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If a patient was getting admitted for peg tube replacement, what kind of orders would be written?
PEG tube admissions order
- Thread starter poormansDO
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Depends on the patient
are you talking about ALL orders or just PEG orders? for specific PLACEMENT orders, i usually just need NPO, and GI consult. GI will also place orders for sedation when they go down to the GI lab. GI will place the orders and write instructions on how soon the PEG tube can be used. i think usually after 24 hours.
you will have to discontinue non-critical medications, and convert the ones you need into IV form. if patient has been taking PO meds, and isn't in a situation where he cannot take them (severe odynophagia from XRT for oropharyngial cancer), then sometimes you can give critical meds that don't come in IV form. just write the NPO as with exceptions for meds. swallowing some pills isn't going to interfere with PEG placement. it's not like making patient NPO for SBO and having a NGT with suction.
your question didn't mention tube feedings, if you were wondering about that too. first you have to pick a type of tube feed. each institution has different ones. some some in a variety, such as high calorie or high protein. after choosing one, you have to calculate the volume you want, based on how many calories you want to give per day. then you have to decide on the administrations, sucha s bolus TID or continuous feeding. you will also need flushes, such as after feeds for boluses, or qshift for continuous. right after PEG placement though, the tube feeds are usually started very low then increased in increments for the first day until you reach your target. you will have to adjust IV fluids to take the feed into account. there are usually order sets if you have electronic charts. these will also include precautions, such as discontinuing or reducing the feed if there seems to be residual feed that isn't going in.
you can also resume PO meds but will have to change the route to G-tube. some of them might not fit, though. and some can or cannot be crushed and flushed into the tube.
i was told never to remove the G-tube aparatus unless you're closing off the stoma, because the stoma will quickly heal itself. if you remove it but want to keep the stoma open, you're supposed to ask a third year med student to stick their finger in there. i mean stick a pencil in here or something, or so i was told.
for diabetics, don't forget to stop insulin meal boluses and change the fingersticks and sliding scales to q6h when patient is NPO. it should still be q6h when getting continuous feeds. you can make them ACHS when they get feeding boluses. the insulin meal boluses will be hard to estimate because it'll be hard to compare their home diet to the tube feed. for long acting insulin, you will have to decrease by 50% or 33% when NPO. back to home dose when starting feeds, but again will have to worry about hypoglycemia if the feeds have less carbs than the home diet. PO hypoglycemics are situational and attending dependent. some attendings never give metformin in-house, but if i tell them there are no contrast sstudies planned, they may agree to restart it. also, metformin can be crushed, but not the extended release form. i think there is a liquid form of metformin but i've never ordered it before.
some of these things, such as tube feeding orders, are appliciable to NG tube orders.
you will have to discontinue non-critical medications, and convert the ones you need into IV form. if patient has been taking PO meds, and isn't in a situation where he cannot take them (severe odynophagia from XRT for oropharyngial cancer), then sometimes you can give critical meds that don't come in IV form. just write the NPO as with exceptions for meds. swallowing some pills isn't going to interfere with PEG placement. it's not like making patient NPO for SBO and having a NGT with suction.
your question didn't mention tube feedings, if you were wondering about that too. first you have to pick a type of tube feed. each institution has different ones. some some in a variety, such as high calorie or high protein. after choosing one, you have to calculate the volume you want, based on how many calories you want to give per day. then you have to decide on the administrations, sucha s bolus TID or continuous feeding. you will also need flushes, such as after feeds for boluses, or qshift for continuous. right after PEG placement though, the tube feeds are usually started very low then increased in increments for the first day until you reach your target. you will have to adjust IV fluids to take the feed into account. there are usually order sets if you have electronic charts. these will also include precautions, such as discontinuing or reducing the feed if there seems to be residual feed that isn't going in.
you can also resume PO meds but will have to change the route to G-tube. some of them might not fit, though. and some can or cannot be crushed and flushed into the tube.
i was told never to remove the G-tube aparatus unless you're closing off the stoma, because the stoma will quickly heal itself. if you remove it but want to keep the stoma open, you're supposed to ask a third year med student to stick their finger in there. i mean stick a pencil in here or something, or so i was told.
for diabetics, don't forget to stop insulin meal boluses and change the fingersticks and sliding scales to q6h when patient is NPO. it should still be q6h when getting continuous feeds. you can make them ACHS when they get feeding boluses. the insulin meal boluses will be hard to estimate because it'll be hard to compare their home diet to the tube feed. for long acting insulin, you will have to decrease by 50% or 33% when NPO. back to home dose when starting feeds, but again will have to worry about hypoglycemia if the feeds have less carbs than the home diet. PO hypoglycemics are situational and attending dependent. some attendings never give metformin in-house, but if i tell them there are no contrast sstudies planned, they may agree to restart it. also, metformin can be crushed, but not the extended release form. i think there is a liquid form of metformin but i've never ordered it before.
some of these things, such as tube feeding orders, are appliciable to NG tube orders.
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check who does this at your institution- at some places GI handles this, at other places IR does it
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Seriously? Were you admitting a patient who needed this and you simply didn't know who to ask, so you posted a question on SDN? Look up what "PEG" stands for and consult the only specialist that does this procedure...
Going a night without tube feeds is not going to kill anyone.
Going a night without tube feeds is not going to kill anyone.
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Not sure how it works where you are, but I know of 3 different specialties that routinely do this procedure.
