enteral feeding adults2

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NOTTINGHAM UNIVERSITY HOSPITAL NHS TRUST

CLINICAL GUIDELINES

Title of Guideline: Enteral Feeding in adults

Date First Issued: July 2009 Latest Re-Issue Date: September2009

Version: 21 Review Date: September 2011

Main Author and Job Title:

Dr Tim BowlingConsultant in Gastroenterology

Local Contact including job titleand Ext. No.

Dr T BowlingQMC CampusExt 63862

Document Derivation: Consultation Process:

Nutrition Steering Committeesubgroup on complex nutritionHeads of (relevant) Services

Ratified by:

Nutrition Steering CommitteeClinical Effectiveness Committee

Distribution:

All Clinical Directorates

Plans for training on/implementingguideline:

Plans for audit of guideline:Verification and documentation of NGtube positionPEG/RIG complication ratesGiven vs prescribed feed

This guideline has been registered with the Trust. However, clinicalguidelines are guidelines only. The interpretation and application of clinicalguidelines will remain the responsibility of the individual clinician. If in doubtcontact a senior colleague or expert. Caution is advised when using the

guidelines after the review date.


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CONTENTS

Page

Abbreviations 4

Members of Writing Group 4

Introduction 5

SECTION 1: POLICIES, STANDARDS & AUDIT PROPOSALS 6

Enteral feeding policy for adults 7

Standards of Service 9

Audit proposals 10

References 10

SECTION 2: GUIDELINES, PROCEDURES AND CARE PATHWAYS 11

When and how to refer to the Nutrition Support Team 12

Requests for Teaching and Training 14

Route of feeding 15Nasogastric 17

Indications/contraindications 18

Placement and verification of position 18

Bridles 24

Wide-bore tubes 25

Nasojejunal 26

Indications/contraindications 26

Placement 26

Tubes available 26

Gastrostomy/jejunostomy 27

Types of stoma 27

Tubes available 28

Administering feed 29Gastric feeding 29

Commercially-prepared feed using a pump 29By pump and reconstituted powdered feed 30

By pump and use of reservoir bottle 33

Jejunal feeding 35

Commercially-prepared feed by pump 35

Reservoir bottle 37

Tube/patient care 40Nasogastric feeding 40

Feeding by NG tube 40

Flushing 41

Administration of medicines 41

Gastrostomy feeding 43Post-insertion care 43

Feeding via gastrostomy 44


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Care of stoma and tube 50

Removing and replacing gastrostomies 52

Accidental removal of gastrostomies 52

Medicines through gastrostomies 53

Jejunal feeding 54

Complications of enteral feeding 61Insertion related 61

Tube related 61

Feeding related 61

Diarrhoea 61

Constipation 63

Nausea, vomiting, regurgitation 63

Management of unexpected discontinuation of enteral feeding 65

Procedure for discharging patients on home enteral feeding 66

APPENDICES

1 Adult critical care enteral feeding 68

2 Wide bore nasogastric tubes 77

3 Starter regimes when dietitians unavailable 86

4 Nutrition team assessment of potential gastrostomy patients 88

5 Care pathway for patients with suspected/confirmed stroke 91

6 Procedure for replacing balloon gastrostomy 96

7 Procedure for fitting button gastrostomy 98


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ABBREVIATIONS

CNC Clinical Nutrition Consultant

CNNS Clinical Nutrition Nurse specialist

HEFT Home Enteral Feeding Team

MUST Malnutrition Universal Screening Tool

NG NasogastricNJ Nasojejunal

NUH Nottingham University Hospital

NSC Nutrition Steering Committee

NST Nutrition Support Team

S&LT Speech & Language therapy

The members of the working group for this document have been:

Kathryn Blount Clinical Lead Dietitian

Tracey Buchanan Clinical Nutrition Nurse Specialist

Janet Crowe Clinical Lead Dietitian

Ewan Forbes Specialist Dietitian

Zoe Hooley Clinical Lead Dietitian

Azma Malik Gastroenterology & Nutrition clinical pharmacist

Hannah Meanwell Specialist Dietitian

Sian Rajakaruna Principal Speech & Language Therapist

Kathy Teahon Clinical Nutrition Consultant


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INTRODUCTION

These guidelines are about enteral feeding in adults. This is the administration of nutrients

directly into the intestinal tract via a tube. The indications, broadly speaking, are for those

patients who have a functioning gut but unable to take any or adequate nutrition in by mouth.

There is considerable overlap between the services described in this guideline and the dieteticand ward services for nutritional care. All patients should be nutritionally screened by ward

staff and those deemed at nutritional risk, for whatever reason, should be referred to the ward

dietitian for further assessment. The nutrition support team, either as a whole or an individual

from the team (usually the nurse) can be asked to review any patient by any member of the

attending multi-professional team. The key remit of the nutrition team is to determine the

need for artificial nutritional support and to facilitate such an intervention when required.

These guidelines will take the reader through the essential background, evidence and

practicalities of enteral nutrition.

Other related/relevant Trust guidelines:

Intravenous or parenteral feeding Prevention and Management ofRefeeding Syndrome:Guidelines for Adults

Feeding in critical care (also included as an appendix here)

Passing and Checking the Position of a Wide Bore Nasogastric Tube(also included as anappendix here)


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SECTION 1

POLICIES, STANDARDS & AUDIT PROPOSALS


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ENTERAL FEEDING POLICY FOR ADULTS

I. The nutritional status of all inpatients will be assessed and monitored using thenational Malnutrition Universal Screening Tool (MUST) or a clinically appropriate

adaptation approved by the Nutrition Steering Committee.

II. The nutritional status of appropriate outpatients and day-care patients will be assessedand monitored using the modified MUST or a clinically appropriate adaptation.

III. Patients assessed to be at nutritional risk with swallowing difficulties and for whomfirst line guidance is not appropriate, or those who are consistently failing despite

dietetic support, will be referred for consideration of artificial feeding.

IV. A multidisciplinary Nutrition Support Team will be available in working hours tosupport, advise on and review the care of patients with complicated nutritional needs.

V. Decision support, via the Trusts Clinical Ethics committee, will be available for staff

when there is difficulty in making or implementing a decision about theappropriateness of feeding

VI. The best route for enteral feeding will, in usual circumstances be determinedfollowing the NUH Choosing a route for enteral feeding algorithm.

VII. The most appropriate tubes and stomas for use in particular circumstances will bedetermined following the NUH guideline Choosing an enteral feeding tube or

stoma. In this circumstance appropriateness refers to: licence for use, availability

and competence in the trust for insertion, care and maintenance.

VIII. If the clinical circumstance results in a variance from the Choosing a route for enteralfeeding or the Choosing an enteral feeding tube or stoma guidelines the variance

and the reason for it will be clearly documented in the patients record.

IX. All tubes and stomas used for enteral feeding will be appropriate for that use and willbe placed by staff who are competent to do so.

X. The clinical assessment and care of tubes and stomas used for enteral feeding will be,by staff who are competent to do so.

XI. A full range of dietary formulae will be available in stock to meet the usual needs ofpatients in the Acute Hospital setting. Non-stock formulae can be obtained on a namedpatient, evidence based, basis.

XII. Dietary regimens will be prescribed and monitored by dietetic staff ,who areappropriately experienced in the relevant area of clinical care. For Out of hours

there will be Starter Regimen guidance available.

XIII. Dedicated & standardized prescription charts will be used for the prescription ofenteral feeds

XIV. Guidance will be available (via the intranet, the dietitians and nutrition support team)on the identification and management of common clinical problems which can occur

during feeding such as: Problems with tubes & stomas, Re-feeding syndrome,


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Diabetes, Unexpected discontinuation of feeding, Constipation, Diarrhoea, Vomiting

and Mouth-care

XV. When patients are transferred into the Trust with feeding tubes or stomas already inplace, the appropriateness, integrity and position of these tubes and stomas will be

confirmed before use.

XVI. Consent will be obtained for feeding and for the insertion of all tubes and stomasfollowing Trust guidelines

XVII. Patient information will be available for all usual types and routes of enteral feeding

XVIII. Teaching, Training and Competency assessment, packages will be available forrelevant staff for the insertion, care and maintenance of tubes and stomas used in

enteral feeding.

XIX. Teaching, Training and Competency assessment, packages will be available for

relevant staff in the identification and management of the common clinical problemswhich can occur during feeding.

XX. Teaching, training and competency assessment and evidence thereof will be theresponsibility of the individual directorates.

XXI. Regular audit of service standards will be performed and the service will be reviewedin response to this. Such audits will be the responsibility of individual directorates to

perform and provide evidence thereof.


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STANDARDS OF SERVICE

I. The MUST, or a clinically appropriate adaptation approved by the Nutrition SteeringCommittee, is in use for all inpatients and relevant Outpatient and Day-care patients

II. Patients requiring nutritional intervention are identified early and referredappropriately to the Dietitians and/or Nutrition Support Team and are seen within two

working days

III. The relevant route of feeding is implemented for all patients, where clinicallyappropriate, according to the sub-speciality guideline and achieved within three

working days

IV. The tubes and stomas in use are in line with the NUH guidelines and appropriate forthe clinical needs of the patient

V. The care and maintenance of all tubes and stomas is in accordance with the guidelines

VI. The dietary regimens prescribed and administered via tubes and stomas are inaccordance with the guidelines for all patients

VII. All patients being enterally fed are appropriately monitored as detailed in the relevantguideline/care pathway

VIII. Nutrition support team advice and guidance is available during working hours andrelevant out of hours guidance is available

IX. For all patients, in whom, there is difficulty making or implementing a decision aboutthe appropriateness of enteral feeding, decision support is available, is easily accessed

and is accessed.

X. Enteral feeding records are accurate, available and up-to-date for all patients

XI. The service standards are regularly audited by the relevant Directorates


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AUDIT PROPOSALS

Each directorate in the Trust should be able to demonstrate compliance with the above service

standards. Regular audit is essential. We recommend a three yearly audit cycle, auditing one

or two of the audits detailed below every year. The audit templates will be made available.

The recommended main audits are:

1. A Directorate audit of individual patient documentation associated with insertion andchecking of nasogastric and nasojejunal feeding tubes

2. An audit of the Directorates nutritional screening and management of outpatients3. An audit of the Directorates staff training and competency profile in nutritional

screening and in the management of feeding tubes and stomas

4. An audit of the Directorates use of patient information on enteral feeding5. An audit of the time from decision of route for feeding to the establishment of the

route

REFERENCES

NICE 2006 Nutrition Support for Adults Oral Nutrition Support, Enteral Tube feeding and

Parenteral Nutrition

St Marks & The Burdett Institute of Gastrointestinal Nursing (2005) Adult Enteral Nutrition

Guidelines

De La Torre AM (2001) Guidelines for Nutrition Support in the elderly. Public Health

Nutrition 4 (6A) 1379-1384

Stroud M (2003) Guidelines for enteral feeding in adult hospital patients GUT 2003 52 Suppl

VII

Raykher A 2007 Enteral Nutrition Support of Head & Neck Cancer patients Nutrition in

Clinical Practice Vol 22: 68-73


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SECTION 2

GUIDELINES, PROCEDURES AND CARE

PATHWAYS


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For Patients with NJ tube related problems the relevant guidelines are:

Care of a patient receiving jejunal feeding (page 54)

For patients with feeding gastrostomy or jejunostomy problems the relevant guidelines are:

Care of patients being fed through a gastrostomy (page 43)

Care of a patient receiving jejunal feeding (page 54)

For feed & pump problems please refer to:

Administration of feed using a feeding pump & commercially prepared feed in a pack (page29)

Administration of feed using a feeding pump & reconstitution of powdered feed (page 30)

Administration of feed using a feeding pump & feed decanted into a reservoir bottle (page 33)

For patients with TPN related problems please refer to:

Guideline Care of patient receiving TPN (this is a separate guideline)

WHEN YOU NEED HELP: WHO TO CONTACT & HOW

Problem Who How

High risk patientsidentified on MUST

Ward dietitian Ward based referral

Feed prescription Ward dietitian Ward based referral

Patients on enteral feed &

issues of tolerance

Ward dietitian Ward based referral

Difficulty with NG tubeinsertion or care

Nutrition support team nurseOut of hours the CNU nurses onQMC campus (62119) or the Hogarth

ward Nurses on NCH campus (55152)can offer guidance but cannot offer anoutreach service

NotIS referral or if urgent bleep80 6417 (QMC campus)80 6993(NCH campus)

To refer for gastrostomy(irrespective of method ofinsertion)

Nutrition support team nurse NotIS referral (code = PEG)

Problems with the care &

maintenance ofgastrostomy orjejunostomy

Nutrition support team nurse

Out of hours the Clinical NutritionUnit nurses on QMC campus (62119 )or the Hogarth ward Nurses on NCHcampus (55152) can offer guidance

but cannot offer an outreach service

NotIS referral or if urgent bleep

80 6417 (QMC campus)80 6993(NCH campus)

DIABETES- Patients whoare feed enterally and havediabetes If they are on oralhypoglycaemic agents orinsulin they made need atotal change in theirtreatment whilst being

enterally feed to ensureoptimum blood glucose

control.

Referral to the diabetes team Notis referral DIAB

Problems giving drugs

down tubes or stomas

Your ward pharmacist Ward based referral

Discharge on enteral feed Ward dietitian Ward based referral

Uncertainty about route or Nutrition Support consultant NCH Campus: NotIS referral


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appropriateness of feeding (Acute gastro & choose Dr TeahonQMC Campus: Dr Bowling, call63862 or bleep 80-0240(if either is not available they willhave organised cover)If urgent bleep84-1170-(QMC campus);

800275(NCH campus)

REQUESTS FOR TEACHING & TRAINING

Teaching and training can be divided into two groups Formalised Teaching and Training and AsRequired Teaching and training

Formalised:

Formalised Teaching and Training How to pass and Check a Fine Bore Nasogastric tube. There will

be two Study sessions a year, one based at either campus. Details will be forwarded to ward managers,please check with your ward manager before booking onto a session. To book a place email JackieGaskil or ring on Extn. 57348 with your details.

As required:Tube and stoma care teaching and training can be provided to ward areas by contacting the Nutrition

Nurse Specialist via e-mail or by leaving a message on Extn. 56754 or 61036. Please note a minimumof 4 staff will be required.

TPN teaching and training can be provided to ward areas by contacting the Nutrition Nurse Specialistvia e-mail or by leaving a message on Extn. 56754 or 61036. Individual teaching and training can beprovided on request.


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Figure 1: Algorithm for nutritional support

YesUnsure

No

No Yes

Yes

No

No

Unsure

Prognosis is assessed to

be < 4 weeks

Persistent vegetative state

No

No

NoYes

No

Yes

Yes

Gastric emptying is normal

without vomiting or GORD

Follow Parenteral Nutrition Pathway

Follow Ethics in Feeding guideline

Jejunostomy or

Gastro-jejunostomy

Seek formal opinion from nutrition

support team re gastrostomy or

jejunal feeding

Gastrostomy

Feeding usually

inappropriate. Follow

Ethics in Feeding guideline

Reduced oral intake will last


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ROUTE OF FEEDING

The algorithm on page 15 outlines guidance for the selection of patients for enteral feeding in itsbroadest sense. It should be combined with the text below, and support from NST should be sought if

there is any concern. In brief:

Nasogastric (NG) feeding will be considered:

Who cannot maintain nutrition by oral means

In whom feeding is appropriate and in line with their wishes

Whose small intestines are functioning

Who have normal gastric motility or respond to prokinetic agents

Who are known not to be at excessive risk of vomiting or gastro-oesophageal reflux

Who are estimated to require feeding for six weeks or less

Nasojejunal (NJ) feeding will be considered: Who cannot maintain nutrition by oral means

In whom feeding is appropriate and in line with their wishes Whose small intestines are functioning

Who have or are predicted to develop abnormal gastric motility or who are known to be atexcessive risk of vomiting or gastro-oesophageal reflux

Who are estimated to require feeding for six weeks or less

Gastrostomy feeding will be considered:




Who have normal gastric motility

Who are known not to be at excessive risk of vomiting or gastro-oesophageal reflux

Who are estimated to require feeding for longer than six weeks

Who do not have contra-indications such as ascites, CAPD, peritoneal shunts,hepatosplenomegaly, portal hypertension, morbid obesity (these contra-indications are relativebut the decision on feeding and route of feeding for these patients should involve one of thenutrition support consultants)

Jejunostomy feeding will be considered:




Who have abnormal gastric motility or who are known to be at excessive risk of vomiting or

gastro-oesophageal reflux Who are estimated to require feeding for six weeks or longer

Who do not have contra-indications such as ascites, CAPD, peritoneal shunts,hepatosplenomegaly, portal hypertension, morbid obesity (these contra-indications arerelative but the decision on feeding and route of feeding for these patients should involve oneof the nutrition support consultants)

(Note : patients undergoing oesophago-gastric surgery will sometimes have peri-operativejejunostomies inserted to aid immediate post operative feeding)


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Best practice notes on choosing feeding route

Gastrostomy formation has a low mortality (approaching 0%) and a high technical success rate (90%)in properly selected patients. In unselected patients the 30 day mortality for gastrostomy is 25 - 30%(Grant et al 1998, Sanders et al 2000). Patients with loss of swallow because of dementing illness havea 54% 1 month mortality and a 90% 1 year mortality (Sanders 2000)

Gastrostomies may be of value for palliation (gastric decompression, drug administration)When commencing tube feed in the "unsure" group, do so in the context of well defined outcome

measures & for a well defined time periodIn patients who lack capacity to make decisions, the decision to or not to site a gastrostomy is that of

the responsible physician but communication with all involved is essential. Clinicians involved in thisdecision should be fully aware of the Mental Capacity Act and IMCA services

NASOGASTRIC FEEDING

INTRODUCTION

Nasogastric tube (NG) feeding remains the most common and the simplest method of providingrelatively short-term artificial nutritional support for intervals of 4 6 weeks. The decision to starttube feeding, which type of tube to use, the type of feed and diet and the feed regimen should be ateam decision involving doctor, nurse, dietitian, speech and language therapist and patient. Unlessspecifically required/requested, the NST would not normally be involved in these decision. The role ofthe ward team is crucial, but it is often the nurse who administers the feed and observes the patient forsigns of improvement and/or complications. Therefore excellent communication between the nurse

and the other members of the team is essential.

The feed can be given intermittently and it is common practice to give a break of at least 4 hours eachday. During the rest period, the tube is usually flushed with fresh freshly drawn drinking tap water.

How often and how much depends on the individual patient. Always refer to the individualsfeeding regimen provided by the dietitian or, if unavailable, consult the dietitian.

For most people, eating is an enjoyable and social experience as well as a physiological necessity. A

patient who is tube fed may no longer be able to eat and drink orally and enjoy his/her food. If this isso, nurses have a responsibility to help the patient come to terms with this situation and endeavour to

help the patient not feel isolated.

Routine mouth care is vitally important for the patient unable to eat or drink; mouthwashes and oral

mouth care should be offered (Hamilton, 2000). (See Guidelines Care of the Mouth).

A fine bore tube can be passed by a health care professional who has been assessed as competent to

perform the procedure. Staff should only start a feed when the tube position has beendocumented as correct(see below).

Nasogastric feeding via a wide-bore tube, e.g. a Ryles tube is possible but is not recommended as:

It is uncomfortable for patients

Has increased risk of complications (reflux & aspiration)

Can impair normal swallowing

Can cause nasal and oesophageal erosions.Feeding via a wide bore tube usually only takes place in critical care and some other specialised areasand each will have area specific guidelines. Widebore tube feeding in Critical Care should only beconsidered in the early stages of enteral feeding if it is necessary to aspirate the contents of thestomach to check for gastric emptying (Rollins, 1997). In ENT wide bore tubes may be used tomaintain the patency of the tracheo-oesophageal puncture for voice rehabilitation. The decision to feed

via a wide bore tube shouldbe made by the specialist team.


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If feeding via a fine bore nasogastric tube is anticipated to last longer than 4-6 weeks, referral for

gastrostomy placement should be considered

INDICATIONS FOR NG FEEDING

1. Physical problems such as:

Facial / jaw trauma under guidance from specialist team

Dysphagia as a complication following stroke

Inflammation of the mouth / throat e.g. following radiotherapy

Unconsciousness

2. Depressed appetite caused by:

Severe systemic illness

3. Hypercatabolic states such as:

Major sepsis

Burns

Major trauma / surgery

4. Other patients unable to meet their nutritional needs via the oral route

CONTRAINDICATIONS FOR NG FEEDING

1. Physical injuries or deformities such as:

Confirmed or suspected basal skull fracture (in such cases an orogastric feeding tube shouldbe passed by an anaesthetist)

Laryngectomy unless under guidance/approval of ENT department

2. Gastro intestinal such as Stasis (gastric stasis or ileus)

Obstruction

3. Withdrawal or refusal of consent (see also Trust Guideline on Informed consent)

PASSING AND CHECKING POSITION OF NG TUBES

Although the decision to insert a fine bore nasogastric tube is often made by the multiprofessionalteam, the procedure must only be carried out following formal consent and only be performed by a

health care professional who can demonstrate relevant theoretical knowledge and who has beenassessed as competent in the procedure in accordance with the Working in New Ways Policy and

Guidelines

Types of NG tube

There are many different types of fine bore nasogastric tube available. If unsure, the medical team,nutrition team or Clinical Nutrition Unit (as appropriate) will advise which type of tube to use. Pleasesee Guidance on the feeding tubes & stomas currently in use at Nottingham University Hospital It isimportant that all tubes and stomas in use are licensed for this purpose, that the correct attachments are

available and that those caring for them are competent/ trained to do so. Most fine bore nasogastrictubes are single use only and should be left in situ for a maximum 4-6 weeks.

Guide WireAll fine bore nasogastric tubes will have a guide wire to aid with the insertion.Always read the manufacturers instructions regarding the guide wire. Prior to insertion of the tube,pull the guide wire in and out by about 5cm to ensure that it moves freely and then replace. The fine-


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bore tubes used in Nottingham University Hospitals Trust require the guide wire to be removed prior

to x-ray or aspiration to ascertain the tube position. This ensures that the tube is not displacedfollowing subsequent removal of the guide wire. To remove the guide wire, refer to the

manufacturers instructions. Some tubes may have a lubricated coating, which is activated by water.Other tubes may require further lubrication with a water-soluble jelly prior to insertion before the wirecan be removed.Guide wires should not be reused or reinserted into the tube as this can cause perforation of the tube.

Syringes

Please see separate guidance: Syringes for Oral & Enteral Use Note that syringes used in hospital

for enteral feeding are single use only.EQUIPMENT NEEDED FOR FEEDING TUBE PLACEMENT

Fine bore nasogastric (NG) tube

Hypo-allergenic tape or commercial attacher

50ml purple enteral syringe

Drinking straw and glass of water (if patient can swallow safely)

Measuring jug and freshly drawn drinking tap water

pH paper

Lubricating gel Disposable non-sterile gloves

Disposable apron

Table 1: Passing an NG Tube

Principle Rationale

1. Check patients notes and enquire if the patient

has a known nasal obstruction e.g. old fracture /polyp / previous operation.

If an obstruction is present or suspected, discusswith medical staff before proceeding.

Passage of the tube may be more difficult or

contraindicated.

2. Ask the patient to sniff with one nostril and then

the other or to blow their nose. If needed, cleanthe nostrils before commencing the procedure.

To check if the nostrils are clear and to identify any

obstruction which may hamper the procedure.

3. Arrange a signal by which the patient cancommunicate if she/he wants to stop the

procedure, for example, by raising their hand.

To give the patient a sense of control, gain their co-operation and to ensure the safe passing of the tube.

4. Sit the patient in an upright position, with headwell supported and with the chin 90 to the neck,unless contra-indicated.

The patients natural inclination is to movebackwards away from the tube.To close the glottis, protecting the airway(McConnell, 1997).

5. Prepare tape or commercial attacher. To facilitate procedure.

6. Wash hands and put on apron. To prevent cross infection and protect clothing.

7. Prepare the tube by making sure that the guidewire moves freely (some manufacturers

recommend that the wire is lubricated ,alwayscheck the manufacturers instructions).

Promote easy removal of guide wire.


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8. Check the distal end of the tube to ensure that theguide wire is not protruding.

Wire could cause trauma to the nasopharynx andoesophagus.

9. Measure the length of tube required by placing the

end of the tube at the patients xiphisternum andmeasure the distance from here to the bridge of

the nose and then from the nose to the earlobe.Note the mark on the tube.

To ensure the appropriate length of tube is passed

into the stomach.

10. Put on gloves. Dip the distal end of the tube intothe water or water soluble jelly. Give mouth careor offer the patient a drink if able to swallow.

To lubricate the tube and oesophagus, makinginsertion easier.

11. Calmly insert the distal end of the tube into theclearest nostril and slide slowly along the floor ofthe nasopharynx.

To facilitate passage of the tube by following thenatural anatomy of the nose.

12. As the tube passes down into the nasopharynx,ask the patient to start sipping water andswallowing (if able).

A swallowing action closes the glottis, enabling thetube to pass into the oesophagus and reduces the riskof it entering the trachea.

13. Advance the tube at a speed acceptable to thepatient, until the pre-determined mark is reached.

To gain patients co-operation.To ensure correct length of tube is inserted.

14. Gently remove the guide wire, ifindicated inthe

manufacturers instructions.

With some tubes removing the guide wire coulddisplace the tube; therefore it is necessaryto remove

the wire before the final checking of the tubesposition.Difficulty in removing the guide wire could indicate

a wrongly placed tube.

15. Anchor the tube securely in position. If possible,a commercial attacher should be used.

Document the exact position (length) of the tube,at the nostril, in the appropriate record. The markon the tube at the end of the procedure should beat the patients nostril.

To secure the tube anddetermine tube position.

16. Document the procedure in the patients recorddetailing date, time, confirmation of consent, any

difficulties during insertion, how the position ofthe tube was confirmed, the length mark of thetube at the patients nostril and how the tube wassecured

To conform to good clinical governance

Checking NG tube position (Figure 2)

Checking the position of the tube is a shared responsibility between the nursing and medical staff.There are two methods of determining tube placement, namely:

Aspiration

RadiographyPLEASE ALSO SEE APPENDIX 2: USE OF WIDEBORE TUBES


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Aspiration (Table 2 and Figure 3)Aspiration and pH testing of the aspirate is a reliable method when determining tubeposition.Please refer to NPSA Alert 05-2005 Reducing Harm by Misplaced Nasogastric Tubes. Aspirateshould be pH 5.54or below to commence feeding. There are no known reports of pulmonary aspiratesat or below this figure. The range of pH 0-5.54balances the risk between increasing the potentialproblems for clinical staff e.g. removing tubes that are actually in the stomach, increase use of x-ray,with the as yet, unreported possibility of feeding at pH 5.5 4when the tube is in the respiratory tract.

Best Practice Use of pH Paper

Only pH paper should be used to obtain an accurate pH reading via aspiration.

Litmus paper is not sufficiently sensitive to distinguish between gastric acid and bronchialsecretions.

Radiography

It is generally accepted that the most reliable method of checking the position of the tube is with the

use of radiography as fine bore NG tubes are radio-opaque. However, this method can result in

excessive exposure to x-rays and delay to nutritional support. It should also be remembered thatalthough radiography has been recognised as the gold standard for determining tube position(Neumann et al, 1995), it can only confirm the tube position at the time of x-ray. For these reasons thebest practice is to check position of nasogastric tubes by the pH method using radiography only when:

Patient on critical care (see Appendix 1)

Gastric aspirate cannot be obtained on at least two occasions (as above) (El-Gamel & Watson,1993)

When the gastric aspirate is above pH 5.54(as is often the case for patients on proton pumpinhibitor medication)

There is significant doubt that the aspirate obtained is gastric (as above)

In high-risk patients where there is any concern that the tube may be in the bronchial tree, e.g.unconscious, sedated or intubated patients and patients with tracheostomies.

The information in the document was originally developed by the National Nurses Nutrition Group(NNNG) and further developed in collaboration with the Medicines and Healthcare productsRegulatory Agency (MHRA), the National Patient Safety Agency (NPSA), NHS clinicians, risk

managers and other leading experts in the field. The Patient Safety Research Programme at theUniversity of Birmingham has commissioned additional research to assess these methods further. Thisadvice may therefore be revised following the outcome of this work. www.npsa.nhs.uk/advice

Auscultation for determining feeding tube placement should not be used. Auscultation alone isnot reliable in the checking of the tubes position, as vigorous peristalsis can be mistaken for airentering the stomach. Insufflation of air into the tube can be misleading because auscultation overthe stomach can register sound transmitted through a tube that has been passed into the mainbronchus (Sobotka, 2000 p83). NPSA Alert 2005 CL NPSA 05-2005


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Table 2: Checking tube position: Aspiration

Principle Rationale

1. Using a 50ml syringe purple enteral syringe (BAPEN 2003)aspirate some fluid from the tube and test it on pH paper.

Always check the expiry date on the pH paper prior tousing.If there is any doubt, confirmation of the pH reading shouldbe made with another health care professional.

To establishthe position of the tube.Aspirate should be pH 5.5 or below tocommence feeding. There are no known

reports of pulmonary aspirates at or belowthis figure. (NPSA Safety Alert 2005).

pH indicator strips can measure thisaccurately. (Metheny et al, 1989,Neumann et al, 1995, Colagiovanni,1999)To rule out subjective analysis.

2. Use only a 50ml purple enteral syringe and dispose ofaccording to local guidelines. The safest syringe size for

flushing or aspirating is a 30-50ml syringe.

A smaller syringe may produce too muchpressure and split the tube (BAPEN2003)

3. Record in patients notes date and time tube passed

number of attempts made to pass

the type of tube used

the nostril used

the exact position of the tube (referring to thedistance mark at the nostril)

method used to check tube position, give details ofPh of aspirate obtained.

any difficulty in passing the tube

To maintain records and to maintainpatient safety.

4. Commence feeding only after the position of the tube hasbeen confirmed by aspiration or radiology.If radiology is used a doctor should record the imageposition of tube in patients medical records

To maintain patient safety.

Figure 3: What to do if aspirate is not obtained

Advance or withdraw tube

10-20 cm and retryChange patients position

and retry

Put the indicator and syringebelow the level of patients

stomach to obtain syphon

effect.

If no aspirate obtained, wait 30-60 minutes and retry

If still no aspirate obtained, consider radiography


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FIGURE 2: REDUCING THE HARM CAUSED BY MISPLACED NG FEEDING TUBES:

ADVICE FOR HEALTHCARE STAFF

Confirming the correct position of nasogastric feeding tubes in ADULTS

CAUTION:If there is ANY query about position and/or the clarity of the colour change on the

pH strip, particularly between ranges 5 and 6, then feeding should not commence.

1 Check if on acid inhibiting medication

2 Check for signs of tube displacement and measure tube length

3 Reposition or repass tube if required

4 Aspirate using 50ml syringe and gentle suction

DO NOT FEED

1 Advance tube by 10-20 cm

2 Try aspirating again

DO NOT FEED

1 If possible, turn adult onto side

2 Inject 10-20ml air into the tube using syringe

3 Wait for 15-30 minutes

DO NOT FEED

1 Leave for up to one hour

2 Try aspirating again

Test on pH strip or paper

Process to feed

DO NOT FEED

1 Call for advice2 Consider replacement/repassing of tube and/or checking

position by x-ray

Aspirate not obtainedAspirate obtained (0.5-1ml)

Aspirate obtained (0.5-1ml)

pH>6 or above4 pH 5.54or below

pH 5.54or belowpH>6 or above4

Aspirate not obtained

Aspirate obtained (0.5-1ml)

Aspirate not obtained


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In critically ill patients where intubation has been difficult and there is a high risk ofdisplacement

In general, their use outside of critical care would usually be at the discretion of the Nutrition NurseSpecialist

WIDE-BORE TUBES (See Appendix 2)

The term wide-bore tube is often used synonymously with the Ryles tube. There are, however, 2types in common use. The Ryles tube is a single lumen unvented tube used for gastric aspiration andsometimes temporary feeding and administration of medicines in critical care. A Salem tube is adouble lumen tube used for venting the stomach, again mainly used in critical care.

While it is possible to use such tubes for feeding, it is not recommended, because

It can be very uncomfortable for the patients

Has increased risk of complications

Can cause oesophageal erosionsIf a patient is discharged from critical care with such a tube in place, but which is only required for

feeding, this should be exchanged for a fine-bore tube.

For further information on wide-bore tubes, please refer to the Trust Guideline Passing and Checking

the Position of a Wide Bore Nasogastric Tube (also included in this document as Appendix 2).

REFERENCES

BAPEN (2003) Administering drugs via enteral feeding tubes - a practical guide London: BAPEN

Cannaby N, Evans L, Freeman A (2002) Nursing care of patients with nasogastric feeding tubesBritish Journal of Nursing Vol. 11 No. 6 pp. 366-372Colagiovanni L (1999) Taking the tube Nursing Times Vol. 95, No. 21 pp. 63-71

El-Gamel A, Watson D (1993) Transbronchial intubation of the right pleural space: A rarecomplication of nasogastric intubation with a polyvinylchloride tube a case study Heart and LungMay/June pp.224-225McConnell (1997) How to determine gastric pH Nursing Times Vol. 27 No. 8 pp. 126Metheny N, Reed L, Worseck M, Clark J (1993) How to aspirate fluid for small bore feeding tubesAmerican Journal of Nursing Vol. 93 No. 5 pp. 86-88Neumann M, Meyer C, Dutton J, Smith R (1995) Hold that x-ray: Aspirate pH and auscultationprove enteral tube placement Journal of Clinical Gastroenterology Vol. 20 No. 4 pp. 293-295Nottingham Acute Trusts (2003) Working in New Ways Policy and Guidelines Nottingham: NATSobotka L (Ed) (2000) Basics in clinical nutrition 2ndEdition Prague: Galen


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NASOJEJUNAL (NJ) FEEDING

Nasojejunal tubes are not commonly used and the indication for use and tube selection will normallybe under the supervision of the Nutrition Support Team. NJ tubes can single-lumen or multi-lumen. A

double lumen tube can be used when gastric stasis necessitates the need for aspiration of the stomachwhile feeding distally, and a triple lumen tube will allow, feeding as well as gastric aspiration and

decompression.

Indications for NJ feeding

Feeding a functioning gastrointestinal tract when the stomach needs to be by-passed, i.e.where there is a mechanical or obstructive gastric outflow obstruction

Pancreatitis

Risk of aspiration with intragastric feeding

Contraindications as for NG feeding

Placement

Nasojejunal tubes can be positioned in three main ways:1. By the bedside in patients who have normal gastric emptying and in whom there is no

vomiting. This is a rare situation, but can occur in patients pre-treatment, such as bone marrowtransplantation or cystectomy when post-treatment vomiting or gastric stasis can be predicted.In this situation a Bengmark tube is used and passed, as for an NG tube. Spontaneous passageinto the jejunum should be confirmed radiologically. We do not currently use magnetic tubetrackers in the Trust.

2. Endoscopically (preferred method in ventilated patients and in those who need their tubespassed in Theatre). In this situation tubes are passed either:

a. Through the scope (Cook or Freka Nasojejunal tubes)b. Over a guidewire (Cook Nasojejunal or Trilumina tubes)c. Endoscopically by differential friction (usually a Bengmark tube)

3. Radiologically (preferred method in patients who are immunosuppressed) The tubes used willbe Bengmark, Cook or Freka Nasojejunal tubes)

Following insertion the procedure report should detail:

Method of insertion

The type of tube used (Manufacturers name and batch number)

Which jejunal position has been achieved and how this has been or should be confirmed

How the tube has been secured at the nose or cheek

At what level the tube has been secured at the nose or cheek

If there is more than one port, how these can be identified

Any variance to standard insertion protocol and the reason for it

NJ tubes in use at NUH

The tubes available for NJ feeding in NUH have three characteristics:1. They are licensed for this purpose2. There is competence in the Trust for insertion, care and maintenance

New tubes will only be introduced when all three of these criteria have been achieved and when the

relevant guidelines have been updated. The Nutrition Steering Committee will need to ratify anyrequests for new tubes.

The following tubes are currently in use:

Flocare Nutricia Nasojejunal (Bengmark)

Cook Nasojejunal single lumen Freka (Fresenius) nasojejunal single lumen

Freka (Fresenius) nasojejunal double lumen

Trelumina Nasojejunal (Fresenius)


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GASTROSTOMY AND JEJUNOSTOMY FEEDING

A gastrostomy or jejunostomy is a tube with an external catheter exiting from a stoma on theabdominal wall, and allows the patient to be fed enterally. Patient selection for gastrostomy and

jejunostomy will normally be with advice from the Nutrition Support Team.

The indications for gastrostomy and jejunostomy feeding are the same as for NG and NJ feedingrespectively (pages 18 and 26), and are usually the route of choice when the anticipated need fornutritional support is prolonged (ie>4-6 weeks). There are, however, a number of relativecontraindications to insertion, including

morbid obesity (technically difficult to access the stomach)

uncorrected coagulopathy

portal hypertension & ascites

active gastric ulceration or malignancy

gastroparesis

Peritoneal dialysis

Previous partial gastrectomyAlthough some of the relative contraindications may preclude endoscopic insertion, radiological or

surgical insertion is often feasible (see below).

All patients referred for consideration of stoma feeding will be assessed by the nutrition nursespecialist (see appendix 4).

Types of stoma

a)Gastrostomy tubesThese may be placed endoscopically (PEG), radiologically (RIG) and occasionally at laparoscopy orby open surgical technique. The type of procedure performed is dependent on the patients diagnosis

and condition. The patients medical team and the nutrition support team will decide on which methodof stoma formation to use. In general the method chosen depends on the issues detailed in thefollowing 3 points:

Percutaneous Endoscopic Gastrostomy (PEG)This method is used providing that the patient is fit enough to undergo gastroscopy and does not haveobstruction of the oesophagus.

Percutaneous using ultrasound and xray screening techniques (RIG radiologically insertedgastrostomy)

A gastrostomy can be placed in X-ray by using ultrasound and/or X-ray screening techniques. Thisallows the structures in the abdomen to be identified to locate the stomach and avoid damage to otherorgans such as transverse colon or liver.

SurgicalGastrostomy insertion during a laparotomy under general anaesthetic is often performed at the same

time as another surgical procedure or when the percutaneous methods have failed (eg large hiatushernia).

b) Jejunostomy tubesAs with gastrostomies, these can be placed endoscopically, but more often surgically.

PEGJThese are extension tubes placed through a pre-existing PEG. Technically straightforward to insert butmaintaining intubation into jejunum is difficult to maintain.

PEJThis is a direct endoscopic puncture into the jejunum. It required deep intubation beyond theduodenojejunal flexure and is technically difficult to achieve. These are done only occasionally.

Surgically placed jejunostomy

Following tube insertion the procedure report should detail:


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Method of insertion

The type of tube used (Manufacturers name and batch number)

How position of the tube has been confirmed

How the tube is secured internally

How the tube has been secured at the skin

At what level the tube has been secured at the skin

If there is more than one port, how these can be identified Any variance to standard insertion protocol and the reason for it

Gastrostomy and jejunostomy tubes in use at NUH

The tubes available for gastrostomy and jejunostomy use in NUH have three characteristics:

1. They are licensed for this purpose2. There is competence in the Trust for insertion, care and maintenance

New tubes should only be introduced when all three of these criteria have been achieved and when therelevant guidelines have been updated. The Nutrition Steering Committee will need to ratify anyrequests for new tubes.

The following tubes are currently in use:

Gastrostomy tubes:o 9 & 15 French Freka tubes (can be placed endoscopically or radiologically)o 12, 14, 16 and 20 French Corflo balloon replacemento 12 French Tilma loop retaining (can be placed radiologically)o 15 French Freka balloon replacemento Skin level devices (buttons) for better cosmesis

Jejunostomy tubes:o Freka gastrostomy with a jejunal limbo 9F Freka gastrostomy in the jejunumo Freka needle catheter jejunostomyo Mickey cuffed jejunostomyo

9 French Freka surgical jejunostomy


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ADMINISTERING FEED

A) NASOGASTRIC FEEDING

Nasogastric feeding is usually administered via a pump as this ensures feeding at a slow steady ratewith greater accuracy. A pump also assists passage of a viscous solution through a fine-bore tube.Pumps should only be used by health care professionals who have the relevant knowledge and

competency in their use and care.Commercially prepared feed should normally be used as it reduces the risk of infection (Anderton,1995). Feed packs should be stored unopened at room temperature as feeds that are warmed are morelikely to become contaminated with harmful pathogens (Jones, 1982). Details of the feed to be usedfor your patient will be given on enteral feeding regimen prepared by the dietitian. (Emergency starter

regimen is available in appendix 3 if required)

i) ADMINISTRATION OF FEED USING A FEEDING PUMP & COMMERCIALLY

PREPARED FEED IN A PACK

EQUIPMENT

Feeding regimen

Prescribed feed pack

Infinity flocare Feeding pump and stand

Suitable giving set


pH paper

Jug and freshly drawn drinking tap water (Sterile for immunosuppressed patients)

Table 3: Administering commercially-prepared feed using a pump

Principle Rationale

1. Check the feed against the prescribed regimenand patient details. Check the presentation andexpiry date.

To avoid errors in administration.

2. Wash hands To minimise the risk of cross infection

3. Check the position of the tube (see page 21).If in any doubt that the tube is not in thecorrect position do not use, and inform medicalteam.

To prevent aspiration and feeding using a displacedtube.

4. Wash hands again or use alcohol hand rub. To minimise the risk of cross infection.

5. Unscrew or open the feeding end of the NG

tube. Attach the 50ml purple enteral syringesyringe, gently and slowly flush the tube usingup to 50 ml of freshly drawn drinking tapwater (or amount indicated on the feedingregimen). Use sterile water forimmunosuppressed patients.

To prevent tube blockage.

Use 30-50 ml syringe as it is possible to rupturefine-bore tubes by using excessive force with asmaller syringe (BAPEN 2003, Shaw, 1994).

6. Shake pack of feed and then hang on the drip

stand.

To distribute the contents throughout the solution.

7. Check the expiry date on the giving set, openpackaging and take out, holding each end.

To ensure sterility.

8. Screw giving set tightly to the feed pack andspike taking care not to touch the sterile foil

end of the feed pack.

To facilitate the procedure and reduce risk ofleakage and of contamination

9. Squeeze the drip chamber to half fill with feed To facilitate the procedure.


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10. Open the pump door and place the giving setin the pump and then close the door.

11. Turn the pump on. Then press the CLR button To power pump and clear previous settings

12. Now you need to set the rate of the infusionand then the total volume to be infused. Firstset the rate to be infused:

Check the feeding regime for the intended rateof feed. Press the (+) or (-) buttons to set this

rate, in mls per hour on the pump

To ensure that the patient gets the prescribedregimen

13. Now set the total volume to be infused:Press the DOSE = VOL button and the pumpwill read CONT, then press the (+) to set the

volume to be infused

14. Press the FILL SET button to prime the givingset

15. Remove the cap from the giving set. Connectthe end of the giving set to the nasogastric tubeand then press START/STOP button tocommence feeding

To commence feeding

16. Document the procedure in the patients recordto include:

How position of feeding tube was confirmedDate & time new feed was commenced

To conform to good governance practice

ii) ADMINISTRATION OF FEED USING A FEEDING PUMP & RECONSTITUTION

OF POWDERED FEED

EQUIPMENT

Feeding regimen

Appropriate prescribed feed

Feeding reservoir bottles and additive labels

Infinity Flocare pump & stand

Suitable giving set

Jug and freshly drawn freshly drawn drinking tap water (sterile water for immunosuppressedpatients) for flush


pH paper

Sterile jug and sterile water (if mixing feed)

Whisking device

Alcohol 70% spray

Paper towel

Alcohol wipe

Table 4: Preparation and reconstitution of powdered feed (must take place in the ward kitchen

away from any food.)

Principle Rationale

1. Prepare equipment needed. Check the feedagainst the prescribed regimen and patient details.

Check the presentation and expiry date.



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2. Wash hands and clean the whisk in hot soapywater and rinse. Dry with a paper towel.

To avoid cross infection.

3. Wash hands and clean the work surface with 70%alcohol and allow the work surface time to dry

(Anderton, 2000).


4. Clean the top of the feed pack with an alcoholwipe and allow to dry.

To avoid cross infection

5. Open the feed and sterile water and pour into ajug (ensuring you have calculated the amount offeed and water needed for the 24hr period).Discard any unused water. Bottles of sterilewater are single use only. Once opened thewater is no longer regarded as sterile. Do not

replace cap. Do not re-use.Mix together in the jug with whisking device

according to the manufacturers instructions.

To facilitate the procedure

6. Remove the lid from the reservoir bottle (ensurethe inside of the lid and reservoir is not touched).Pour the feed into the reservoir and replace the lidfirmly.Repeat this procedure until you have filledenough reservoir bottles for 24 hrs.


7. Discard any unused feed and water and the jug(MDA, 2000).

To ensure opened feed and water is not usedagain

8. Record thedate and time;feed type;volumefeed expiry timepatients name and numberon the additive labels and fix to all the reservoirbottles.

For monitoring purposes

9. Store the additional filled reservoir bottles in thefridge.

To minimise the risk of cross infection.

10. Take the feed to be used to the patient. To facilitate the procedure

11. Check the position of the tube. (See Guidelinesfor Passing and Checking a Fine Bore NGTube).If in any doubt that the tube is not in thecorrect position do not use and inform medicalteam.

To prevent aspiration and feeding using adisplaced tube.

12. Wash hands again or rub with alcohol hand rub. To minimise the risk ofcross infection.

13. Unscrew or open the feeding end of the NG tube.Attach the 50ml purple enteral syringe and gentlyand slowly flush the tube using up to 50 ml offreshly drawn drinking tap water (or amountindicated on the feeding regimen).Use sterile water for immunosuppressed patients.


Use 30-50 ml syringe as it is possible torupture fine-bore tubes by using excessiveforce with a smaller syringe (BAPEN 2003,Shaw, 1994).


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14. Check the expiry date on the package of the

giving set prior to opening.Open packaging of the giving set.


15. Hang the reservoir bottle on the drip stand.Hanging will be considered carefully when the

dietitian is planning the feeding regime ideallyreservoirs of reconstituted or decanted feed

should only hang for 4 hours. This may beextended to a maximum of twelve hours (forexample, overnight) in response to client or carerneeds.Attach the giving set to the reservoir taking care

not to touch the sterile end of the reservoir orgiving set.


16. Screw giving set tightly to the feed pack and

spike taking care not to touch the sterile foil endof the feed pack.

To facilitate the procedure and reduce risk of

leakage and of contamination


18. Open the pump door and place the giving set in

the pump and then close the door.


20. Now you need to set the rate of the infusion andthen the total volume to be infused. First set the

rate to be infused:Check the feeding regime for the intended rate offeed. Press the (+) or (-) buttons to set this rate, in

mls per hour on the pump


Now set the total volume to be infused: Press theDOSE = VOL button and the pump will readCONT, then press the (+) to set the volume to beinfused

21. Press the FILL SET button to prime the giving set

22. Remove the cap from the giving set. Connect the

end of the giving set to the nasogastric tube andthen press START/STOP button to commence

feeding

To commence feeding

23. Document the procedure in the patients record toinclude:

How position of tube was confirmed

Time new feed commenced


24. Remove next feed from refrigerator our beforeit is required

To allow the feed to come to roomtemperature and prevent abdominal

discomfort.


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iii) ADMINISTRATION OF FEED USING A FEEDING PUMP & FEED DECANTED

INTO A RESERVOIR BOTTLE

EQUIPMENT

Feeding regimen

Appropriate prescribed feed e.g. can, bottle Feeding reservoir bottle and additive label

Flocare Infinity pump and stand

Suitable giving set

Jug and freshly drawn drinking tap water (Sterile water for immunosuppressed patients) forflush


pH paper

Alcohol wipe

Table 5: Administration of feed using a feeding pump and reservoir bottle

Principle Rationale

1. Check the feed against the prescribed regimenand patient details. Check the presentation andexpiry date.


2. Wash hands To minimise the risk of cross infection.

3. Check the position of the tube. (See Guidelinesfor Passing and Checking a Fine Bore NGTube).If in any doubt that the tube is not in the correct

position do not use and inform medical team.

To prevent aspiration and feeding using adisplaced tube.

4. Wash hands again or rub with alcohol hand rub. To minimise the risk ofcross infection.

5. Unscrew or open the feeding end of the NG tube.Attach the 50ml purple enteral syringe and gentlyand slowly flush the tube using up to 50ml offreshly drawn drinking tap water (or amountindicated on the feeding regime).Use sterile water for immunosuppressed patients.


Use 30-50 ml syringe as it is possible torupture fine-bore tubes by using excessiveforce with a smaller syringe (BAPEN 2003,Shaw, 1994).

6. Clean top of feed pack/can with alcohol wipe To prevent cross infection

7. Fix a completed additive label to the reservoir,indicating feed, volume, date and time.

To allow the contents to be checked andensure the feed is only hung for 24 hrs.

8. Shake the container of feed. To mix the contents of the feed.

9. Fill the reservoir with the correct volume of feedand replace the lid.

To ensure the volume is administeredaccording to the feed regime and facilitatethe procedure.

10. Open packaging and close the roller clamp.Check the expiry date on the package of thegiving set prior to opening.


11. Hang the reservoir on the drip stand. Ideallyreservoirs of reconstituted or decanted feed



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should only hang for 4 hours. This may beextended to a maximum of twelve hours (forexample, overnight) in response to client or carer

needs.Attach the giving set to the reservoir taking care

not to touch the sterile end of the reservoir orgiving set.

12. Screw giving set tightly to the feed pack andspike taking care not to touch the sterile foil end

of the feed pack.

To facilitate the procedure and reduce riskof leakage and of contamination


14. Open the pump door and place the giving set inthe pump and then close the door.


16. Now you need to set the rate of the infusion andthen the total volume to be infused. First set therate to be infused:

Check the feeding regime for the intended rate offeed. Press the (+) or (-) buttons to set this rate, in



17. Now set the total volume to be infused:Press the DOSE = VOL button and the pump willread CONT, then press the (+) to set the volume

to be infused


19. Remove the cap from the giving set. Connect theend of the giving set to the nasogastric tube andthen press START/STOP button to commencefeeding

To commence feeding

20. Document the procedure in the patients record toinclude:

How position of tube was confirmed

Time new feed commenced


21. Remove next feed from refrigerator our beforeit is required

To allow the feed to come to roomtemperature and prevent abdominaldiscomfort.


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B) JEJUNAL FEEDING

ADMINISTRATION OF COMMERCIALLY PREPARED FEED USING A FEEDING

PUMP

Details of the feed to be used for your patient will be given on enteral feeding regimen prepared by

the dietitian. (see appendix 3 for emergency starter regimen if required)

ONLY USE STERILE WATER AND STERILE JUGS WHEN DEALING WITHJEJUNAL TUBES

Table 6: Administering commercially prepared feed via jejunal tube

Principle Rationale

Commercially prepared Feed in a Pack

i) Equipment Required:Feeding regimen

Appropriate feed pack, check pack size to beused

Feeding pumpDrip standSuitable giving set50ml purple enteral syringe x 2Sterile JugSterile water

1. Check the feed against the prescribed regimen andpatient details. Check the feed type, presentation,

volume and expiry date.


2. Wash hands To remove germs and prevent crossinfection

3. Check the position of the tube prior to each timethe tube is used. Check the visual length of thetube and compare with other visual checks. Ifmarkings are available check actual length. If inany doubt the tube is not in the correct positionDo Not Use. Check with medical team or theNutrition Support team.

To prevent aspiration or when gastricfeeding is contraindicated.

4. Wash hands again or rub with the alcohol hand

rub.

To minimise risk of infection

5. Always flush the jejunal tube prior to feeding (andrepeat after feeding)ONLY USE STERILE WATER.

Draw up 15-50ml water into a 50ml purple enteralsyringe (see feeding regime to check amount of

flush required)Unscrew or open the feeding end of the jejunaltube. Attach the 50ml purple enteral syringe andgently and slowly flush the tube.

To prevent the tube from blocking andensure patency of the tube.


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6. Shake pack of feed. To distribute the contents throughout thesolution. This is especially important if thefeed contains fibre.

7. Hang pack on drip stand. To facilitate the procedure.

8. Obtain giving set; check the expiry date on thepackage prior to opening. Open packaging andtake out giving set, holding each end.

To ensure the giving set is sterile

9. Unscrew and remove the protective cap from thepack, ensure you do not touch the sterile foil end.

Whilst keeping the feed still by holding the purpleconnector above the sterile end on the pack offeed, push on the purple end of the giving set andscrew on.

Hold the purple end of the giving set that has beenscrewed onto the feed and with the other handpush up sharply the giving set allowing theinternal spike to break the foil seal.





12. Now you need to set the rate of the infusion and

then the total volume to be infused. First set therate to be infused:

Check the feeding regime for the intended rate offeed. Press the (+) or (-) buttons to set this rate, in


To ensure that the patient gets the

prescribed regimen

13. Now set the total volume to be infused:Press the DOSE = VOL button and the pump willread CONT, then press the (+) to set the volume

to be infused


15. Remove the cap from the giving set. Connect theend of the giving set to the jejunal tube and and

then press START/STOP button to commencefeeding


16. Flush feeding tube at the end of feeding, beforeand after medication; refer to feeding regimen for

flushing instructions.Use sterile water only.

To prevent blocking tube.


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ONLY USE STERILE WATER.Draw up 15-50ml water into a 50ml purpleenteral syringe (see feeding regime to checkamount of flush required).

Unscrew or open the feeding end of the jejunal

tube. Attach the 50ml syringe and gently butslowly flush the tube.

6. Remove the lid from the reservoir taking care notto touch the inside of the lid or reservoir


7. Pour in the amount of feed required and firmlyclose the lid.


8. Fix the completed additive label to the reservoir,indicating type of feed, volume, date and time

and patients name and hospital number.

To allow other nurses/Dietitians to checkcontents.

9. Hang reservoir on drip stand. To facilitate the procedure.

10. Obtain giving set; check expiry date on packageprior to opening. Open packaging and take outgiving set, holding each end.

Package is within expiry date.

11. Hang the reservoir containing feed on the dripstand


12. Attach the giving set to the reservoir; ensure youdo not touch the inside of the connection on the

giving set and reservoir. Screw on.





16. Now you need to set the rate of the infusion andthen the total volume to be infused. First set therate to be infused:Check the feeding regime for the intended rate offeed. Press the (+) or (-) buttons to set this rate, inmls per hour on the pump


17. Now set the total volume to be infused:

Press the DOSE = VOL button and the pumpwill read CONT, then press the (+) to set thevolume to be infused

18. Press the FILL SET button to prime the giving

set

19. Remove the cap from the giving set. Connect theend of the giving set to the jejunal tube and thenpress START/STOP button to commence feeding



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20. Turn on the pump and set at the required rate, asrecommended by the Dietitian. Set the volume tobe infused using the dose key on the pump.Always ensure mls/hr and volume to be infusedare set on pump prior to feeding. A secondperson should check the rate, volume and type offeed.

To ensure correct administration.

21. Flush feeding tube at the end of feeding, beforeand after medication; refer to feeding regimen forflushing instructions.Sterile water only

To prevent blocking tube.

22. Commence a fluid balance chart and documentaccurately input and output.

Weigh twice weekly if possible, or more

frequently if indicated by medical staff.

To ensure adequate hydration.

To monitor nutritional status or signs of

over/under hydration.

23. Prior to commencement to feeding ensure thatbase line blood monitoring has been undertaken.Repeat at regular intervals as required bymembers of the team.

To maintain normal metabolic state.

24. Check bowel movements daily by observation, orby asking the patient about the frequency andnature of stools. If any increased frequency,commence a stool chart and inform the Dietitian.

To maintain normal bowel function.


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TUBE CARE AND MANAGEMENT

NG TUBE

Table 8: On-going (tube) care of patients on NG feedingFeeding

Principle Rationale

1. The position of the tube and the length of tubeat the nostril must be re-checked every timefeeding is commenced and each time the tubeis used to administer medication. It shouldalso be checked by the nurse taking over the

care of the patient at the start of the shift. Thisprocess should be clearly documented. See

page 18 on passing and checking position ofNG tube.

The tube can become dislodged, increasing the riskof aspiration.

Establishing the correct position of the tube in the

stomach is essential to the safety of the patient, asintrapulmonary feeding or aspiration owing to a

poorly positioned tube can have seriousconsequences (Cannaby et al, 2002).

2. Flush feeding tube before and after feeding,before and after medication and as per feedingregimen.

To prevent blocking NG tube and to maintainhydration.

3. The giving set and reservoir (if used) must belabelled and changed every 24 hoursand anyremaining feed discarded. Decanted feedsshould only hang for 4 hours. This may beextended to a maximum of twelve hours (for

example, overnight) in response to client orcarer needs.

To reduce the risk of infection (Anderton, 1995).

4. Document input & output accurately on a fluid

balance chart

To ensure accurate records

5. Weigh patient twice weekly if possible, or asindicated by the dietitian or medical staff.

To monitor nutritional status.

6. Prior to commencement of feeding ensure that

baseline blood monitoring has beenundertaken: (urea & electrolytes, magnesium,

calcium, phosphate & glucose). Repeat atregular intervals as required by members of theteam

To establish baseline biochemistry and identify

abnormalities which need monitoring.

7. Record bowel movements daily. If any changeto usual pattern, commence a stool chart and

inform the Dietitian and/or medical team.

To maintain normal bowel function.

8. Observe the patient for signs of complications(e.g. new breathlessness, coughing, fever orregurgitation or vomiting) throughout theduration of the feed. If signs of complicationsor distress are seen, stop the feed and seekmedical advice.

To monitor and maintain patient safety

9. Inform the Dietitian of any problems involvingthe feed, equipment etc.


10. Change the tape, which secures the tube at thenostril as required. A commercial attacher

should be used where possible.

To reduce risk of accidental removal ordisplacement of the tube.

11. Assist the patient to clean mouth and nostrils. To promote comfort.


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Flushing the Tube

Principle Rationale

1. Only use 50ml purple enteral syringes to flushthe tube and discard after single use.

A smaller syringe may produce too much pressureand split the tube (BAPEN, 2003).

Re-use of single use only items contravenesMedical Devices Regulations (MDA, 2000).

2. Tubes should be flushed with freshly drawn

drinking tap water before and after feeding,administration of medication and as indicatedon the feeding regimen.


3. Sterile water should be used if the patient is

immunocompromised (Taylor and Goodinson-McLaren, 1992).

To reduce the risk of infection (Anderton, 1995).

Medicines (Refer to Separate Guideline on The use of syringes to administer flushes, feeds and medicationvia the oral and enteral route in adults currently in preparation)

Principle Rationale

1. Tubes should be flushed with at least 15ml of

freshly drawn drinking tap water (Adams,1994) before and after each individualmedication.

If more than one drug is to be administered they

should be administered separately and the tubeshould be flushed with water between each one(Colagiovanni, 2000) to prevent the tube blocking.Inadequate tube flushing is the most common causeof tube blockage (BAPEN 2003)

2. Medication should ideally be in liquid form.

Some thick liquid medications may requirediluting in an equal amount of water beforeadministration.

All medications should be given separately.

To reduce risk of blocking the tube.

Some liquids are viscous and this may block thetube.

3. If medicines are only available as a tablet,check with the pharmacist that they can becrushed. Do not administer crushed tablets thathave not been completely dispersed in water.

Liquids or soluble tablets are preferredformulations to be administered via a feedingtube.

Tablets that have not been completely crushed canblock feeding tubes, as can preparations that areincompatible when mixed with enteral feeds(Marcuard and Perkins, 1988)

4. Some medicines react with feed, affecting theefficacy of the drug. Always check with thepharmacist before administering anymedication down an enteral feeding tube.Where possible give dose during the feed restperiod.

To maximise drug efficacy.

Best Practice FLUSHING THE TUBE

Tubes which are not flushed immediately before and after feed and/or medication have a much higher risk ofblocking (Brennan Krupp and Heximar, 1998; Adams, 1994).


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Tait, (2001) Going Nasogastric Current thinking in Nasogastric Techniques Complete Nutrition

Vol 1 No. 2Taylor S, Goodinson-McLaren S M (1992) Nutritional Support - A Team Approach. London: WolfePublishingWard V, Wilson J, Taylor L, Cookson B, Glyns A (1997) Preventing Hospital Acquired Infection.Public Health Laboratory Service, London.

GASTROSTOMY TUBE

CARE OF A PATIENT WITH A PERCUTANEOUS ENDOSCOPIC GASTROSTOMY

(PEG)

Table 9: IMMEDIATE CARE POST-PROCEDURE

Principle Rationale

1. Follow instructions for care of the patient as

indicated in the post-operative sheet.

To ensure safe recovery.

2. Wash hands and apply non-sterile gloves. To reduce the risk of cross infection.

3. Check stoma site for swelling, bleeding and

leakage.

To detect for haemorrhage or signs of infection.

4. Check the fixation device is in the correctposition (procedure report) and remainssecure.Do not open or adjust fixation device for the

first 48hrs.

Record position of the tube using thegraduated markings

To ensure the tube is in the correct position.

5. Check and record blood pressure, pulse andtemperature as requested on the post-operativesheet.

To detect early signs of sepsis / peritonitis.

6. Patient should remain nil by mouth for 4hours post procedure or longer if indicated inthe procedure notes. Sterile water at 50mls perhour via gastrostomy is then used for first 4hours. If there are any adverse symptoms or

signs during the water infusion (excess pain,fevers etc) then medical advice should besought

To reduce the risk of peritonitis


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FEEDING VIA GASTROSTOMY

The dietitians will normally have prescribed a starter regimen (see appendix 3 for emergency starterregimen if required). Ensure that this is available and used. Feeding will usually start at 8 hours afterthe procedure providing there are no signs of peritonitis or organ damage.

Table 10: Pump feeding using agreed feeding pump and giving set

Principle Rationale

1.i) Commercially prepared feed in a pack, requirements:

Feeding regimen

Appropriate feed pack, check pack size to be used

Feeding pump

Drip stand

Suitable giving set

Label for giving set


Jug Freshly drawn drinking tap water for flushing

1. Check the feed against the prescribed regimen and patientdetails. Check the feed type, presentation, volume andexpiry date.


2. Wash hands. To prevent cross infection.

3. Check the position of the tube by looking at the graduatedmarkings on the tube or the visual length of the tube andcompare this with the information recorded following

insertion regarding tube position, if available.

If in any doubt aspirate some gastric contents and check thepH level with pH paper. The pH should be 5.5 or below.

If there is still any doubt that the tube is not in the correctposition, do not use. Check with medical staff or theNutrition Support team.

To prevent feeding the patient whenthe tube is displaced and to avoidaspiration.

Only pH Paper should be used toobtain an accurate reading followingaspiration. Litmus paper is notsufficiently sensitive to distinguishbetween gastric acid and bronchialsecretions.

4. Always flush the gastrostomy tube prior to feeding (andrepeat after feeding).Use freshly drawn drinking tap water or sterile water for

immunosuppressed patients. In some hospital areas sterilewater may need to be used for all patients (check local

policy)Draw up, or measure out, 15-50ml water (see feeding

regimen to check amount of flush required).Flush the tube using either low pressure or free flowtechnique (see best practice box ).

To maintain a patent tube.


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5. Check feed labels to ensure feed type and expiry dates arecorrect.

Shake pack of feed.

To ensure correct feed is given

To distribute the contents throughoutthe solution. This is especiallyimportant if the feed contains fibre.

6. Hang pack on drip stand. To facilitate the procedure.

7. Obtain correct giving set, check the expiry date on thepackage prior to opening. Open packaging and take outgiving set, holding each end.

To ensure the giving set is safe to useand to facilitate the procedure.

8. Unscrew and remove the protective cap from the pack offeed, ensure you do not touch the now exposed sterile foilend.Whilst keeping the feed still by holding the purpleconnector above the sterile end on the pack of feed, push on

the purple end of the giving set and screw on.Hold the purple end of the giving set that has been screwed

onto the feed and with the other hand sharply push up thegiving set allowing the internal spike to break the foil seal.



10. Open the pump door and place the giving set in the pumpand then close the door.

11. Turn the pump on. Then press the CLR button To power pump and clear previoussettings

12. Now you need to set the rate of the infusion and then thetotal volume to be infused. First set the rate to be infused:Check the feeding regime for the intended rate of feed.

Press the (+) or (-) buttons to set this rate, in mls per hour onthe pump

To ensure that the patient gets theprescribed regimen

13. Now set the total volume to be infused:Press the DOSE = VOL button and the pump will readCONT, then press the (+) to set the volume to be infused


15. Remove the cap from the giving set. Connect the end of thegiving set to the gastrostomy tube and then pressSTART/STOP button to commence feeding

To minimise air entry, thus reducingthe risk of gastric distension andpatient discomfort.To commence the feed

16. Flush feeding tube at the end of feeding, before and aftermedication; refer to feeding regimen for flushinginstructions.

To prevent blocking the tube.


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17. Commence a fluid balance chart and document accurately

input and output. Prior to commencement of feeding ensurethat base line blood monitoring has been undertaken (ureaand electrolytes, magnesium, calcium, phosphate andglucose). Repeat at regular intervals as required bymembers of the team.

To monitor metabolic and hydration

state.

18. Monitor bowel movements daily by observation, or byasking the patient about the frequency and nature of stools.If abnormal, commence a stool chart and inform theDietitian and/or medical team.

To monitor normal bowel function.

19. Inform the Dietitian of any problems involving the feed,equipment etc.

To maintain patient safety

20. Document all interventions and variances in the patientsrecord

In accordance with good clinicalgovernance

Best Practice FLUSHING THE TUBE

To flush the tube using low pressure technique:Draw up the required volume of freshly drawn drinking tap water (sterile water is often used as routinein hospitals if there is concern about tap water, please check local guidelines. Always use sterile waterfor immunosuppressed patients). Open the port or cap on the gastrostomy tube. Attach the 50ml

syringe and gently and slowly depress the plunger to flush the tube.

To flush the tube using free-flow technique:Remove the plunger from a 30-50ml syringe. Open the port or cap on the feeding tube, attach thesyringe barrel and fill with the required amount of water, open the clamp and allow the water to go

through the tube.

Principle Rationale

1 ii) Feed Decanted into a Reservoir....

Equipment Required

Feeding regimen

Appropriate feed e.g. can, sachet, bottle

Reservoir bottle Additive label

Pump and stand

Pump giving set or other if indicated

Label for giving set


Sterile jug and sterile water if mixing feed (refer toguidelines for preparing powdered feed)

Jug and fresh drinking tap water for flushing (sterilewater for immunosuppressed patients)

1. Check the feed against the prescribed regimen and patientdetails. Check the feed type, presentation, volume andexpiry date.



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2. Wash hands To prevent cross infection.

3. Check the position of the tube by looking at the graduated

markings on the tube or the visual length of the tube andcompare this with the information recorded following

insertion regarding tube position, if available.

If in any doubt aspirate some gastric contents and check thepH level. The pH should be 5.5 or below.

If there is still any doubt that the tube is not in the correctposition, do not use. Check with medical staff or the

Nutrition Support team.

To prevent aspiration.

4. Always flush the gastrostomy tube prior to feeding (andrepeat after feeding).

Using freshly drawn drinking tap water or sterile water

(according to local guidelines) and measure out, 15-50ml(see feeding regimen to check amount of flush required).

Flush the tube using either low pressure or free flowtechnique (see best practice box).

To ensure the tube remains patent.

5. Wash hands again or use alcohol rub. To prevent cross infection.

6. Before putting in the reservoir check the expiry date, type offeed and duration against the feeding regimen and add feedto reservoir.

To facilitate the procedure and toprevent errors in administration.

7. Obtain correct giving set, check the expiry date on the

package prior to opening. Open packaging and take outgiving set, holding each end.Attach and screw on the giving set to the reservoir

To ensure the giving set is safe to use

and to facilitate the procedure.


8. Hang reservoir on drip stand.

9. Screw giving set tightly to the feed pack and spike takingcare not to touch the sterile foil end of the feed pack.

To facilitate the procedure and reducerisk of leakage and of contamination


11. Open the pump door and place the giving set in the pumpand then close the door.

12. Turn the pump on. Then press the CLR button To power pump and clear previous

settings

13. Now you need to set the rate of the infusion and then thetotal volume to be infused. First set the rate to be infused:

Check the feeding regime for the intended rate of feed. Pressthe (+) or (-) buttons to set this rate, in mls per hour on the

pump

To ensure that the patient gets theprescribed regimen

14. Now set the total volume to be infused:

Press the DOSE = VOL button and the pump will readCONT, then press the (+) to set the volume to be infused



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16. Screw giving set tightly to the feed pack and spike takingcare not to touch the sterile foil end of the feed pack.

To facilitate the procedure and reducerisk of leakage and of contamination

17. Remove the cap fro

enteral feeding adults2

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