back the GI doctor which i did. The peg was in fact clogged. I felt I had no other choice, I even contacted the house dr which told me to call the GI. I am a little nervous as to the legality of having to omit the meds due to the clogged peg. I did put on the mar the meds could not be adm due to the clogging of the peg though, so i was unsure of how to go about the situation, and I thank you all for your responses again. Is this is a good enough reason to hold meds without being held liable at some point giving that I did everything I could have?

What legalities are you concerned with? How are you supposed to administer meds via PEG when the PEG is clogged?

[Altra, BSN, RN]

I don't know that you really need an order, although writing a clarification in the chart can be helpful (prescribing MD aware PEG is obstructed, no alternate route/tube ). But you don't really need an order, what happens if you don't get the order?

Agree with this -- getting an "order" to ... not do what is currently not doable ... seems like a redundant feedback loop of logic.

OP - as you progress in your nursing career you will encounter many situations in which a patient cannot get their prescribed meds exactly on time for a wide variety of reasons. Patients refuse. Patients are off the unit for testing or other reasons. Meds may be unavailable. The patient's status may have changed and you are awaiting clarification/new orders from the provider. etc. etc. As long as your documentation paints a clear, complete picture of what went on with the patient, you should be fine.

[Altra, BSN, RN]

Only once - unsuccessfully.