standard operating procedure for enteral tube feeding

Document level: West Locality Code: CC54

Issue number: 1

Standard Operating Procedure for Enteral Tube Feeding

Lead executive Director of Operations

Authors details Community Nutrition Nurse, Community Nutrition Service - 01244366581

Type of document Standard Operating Procedure

Target audience Community Care Teams

Document purpose To advise health care professionals on aspects relating to enteral tube feeding.

Approving meeting Neighbourhood-Based Care Governance Group Date 10-Feb-20

Implementation date 10-Feb-20

CWP documents to be read in conjunction with

IC2 Hand decontamination policy and procedure HS1 Waste management policy IC3 Standard (universal) infection control precautions policy IC1 Trust wide infection prevention and control operational policy MP1 Medicines policy

Document change history

What is different? CC46, CC47, CC48, CC49 have been amalgamated into one SOP.

Appendices / electronic forms

Not previously available on the intranet.

What is the impact of change?

None, updated information.

Training requirements

Training requirements for this policy are in accordance with the CWP Training Needs Analysis (TNA) with Education CWP. It is the responsibility of the individual and / or community care team to identify training needs to the community nutrition nurse /dietitian.

Document consultation

Clinical Services via policy discussion forum Corporate services via policy discussion forum External agencies N/A

Financial resource implications

No

External references

1. N/A

http://www.cwp.nhs.uk/resources/policies/ic2-hand-decontamination-standard-operating-procedure-sop/

http://www.cwp.nhs.uk/resources/policies/hs1-waste-management-policy/

http://www.cwp.nhs.uk/resources/policies/ic3-standard-universal-infection-control-precautions-policy/

http://www.cwp.nhs.uk/resources/policies/ic1-trustwide-infection-prevention-and-control-operational-policy/

http://www.cwp.nhs.uk/resources/policies/mp1-medicines-policy/

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Do not retain a paper version of this document, always view from the website www.cwp.nhs.uk to ensure it is the correct version

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Where an adverse or negative impact on equality group(s) has been identified during the initial screening process a full EIA assessment should be conducted. If you have identified a potential discriminatory impact of this procedural document, please refer it to the human resource department together with any suggestions as to the action required to avoid / reduce this impact. For advice in respect of answering the above questions, please contact the human resource department.

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To view the documents Equality Impact Assessment (EIA) and see who the document was consulted with during the review please click he

http://www.cwp.nhs.uk/

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Contents Quick reference flowchart – Suggested treatment for over-granulation of PEG/ RIG sites .................... 4 1. Introduction ................................................................................................................................ 5 2. General feeding tube care and information ................................................................................ 5 2.1 Type of feeding tube and feeding regimen ................................................................................. 5 2.2 Pre-procedure checks ................................................................................................................ 6 2.3 Infection prevention.................................................................................................................... 6 2.4 Condition of tube ........................................................................................................................ 6 2.5 Using a clamp (If applicable) ...................................................................................................... 6 2.6 Stoma site .................................................................................................................................. 6 2.7 Equipment ................................................................................................................................. 7 2.8 For balloon retained gastrostomy tubes / Radiologically inserted gastrostomy (RIG) ................. 7 2.9 Balloon retained low profile devices ........................................................................................... 8 2.10 Percutaneous Endoscopic Gastrostomy (PEG) .......................................................................... 8 2.1 Capsule Monarch Tube .............................................................................................................. 9 2.12 Nasogastric Tube ....................................................................................................................... 9 2.13 How to unblock a feeding tube ................................................................................................. 10 2.14 Dislodged feeding tube ............................................................................................................ 10 2.15 End of procedure ..................................................................................................................... 10 3. Changing the water of a balloon gastrostomy tube ................................................................... 11 3.1 Procedure ................................................................................................................................ 11 4. Administering medications via an artificial feeding tube ........................................................... 13 4.1 Procedure ................................................................................................................................ 13 5. Setting up and administering artificial nutrition via the Abbott FreeGo pump and a bolus. ........ 15 5.1 Procedure ................................................................................................................................ 15 5.2 Continuous (pump) feeding ...................................................................................................... 17 5.3 Bolus feeding (without using a pump) ...................................................................................... 21 6. Contact details ......................................................................................................................... 22 Appendix 1 – Replacement of CORFLO PEG Adaptor ....................................................................... 23 Appendix 2 – Replacement of FREKA PEG Connector ...................................................................... 24 Appendix 3 – Guidance on inserting ENPLUGTM ................................................................................ 25


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Quick reference flowchart – Suggested treatment for over-granulation of PEG/ RIG sites


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1. Introduction This document was developed to advise health care professionals on aspects relating to enteral tube feeding. Within this document are three standard operating procedures (SOPs) related to enteral tube feeding. 2. General feeding tube care and information

2.1 Type of feeding tube and feeding regimen

Patients with an enteral feeding tube will have an individualised care

plan and feeding regimen dependent on their medical condition. Some

patients may be nil by mouth, some receiving nutrition orally and via

their tube and some may not currently be using their tube for feeding.

Identifying the type of feeding tube and when it was inserted is

important as this will influence the type of care the patient requires.

This information should be provided in the patient’s home enteral tube

feeding information pack. If unsure contact the nutrition nurse or

dietitian.

Corflo PEG

Freka PEG

Low profile device

Balloon gastrostomy tube


http://en.wikipedia.org/wiki/File:PEG_01.jpg

https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=&url=https://www.medicalhomeportal.org/clinical-practice/medical-technology/feeding-tubes-and-gastrostomies&psig=AFQjCNFdqFZc4Ejzy0t0nqDYycGD1JqjyA&ust=1477489031967615

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2.2 Pre-procedure checks Check patient identity. Explain procedure to the patient. Ensure that valid consent is gained.

If patient unable to consent, record

procedure as ‘best interest’ in health

care records.

2.3 Infection prevention Prior to any intervention, local standard handwashing

procedures should be adhered to and gloves and aprons

worn.

Ensures compliance with IC2 Hand

decontamination standard operating

procedure and IC3 Standard universal

infection control precautions policy.

2.4 Condition of tube Assess the condition of the tube, check the tube is not

cracked or leaking and all parts are in good working order.

The tube will also become stained (mainly brown) by

medications, this is normal. Over time the tube will become

soft and may start to lose its shape and flatten. If there are

any concerns regarding the tubes condition please contact

the nutrition nurse or dietitian.

2.5 Using a clamp (If applicable) If the tube has a clamp it should be placed nearer the end

of the tube and should be left undone when not using the

tube to prevent tube damage.

Moving the position of the clamp will also avoid damage /

wear to the same part of the tube.

Example of

clamped

tube:

2.6 Stoma site Observe the stoma site for signs of clinical infection such as

redness, swelling, heat, increased exudate, purulent

discharge, odour and pain. Consider taking a swab of the

stoma site if indicated.

Overgranulation is a common complication found in patients

with an artificial feeding tube. Good hand and stoma site

hygiene can help to prevent this and ensuring the external

fixator is not too tight or too loose.

See quick reference flowchart


http://www.cwp.nhs.uk/resources/policies/ic2-hand-decontamination-policy-and-procedure/





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2.7 Equipment Enteral syringes should be washed after every use, remove

barrel and wash all parts in warm soapy water, rinse, air dry

on clean towel and store in clean container when not in use.

Giving sets can be used for up to 24 hours then discarded.

The dietitian / nutrition nurse will advise

the patient on how many syringes they

will be provided with per week. If any

more equipment is required please

contact the nutrition nurse / dietitian.

2.8 For balloon retained gastrostomy tubes / Radiologically inserted gastrostomy (RIG)

Initial placement:

When a new RIG is inserted it is categorised as a surgical

wound for approximately 7-10 days. The nutrition nurse will

provide cleaning solution to be used during this time. Under

the external fixator should be cleaned daily without

adjusting it if you are able to do so and dried thoroughly.

Following this the RIG site should be cleaned daily with

warm soapy water and dried thoroughly.

When the RIG is initially inserted there will generally be 3

anchor sutures. These can fall off on their own but if they

don’t should be removed with a suture remover 10-14 days

post procedure.

4 weeks post RIG insertion:

The tube should be rotated 360 degrees daily.

The internal balloon is inflated with water, 4 weeks after the

initial tube insertion and every week after this the water

should be checked and changed weekly (ideally Monday to

Thursday, before lunchtime). For guidance on this see

section 3.

Be aware that the external fixator

should not be undone for the first 4

weeks until the stoma tract has healed.

Following this the external fixator can

be undone on a daily basis to allow for

cleaning

Note the position of the external fixator.

This is the disk that is visible at the

point at which the tube exits the

stomach. The external fixator should not

be too loose or too tight. A distance of

2-3mm is recommended from abdomen.

Leakage of gastric content / over

granulation can occur when the fixator

is loose. Pain and irritation can occur if

it is too tight.

Other NHS Trusts referring to Cheshire

and Wirral partnership NHS Foundation

Trust may have different policies in

relation to when to carry out the suture

removal and / or first balloon water

change following a new RIG insertion.

Seek advice from the nutrition nurse or

dietitian if there is any uncertainty.


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2.9 Balloon retained low profile devices Note the position of the low profile device; it should

not fit too loose or too tight. This is to reduce the risk

of pressure around the stoma site and skin

breakdown.

The Device should be rotated and repositioned daily.

The internal balloon is inflated with water. This should

be changed weekly (ideally Monday to Thursday,

before lunchtime). See section 3.

2.10 Percutaneous Endoscopic Gastrostomy (PEG) Patients with a PEG will generally have either a Corflo

or Freka PEG.

Initial placement:

When a new PEG is inserted it is categorised as a

surgical wound for approximately 7-10 days. The

nutrition nurse will provide cleaning solution to be

used during this time. Under the external fixator

should be cleaned daily without adjusting it and dried

thoroughly.

Following this the PEG site should be cleaned daily

with warm soapy water and dried thoroughly.

The PEG should also be rotated 360 degrees daily

following insertion.

4 weeks post initial insertion:

CORFLO tubes should be advanced and rotated

weekly.

FREKA tubes should be advanced and rotated daily.

This is to prevent buried bumper syndrome where the

mucosa of the stomach grows over the internal

bumper.

To advance the tube, clean the stoma site, undo the

external fixator and slide it towards the end of the

tube. Visualise the full length of the tube for signs of

damage. Advance the tube into the tract by 2-3cm,

rotate the tube 360 degrees and retracted to previous

position. Readjust the external fixator; it should be

repositioned 2-3mm from the abdomen.

Corflo PEG

Freka PEG

Note- PEG tubes with jejunal

extensions and surgical

jejunostomy tubes should NOT be

rotated. If you have a patient

referred to your service with this

type of tube, please contact the

nutrition nurse or dietitian for

specialist advice.

Spare PEG replacement feeding

adaptors (PEG ends) are available

should they require replacement.

Patients are encouraged to keep a

spare at all times. These are ordered

via Abbott or can be accesses from


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the nutrition nurse or dietitian.

See replacement of CORFLO PEG

adaptor (appendix 2) and replacement

of Freka PEG connector (appendix 3).

Corflo PEG Adaptor

Freka PEG connector

2.11 Capsule Monarch Tube The tube should be rotated 360 degrees daily and

advanced weekly. To advance the tube the external

fixator / T bar should be moved down towards the end

of the tube. Visualise the full length of the tube for

signs of damage. Advance the tube into the tract by 2-

3cm, rotate the tube 360 degrees and retracted to

previous position. The external fixator / T bar should

then be repositioned 2-3mm from the abdomen.

Replacement feeding adaptor ends

are available for these tubes. Patients

are encouraged to keep a spare at all

times. These are available from the

nutrition nurse or dietitian.

2.12 Nasogastric Tube This is a feeding tube placed via the nose into the stomach. It may be secured with a dressing, tape or nasal bridle at the nose. Nasogastric tube tip position needs to be confirmed before every use of the tube, for example before the feed is started, restarted and/or water/medications are given via the nasogastric tube.


https://www.phsonlineordering.com/kit-repair-corpak-peg-12fr-ef

https://www.cobramedical.com/enterale-voedings-producten/peg-sonde/polyurethaan-peg/freka-peg-connectoren/36253_freka-peg-connector-ch20-enfit

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2.13 How to unblock a feeding tube You will need a 60ml syringe and some warm water or carbonated water. Check your feeding tube to see if you can identify where the blockage is. Squeeze along the feeding tube with your fingers to try and clear the blockage.

Draw up approximately 30mls of warm water or

carbonated water into the 60ml syringe. Try to flush

this down the feeding tube but do not force it. If it will

not flush, pull back on the syringe plunger and use a

push- pull technique. Do this several times to try to

dislodge the blockage. Repeat the above steps until

blockage is cleared.

If you are unable to clear the blockage please contact the nutrition nurse or dietitian as soon as possible. If the tube is the patients only means of diet and fluids and it is outside of normal working hours of Monday to Friday the patient will need to attend A&E. Adequate flushing pre and post any administration down the feeding tube and administering medications separately with small flushes in-between will help to prevent blocking.

2.14 Dislodged feeding tube If a gastrostomy (feeding) tube has become dislodged the site can close over within one to two hours. During working hours contact the nutrition nurse or dietitian immediately. Some patients will have been provided with ENplugs. These are stoma plugs which if they are able to be inserted will prevent the stoma tract from closing over. The patient will have been provided with instructions on what to do in the event of this happening.

See Appendix 4 If the tube is the patients only means of diet and fluids and it is outside of normal working hours of Monday to Friday the patient will need to attend A&E.

2.15 End of procedure Discard all equipment in line with trust policy, Wash / decontaminate hands post procedure, Document care carried out in the patient’s record.

Ensures compliance with IC2 Hand

decontamination policy and procedure

and IC3 Standard (universal) infection

control precautions policy.






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3. Changing the water of a balloon gastrostomy tube It is important that you check the volume of balloon inflation every seven to ten days to make sure that there is enough water in the balloon to keep it in the correct position. List of equipment required: Wound care pack with apron and gloves Saline if required for site cleansing Water for injection / sterile water ampoule Filter needle (if required) 2x luer slip syringes (10ml) Sharps disposal bin (If required) 3.1 Procedure

Check patient identity. Explain procedure to the patient. Ensure that valid consent is gained.

If patient unable to consent, record procedure as ‘best interest’ in health care records.

Ensure that the working area is as clean as possible. Ensure that all equipment is gathered before commencing the procedure and all packaging is intact and within expiry date Wash hands prior to the procedure and open sterile dressing pack, apply apron and gloves.

To minimise risk of infection and ensures compliance with IC2 Hand decontamination standard operating procedure and IC3 Standard (universal) infection control precautions policy

Open one of the syringes. Fill the syringe with the correct amount of sterile water. Lay this on sterile area. Open the 2nd syringe Luer slip syringe:

It is recommended that plastic ampoules are used. If using glass ampoules a filter needle will be required and a sharps bin for disposal. The amount of water required will depend on the brand and size of the tube. It is usually printed on the balloon inflation value or on the tube. It should also be recorded in the patient’s home enteral tube feeding pack. If there is any uncertainty please contact the nutrition nurse or dietitian.

Identify type of tube

For balloon retained gastrostomy tubes: Observe the centimeter (CM) measurement on the tube where it exists from the abdomen. Hold the tube with two fingers under the external fixator/disk and move the external fixator/disk away from the abdomen with the other hand. Gently push the tube into the stomach by 2-4 CM. Hold the gastrostomy tube in pace, you may ask the patient to secure it with their hand or use surgical tape to keep it in place. Attach the tip of the empty syringe to the balloon inflation valve on the gastrostomy tube.

This helps prevent the tube failing out accidentally whilst changing the water and helps prevent inflation of the balloon whilst in the stoma tract.







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Pull back on the syringe plunger until no more water can be removed. Discard the water and reinsert the syringe. Repeat the procedure to ensure all the water is drained out. Measure how much water has come out of the balloon. To re-inflate the balloons attach the tip of the syringe containing the fresh sterile water onto the balloon inflation valve. Continue to hold the gastrostomy tube in place Push the plunger in and re-inflate the balloon. Remove the syringe and discard it.

Pull back gently on the tube until resistance is met, check that the cm measurement at the abdomen is correct and reposition the fixation device 2-3mm away from abdomen. Document how much water was removed and how much water was used to re-inflate the balloon and date and time of procedure.

Note: there will be some natural wastage of water. Regardless of how much water is removed always replace with the required volume of the tube. If you are uncertain or there is more than 2ml loss from the balloon please contact the nutrition nurse or dietitian immediately.

If you are withdrawing more water than previously documented the balloon integrity may be compromised. The water may also be cloudy. If you can’t draw any water out of the balloon,

Ensure that clamp (if present) is open.

Ensure that the syringe is firmly attached to valve port and that you are using a luer slip syringe.

If you experience either of the above, secure the tube with tape, and contact the nutrition nurse or dietitian immediately

For low profile device: Hold the device in place Attach the tip of the empty syringe to the balloon inflation valve on the gastrostomy tube. Pull back on the syringe plunger until no more water can be removed. Discard the water and reinsert the syringe. Repeat the procedure to ensure all the water is drained out. Measure how much water has come out of the balloon. To re-inflate the balloons attach the tip of the syringe containing the fresh sterile water onto the balloon inflation valve. Continue to hold the gastrostomy tube in place Push the plunger in and re-inflate the balloon. Remove the syringe and discard it. Document how much water was removed and how much water was used to re-inflate the balloon and date and time of procedure.

When the procedure is complete, remove gloves and apron, dispose of waste and wash hands. Document care carried out in the patient’s record.

Ensures compliance with IC2 Hand decontamination policy and procedure, IC3 Standard universal infection control precautions policy and HS1 Waste management policy








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4. Administering medications via an artificial feeding tube List of equipment required: PPE: Gloves and apron 60ml enteral ENfit syringes Smaller volume ENfit syringes (if required) Medicine pot’s (if required) Freshly drawn tap water (or cool boiled water if advised) Towel to cover the patient CE marked pH strips (if using a Nasogastric tube) If administering medications via a naso-gastric (NG) tube please see section 4: Setting up enteral/bolus feeds. Before using the NG tube a gastric aspirate must be obtained and must be within the safe range before administering fluid and medication. The CM marker at the nose must also be checked and the back of the patients mouth for tube coiling. 4.1 Procedure

Check patient identity. Explain procedure to the patient. Ensure that valid consent is gained.

When a patient is unable to consent to treatment, medicines can be prescribed for them and administered in their best interest under the Mental Capacity Act. This should be clearly documented in their health record. Please refer to MP1 Medicines Policy.

Check method for which each drug has been prescribed (e.g. via feeding tube / orally) as per Patient Medication Administration Chart. Check that the method of administration (e.g. crush tablet) is clearly documented by prescriber.

Administration of drugs via a feeding tube, opening capsules and crushing tablets will generally place a drug outside of the marketing authorisation. The prescriber must state method of drug administration e.g. crush tablet and administer via feeding tube. A non-prescriber cannot legally administer an unlicensed drug if directions such as these are not provided. NB some drugs are not suitable for administration via a feeding tube. If in doubt, check with Medicines Information on 0151 794 8113.

Stop the feed (if applicable). Check if a break from feeding is required prior to medication administration. Ensure patient is positioned correctly prior to medication administration to reduce the risk of aspiration (at least a 30 degree angle if in bed, or sitting out in chair), whilst maintaining patients comfort and dignity.

Some drugs will interact with the enteral feed and a break from feeding may be required to reduce this. This should be clearly documented on the drug prescription or enteral feeding regimen. If in doubt, check with Medicines Information.

Wash hands prior to the procedure. Ensure that the working area is as clean as possible. Ensure that all equipment is gathered before commencing the procedure and all packaging is intact and in date. Maintain a clean procedure technique. Apply apron and gloves.

Ensures compliance with IC2 Hand decontamination policy and procedure and IC3 Standard (universal)l infection control precautions policy








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Measure out and prepare all medications separately in enteral syringes of appropriate size (if supplied) or in separate medicine pots. Each medication may require a different form of preparation, for example ‘crush and mix with water’. This should be clearly stated on the pharmacy label and Patient Medication Administration Chart.

This also allows you to know which medications have been administered, should there be any incidences of tube blockage. Medicines can be incompatible with each other, if in doubt seek further advice from medicines information.

Clamp tube (if applicable) Open cap of feeding tube or medicine port on giving set. Flush the feeding tube with a minimum of 30mls of water using a 60ml syringe.

To ensure tube patency Check patients feeding regimen for how much water should be administered. N.B. ensure the patient is not on a fluid restriction – flushes may need to be reduced in this case. Check with patients GP, nutrition nurse / dietitian if unsure.

Administer each medication separately via the feeding tube / giving set using an enteral syringe with the plunger attached. Flush with a maximum of 30mls of water between each medication. If provided a clamp may be used to prevent leakage during the procedure. If separate medicine syringes have not been provided, the syringe being used must be washed between each medication. Medications can clump together once dissolved. The syringe may need to be continuously agitated during the administration to prevent tube blockage.

This will prevent medicines interacting with each other in the enteral feeding tube and will reduce the incidence of tube blockage.

Flush the feeding tube with a minimum of 30mls of water after the last medication is given. A push-pause technique can also be used; this creates turbulence within the tube removing the build-up of feed and medication.

Close the cap on the feeding tube or restart feed if applicable. Unclamp tube when not in use.

Remove apron and gloves, discard all equipment and wash hands. Document all medications administered.

Ensures compliance with IC2 Hand decontamination policy and procedure, IC3 Standard universal infection control precautions policy and HS1 Waste management policy. Medication document as per MP1 Medicines Policy.









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5. Setting up and administering artificial nutrition via the Abbott FreeGo pump and a bolus. List of equipment required: PPE: Gloves and apron 60ml enteral ENfit syringes Freshly drawn tap water (or cool boiled water if advised) Abbott FreeGo enteral feeding set (giving set) Prescribed artificial nutrition CE marked pH strips (If using a Nasogastric tube) Clean jug (if required) Towel to cover the patient 5.1 Procedure

Explain the procedure to the patient.

Ensure consent is obtained prior to

commencing procedure.

If patient unable to consent, record procedure as ‘best interest’ in health care records. When a patient is unable to consent to treatment, artificial nutrition can be prescribed for them and administered in their best interest under the Mental Capacity Act. This should be clearly documented in their health record. Please refer to MP1 Medicines Policy.

Ensure the patient is positioned correctly prior to setting up the artificial nutrition (at least a 30 degree angle if in bed, or sitting out in chair), whilst maintaining patients comfort and dignity. If a pause in feeding administration is required, for example to carry out personal care the patient must remain at 30 degrees for 30 minutes if they are required to lie flat.

To reduce the risk of aspiration during feeding

Wash hands, apply apron and gloves.

To minimise the risk of infection / contamination. Ensures compliance with IC2 Hand decontamination policy and procedure and IC3 Standard universal infection control precautions policy.

FOR NASOGASTRIC TUBES (NG Tube) ONLY. You must confirm the position of the NG tube prior to flushing the tube and setting up the artificial nutrition by withdrawing gastric aspirate and testing its pH. Document this in the patients’ records.

If pH of aspirate is 6.0 or above, or no aspirate obtained, refer to the flow chart in the patient’s home enteral tube feeding pack. If the problem persists, contact the nutrition nurse or dietitian.

PH indicator strips must be used and must be CE marked for testing aspirate of human origin. Please ensure that pH strips are within their expiry









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The gastric aspirate must be pH 5.5 or below. The CM marking at nose must be checked and recorded and you must check for coiling at the back of the patient’s mouth. Only move to step 4.5 if position of feeding tube is confirmed in correct place.

date.

Please note for nasojejunal tubes: Only the cm marking at the nostril and coiling at the back of the mouth is observed and pH is not taken.

FOR CONTINUOUS (PUMP) FEEDING FOLLOW STEPS 5.2

FOR BOLUS FEEDING FOLLOW STEPS 5.3 ONWARDS


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5.2 Continuous (pump) feeding

If not already set up attach the feeding pump to the stand and ensure firmly secured. Plug in the FreeGo pump and turn it on. Carry out the appropriate safety checks of patient’s immediate environment. Collect all necessary equipment required to set up feed (see above). Ensure correct feed is chosen using the patients’ nutritional plan / regimen for reference.

A mains plug icon and LED light should be visible when plugged into the mains Any issues with the function of the pump please contact Abbott hospital2home service directly 0800 0183 799.

Only run the pump off the battery when it is not possible to attach to the power supply, and plug back in as soon as possible.

Open the giving set from its packaging, ensuring it is in date, remove the paper strip and uncurl. Ensure the end of the giving set does not come in to contact with any surfaces.

To prevent contamination and risk of infection. There is no requirement to label the giving set with the time/date opened. A newly opened giving set should be used every day and for a maximum of 24 hours.

Select the bottle of artificial nutrition as per patient’s nutritional plan / regimen and ensure it is in date and a clean technique is used as shown on right.

To prevent contamination of feed and minimise risk of infection: Each bottle of feed should not be hung for longer than 24 hours.


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Gently shake the container. To attach the giving set to the bottle of feed, unscrew the white cap and discard. Screw the giving set onto the top of the bottle and hang upside down from the drip stand.

If using a flexitainer for administration of water,

open new flexitainer from packaging and

decant the required amount into the flexitainer.

Attach to the giving set and hang from drip

stand.

This may be required if patient has high additional fluid requirements or if more specialised feed required.

It is not recommended that feed is decanted into flexitainers and administered unless instructed to do so by the nutrition nurse / dietitian.

Load the giving set into the pump: Open the door on the pump. Grasp the lilac cassette body on the feeding set and loop the pump insert around rotor stretching lightly. Gently pull down and then seat the lilac cassette into the pump.


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Gently press the tubing to ensure it is fully seated in slots below the cassette. Close the door firmly.

If required: using the patient’s nutritional plan / regimen for guidance set the rate and dose/total volume of feed on the FreeGo feeding pump. Turn pump dial to set rate. Select flow rate by pressing the up or down arrows. Keeping an arrow depressed will cause the scroll rate to increase. Only set the rate that is specified on the patient’s nutritional plan. To set dose – turn dial to SET DOSE. Programme desired dose by using the Up or Down arrows. If your clinician tells you not to set a dose, depress the Down arrow until INF DOSE is displayed (will feed until the container is empty)

If there is any doubt regarding the rate or dosage of feed, contact either the dietitian or nutrition nurse. The Rate and dose will only need to be set once and will be retained by the pumps memory. You may be required to change this if instructed by the dietitian.

AUTO PRIME THE SET: Use the prime button. Turn pump dial to SET RATE or SET DOSE. Press and hold the Prime Button for two seconds then release. “PRIMING” will be displayed. Auto priming will


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stop when the priming volume has been reached.

Once the feeding tube has been flushed connect the end of the giving set to the feeding tube and commence feed by turning dial on pump to RUN. Four drop icons will scroll in the lower right hand corner of the display while feed is running. Do not attach the giving set too tightly to the feeding tube. It is a locking mechanism, attach gently until slight resistance felt.

Flush the feeding tube as per patient’s nutritional plan / regimen before and after feeding administration to maintain tube patency. Ensure both the ends of the giving set / feeding tube do not come in to contact with any surfaces whilst connecting the two together to prevent contamination and minimise risk of infection.

Document in patient’s record: Feed/ water administered. pH obtained, CM at nose and observe for

coiling at the back of the throat (if applicable).

Remove gloves and apron. Ensure all waste is disposed of as per local policy and wash hands.

Ensures compliance with IC2 Hand decontamination policy and procedure and IC3 Standard universal infection control precautions policy

When the pump has completed the cycle. Turn the dial to clear, wait 5 seconds then turn the dial to off.

Open pump door and remove giving set. Dispose as per local policy and wash hands.


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https://www.google.com/imgres?imgurl=x-raw-image:///33aaba066e6b9afcbaf5d5519f503cb96f974a970ba7c09170754c84dcbdeb85&imgrefurl=https://www.abbottnutrition.ie/downloads/ENFit_NPSA_connection_poster_pdf_670KB.pdf&docid=043Au-d1_K8J7M&tbnid=_Jprbga6qjM6fM:&vet=10ahUKEwiN7uDsx4fkAhUjpnEKHd3DD3cQMwiaASg-MD4..i&w=402&h=382&safe=strict&bih=1243&biw=2560&q=abbott%20enfit%20giving%20set&ved=0ahUKEwiN7uDsx4fkAhUjpnEKHd3DD3cQMwiaASg-MD4&iact=mrc&uact=8






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5.3 Bolus feeding (without using a pump)

Flush the feeding tube with the recommended amount of water.

Check the expiry date and open the feed container. It may be necessary to decant into a clean jug (this will make it easier to pour). It may be appropriate to place a towel on the patients lap in case of any spillage.

Example feed used for boluses

Remove the internal purple plunger from the 60 ml syringe and attach the syringe to the feeding tube. Unclamp the tube (if applicable). Pour the artificial feed into the syringe to administer via gravity. Continue to administer until the prescribed amount has been given.

Hold the syringe at a height which is comfortable for you and allow feed to flow freely. If you hold the syringe at a lower height this will slow the feeding rate. Bolus feeding should take between 15-20 minutes.

When the feed is finished, clamp the tube (if applicable), remove the empty syringe and then flush with the tube with the recommended volume of water. This is very important - to clear the tube of the feed and helps to prevent it from blocking.

After flushing the tube: - remove the syringe - put the cap back on the feeding tube - undo the clamp (if applicable).

Remove gloves and apron, ensure all waste is disposed of as per local policy and wash hands.

Ensures compliance with IC2 Hand decontamination policy and procedure, IC3 Standard universal infection control precautions policy and HS1 Waste management policy








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6. Contact details If you require any help or advice regarding patients who have an Enteral feeding tube please contact: Community Dietitian 01244 366581 07770 332048 Community Nutrition Nurse 07964122954 Nutrition Nurse COCH 01244 362384 Abbott Nurse 07977911195 Abbott Hospital2Home 0800 0183799


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Appendix 1 – Replacement of CORFLO PEG Adaptor

In the event that your CORFLO Y adaptor (PEG end) becomes damaged it can easily be easily

replaced. We recommend you only replace it if it is broken or becoming difficult to feed through over

time. To preserve the life of your CORFLO PEG end always lock any syringes or giving sets gently in

place, they only need one gently twist to secure them until resistance is felt, the same when you are

closing your PEG ends after use. Clean the outside of your tube daily with warm soapy water and dry

the tube. Flush the tube daily as directed by your Dietitian/ Nutrition nurse.

1. Prepare the new PEG end, gently close both ports and untwist the skirt so it is in two pieces.

2. Turning to the patient, ensure the clamp is closed and cover the patient/area with paper towels.

3. Untwist the skirt on the old PEG end attached to the tube and move it up the tube towards the

patient. Holding the tube firmly in one hand pull out the adaptor end from the PEG tube. When

this has been pulled out you will be able to remove the old skirt.

If you are unable to do step 3 because the PEG end has snapped in such a way the skirt cannot

be untwisted or is fixed onto the tube too tight you may cut the tube as close to the old PEG end as

possible. Please note cutting the tube is a last resort as it shortens the life of the tube. If the

connection is loose or the tube end is stretched you may need to trim off 0.5-1cm of tube length.

4. Once the old PEG end is completely removed, apply the new skirt to the tube, with the

threaded end away from the patient then insert the second part of the PEG end on to the tube,

making sure the tube goes over the barb and reaches the tube stop at the bottom end of the

threaded portion (see diagram).

5. Move the skirt down towards the end of the tube and twist it onto the PEG end. It does not

need to be twisted to too tight as this will be difficult to remove next time.

To replace the PEG end you will need:

Appropriate size Corflo PEG adaptor

Repair KIT: 12FR, 16FR or 20FR, this

information should be in the patients

care notes.

Paper towel to cover patient and the

working area

Gloves / apron

Scissors (if required)


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Appendix 2 – Replacement of FREKA PEG Connector

In the event that your FREKA PEG ENFit connector (PEG end) becomes damaged it can be easily

replaced. We recommend you only replace it if it is broken or becoming difficult to feed through over

time. To preserve the life of your FREKA PEG end always lock any syringes or giving gently in place,

they only need one gently twist to secure them until resistance is felt, the same when you are closing

your PEG ends after use. Clean the outside of your tube daily with warm soapy water and dry the

tube. Flush the tube daily as directed by your Dietitian/Nutrition nurse.

To replace the Peg end you will need:

Appropriate size FREKA connector PEG

Repair KIT: 9FR, 15FR or 20FR, this

information should be in the patients care

notes.

Paper towel to cover patient and the

working area

Gloves / apron

Scissors (if required)

A. Ensure the clamp is closed and cover the

patient/area with paper towels.

B. To remove the old PEG end: detach the outer

white ring from the new PEG end and attach the

white ring to the hexagonal fixing screw of the

old/current end of the tube.

C. Unscrew the old hexagonal fixing screw

D. The old PEG end should now be in two parts,

holding the tube firmly in one hand pull of the pin

section (C) and (D) should slide off. If the

connection is loose or the tube end is stretched

you may need to trim off 0.5-1cm of tube length.

E. to attach new PEG end replace the outer

white ring back on to the hexagonal fixing screw

on the new end and slide onto the tube.

F. Push the pin with adaptor into the tube. If the

connection is loose or the tube end is stretched

trim off 0.5-1cm of tube length. Slide the fixing

screw towards the adaptor and screw together

using the outer white ring.

G. Remove the outer white ring and close the

tube end.


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Appendix 3 – Guidance on inserting ENPLUGTM

You have been issued with a pack of EN-Plugs to place in your stoma tract should your

gastrostomy

tube come out.

Your stoma tract will begin to close when your gastrostomy tube comes out. It is likely to heal

over completely in around 1 hour.

If your gastrostomy tube should come out, please

stay calm and follow the steps below.

Please call your nutrition nurse as soon as possible,

preferably after following the below steps.

Your gastrostomy size is: ………………….. Initial ENplug colour:……………………………..

Guide to EN-Plug insertion:

The first EN-Plug that you attempt to insert should be the same size as the current gastrostomy

(see above)

Gently try to insert the tapered tip into the existing tract (use water based lubrication provided)

If the stoma has already begun to close, and you are unable to insert this size, please try to

insert the next size down. DO NOT insert with excessive pressure

Once you have placed your EN-Plug, tape it in place to prevent it coming out, and telephone

your Nutrition Nurse.


standard operating procedure for enteral tube feeding

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