Enteral Tube Feeding Policy - RDaSH NHS Foundation Trust · enteral feeding tubes 3 SCOPE The...

DOCUMENT CONTROL:

Version: 2.2

Ratified by: Covid-19 Gold Command

Date ratified: 7 April 2020

Name of originator/author: Dietetic Service Lead and Clinical Practice Educator

Name of responsible committee/individual:

Executive Director of Nursing and Allied Health Professionals

Unique Reference Number: 385

Date issued: 30 April 2020

Review date: March 2021

Target Audience All staff within the Trust (in-patient/community/day services/care homes) who care for adults with an enteral feeding tube

Description of Changes: Due to the Covid-19 Pandemic Gold Command agreed a review extension from October 2020 to March 2021

Enteral Tube Feeding Policy

(Adults)

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Section

CONTENTS

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1 INTRODUCTION 5

2. PURPOSE 5

2.1 Definitions 5

3 SCOPE 6

4 RESPONSIBITIES, ACCOUNTABILITES AND DUTIES 6

4.1 Care Group Directors 6

4.2 Clinical Leads/Service Managers/Modern Matrons 6

4.3 All Clinical Staff 7

4.4 Dietitians 7

4.5 Speech and Language Therapist 7

4.6 The Nutricia Nursing Service 7

5 PROCEDURE/IMPLEMENTATION 8

5.1 Indications for Enteral Feeding 8

5.2 Consent 9

5.3 Types of Enteral Feeding Tubes 9

5.3.1 Percutaneous Endoscopic Gastrostomy (PEG) Tube 9

5.3.2 Button Gastrostomy/Low Profile Feeding Device (LPFD) 9

5.3.3 Balloon Gastrostomy Tube (BGT) 10

5.3.4 Percutaneous Endoscopic Jejunostomy (PEJ) 10

5.3.5 Radiologically Inserted Gastrostomy (RIG) 10

5.4 Methods of Delivery 10

5.4.1 Infusion (Feed Delivered by Pump) 11

5.4.2 Bolus Feeding (Without Pump) 11

5.5 Types of Feed 11

5.6 Re-Feeding Syndrome 12

5.7 Infection Prevention and Control Precautions 12

5.7.1 Hand Hygiene 13

5.7.2 Personal Protective Equipment 13

5.7.3 Aseptic Technique 13

5.7.4 Preparation and Storage of Feeds 14

5.7.5 Administration of Feeds 14

5.7.6 Syringes 14

5.7.7 Care of Insertion and Enteral Feeding Tube 15

5.7.8 Mouth Care 15

5.7.9 Education of Patients, Carers and Healthcare workers 16

5.8 Stoma Skin Care 16

5.8.1 Peri-Stomal Skin Assessment General Principles 16

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Section

CONTENTS

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5.8.2 Peri-Stomal Skin Management 16

5.8.3 Cleansing of Peri-Stomal Skin 17

5.9 Administration of Medicines Via Enteral Tubes 17

5.9.1 Legal and Professional Issues 17

5.9.2 General Considerations 18

5.9.3 Preferred Formulations 18

5.9.4 Crushing Tablets 19

5.9.5 Enteric Coated Tablets 19

5.9.6 Modified Release Tablets 19

5.9.7 Buccal or Sublingual tablets 20

5.9.8 Tablets that maybe toxic when crushed 20

5.9.9 Known Problems with Administration of Medicines via Enteral Tubes

20

5.9.10 Medicines which need to be administered on an empty stomach

22

5.9.11 Administration via Enteral Feeding Tubes: Procedure 22

5.10 PEG 22

5.10.1 Care of PEG Following Placement 22

5.10.2 Immediate Post Placement Care (up to 14 days) 23

5.10.3 Daily Care of PEG Tube 23

5.10.4 Additional Information on PEG 24

5.11 Balloon Gastrostomy Tube (BGT) 24

5.11.1 Daily Care of Balloon Gastrostomy Tube (BGT) 24

5.11.2 Checking Water in BGT 25

5.12 Low Profile Feeding Device (LPFD)/ Button 25

5.12.1 Daily Care of Button 25

5.12.2 Checking Water in Button 26

5.13 Checking Placement of BGT/Button by pH Measurement 26

5.14 Flushing the Feeding Tube 27

5.15 Feeding Pump Instructions 28

5.16 Bolus Feeding 29

5.17 Emergency Enteral Feeding Regimen 30

5.18 Troubleshooting 30

5.18.1 The Tube Becomes Blocked 30

5.18.2 Accidental Tube Removal 30

5.19 Discharge Planning for Community 31

6 TRAINING IMPLICATIONS 31

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Section

CONTENTS

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7 MONITORING ARRANGEMENTS 32

8 EQUALITY IMPACT ASSESSMENT SCREENING 32

8.1 Privacy, Dignity and Respect 32

8.2 Mental Capacity Act 32

9 LINKS TO ANY ASSOCIATED DOCUMENTS 33

10 REFERENCES 33

11 APPENDICIES 33

Appendix 1 Definitions 34

Appendix 2 Contact Details – Patients/Carers 35

Appendix 3 Emergency Enteral Feeding Regime for Adults 36

Appendix 4 Medication Advice 38

Appendix 5 Troubleshooting 44

Administration of Medicines Via Enteral Tubes - Further Information

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1 INTRODUCTION Enteral tube feeding involves the administration of nutrients and fluids via a tube into the stomach, duodenum or jejunum. It is used for adults or children who are unable to take adequate food/ fluid orally due to dysphagia or malnutrition. It can only be used if there is a functioning and accessible gastrointestinal tract. The aim of the policy is to ensure that all patients receive a high standard of evidence-based care after placement of a tube. This policy provides information on Percutaneous Endoscopic Gastrostomies (PEG) but also other feeding tube such as Low Profile Feeding Device (LPFD)/Buttons and Balloon Gastrostomy Tubes (BGT). The policy excludes naso-gastric (NG) and naso-jejunal (NJ) tubes.

2 PURPOSE 2.1 Definitions

This policy is intended to enable the safe and effective management and care of patients who have an enteral feeding tube and to reduce risk to the Trust to the lowest level possible. In respect of enteral feeding and infection prevention and control, the aim is to:-

Reduce the risk of infection associated with enteral tube feeding

Reduce the risk of microbial contamination in everyday practice and to ensure there is a managed environment that minimises the risk of infection to patients, carers and visitors

Direct staff on the management of patients who have enteral tube feed

Ensure the Trust complies with the requirements of the Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance

Comply with NICE (2012) clinical guidance on enteral feeding Care of the peri-stomal skin, the aim is to:-

Set out a framework for the management of peri-stomal skin based on the evidence of current best practice

Maintain a standardised approach to peri-stomal skin care

Lower the incidence of resistance of infections, requiring hospital admission

Ensure no act or omission on the nurses part leads to inappropriate management of peri-stomal skin

Ensure that continuity of care takes place where different nurses may be called upon to meet the needs of the patient

Ensure that the appropriate skin care product is utilized for optimum

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peri-stomal skin care and patient comfort

Administration of medicines via enteral tubes, the aim is to:-

Provide guidance for those who administer medications via enteral feeding tubes based on the evidence of current best practice

Ensure a holistic and standardised approach to the management of patients with an enteral feeding tube

Ensure that no act or omission on the health professional’s part leads to inappropriate management of this group of patients

Reduce the risk of harm to patients

Ensure that continuity of care takes place where different people may be called upon to meet the needs of the patient

Advice and Troubleshooting, the aim is to:-

Provide guidance and advice on how to perform procedures and manage common problems associated with care of patients with enteral feeding tubes

3 SCOPE

The policy applies to all staff across the Trust who care for adults with an enteral feeding tube. The Rotherham Care Group would not be the direct care provider in relation to enteral feeding, if a patient is admitted to an inpatient ward appropriate professional advice should be sought.

4 RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1 Care Group Directors

The implementation of all policies and procedures which are in place to meet the needs of patients

Monitoring adherence to this and other related policies

The provision of adequate resources and training being available to the clinical teams

Monitoring staff compliance with training as set out in the mandatory Risk Management Training Policy and Mandatory Risk Management Training Needs Analysis Matrix

The development, implementation and monitoring of effective systems of supervision of clinical staff

4.2 Clinical Leads/Service Managers/Modern Matrons

The dissemination of this policy to their staff

Highlighting the training needs of their staff in relation to this policy

Releasing staff to attend for training

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Supporting staff who care for patients with an enteral tube

Monitor compliance with this policy and take immediate action when non-compliance is identified

4.3 All Clinical Staff

All staff involved in the care of patients outlined within this policy should be aware of and adhere to the procedures outlined. All staff should be up to date with their knowledge and skills and maintain competency by attending relevant training as identified within the policy.

4.4 Dietitians

Estimation of nutritional requirements and current nutritional intake

Advice on the appropriateness of enteral feeding considering medical condition, prognosis and practical circumstances

Advising on an appropriate feeding regimen to meet nutritional requirements tailored to social circumstances

Registration of the patient with Homeward (the contracted Home Enteral Feeding Company) to arrange initial feeding equipment and ancillaries. To request feed prescriptions from the GP

Provide on-going monitoring of nutritional state and tolerance making any necessary amendments to enteral feed prescription or regimen

Arranging training for nursing staff/ carers/ family members to prepare for and support discharge

4.5 Speech and Language Therapist

Assessment of dysphagia

Provision of advice on the appropriateness of enteral feeding with regards to dysphagia

Monitoring of dysphagia whilst the patient is being fed enterally

Advice on oral intake/ tasters for patients who are on long term enteral feed

4.6 The Nutricia Nursing Service

Training of patients and carers on the practical aspects of home enteral feeding

Troubleshooting for problems relating to enteral feeding

Routine changes of BGTs and buttons

Nutricia have their own Training Policies and Procedures but will work to RDaSH policy

Work office hours Monday to Friday. Outside these hours staff need to contact A&E DBHFT with any immediate concerns

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5 PROCEDURE/IMPLEMENTATION 5.1 Indications for Enteral Feeding

Whenever possible, oral food intake is always preferred. Enteral feeding is only necessary/desirable when a patient’s nutritional needs cannot be met orally, for example in:

Food/fluid refusal or hunger strike

Psychiatric conditions e.g. anorexia nervosa, severe depression

Neurological problems, when energy requirements may be increased e.g. Huntington’s disease

Swallowing disorders (dysphagia)

Stroke or head injury

Head and neck cancer

GI dysfunction or mal-absorption

Upper GI obstructions

Specific treatments, e.g. Crohns disease Indications for enteral feeding in patients with a functional and accessible gastrointestinal tract but inadequate oral intake are:

Patient has eaten little or nothing > 5 days, and/or is likely to eat little or nothing for the next 5 days or longer

Unintentional weight loss >10% within the previous 3 to 6 months

BMI<18.5 kg/m2

BMI<20 kg/m2 and unintentional weight loss >5% within the previous 3 to 6 months.

Patient has poor absorptive capacity, is catabolic and/or has high nutrient losses

Patient with weight loss consistent with the above AND who lacks the mental capacity to make an informed decision in respect of food/fluid intake

AND/OR

Patient detained under the Mental Health Act 1983 whose refusal to refuse food/fluids is linked to her/his mental disorder

The decision to place a feeding tube should be made by the Multi-Disciplinary Team (MDT). Nutritional support is not always appropriate. Prior to referring any patient for tube placement refer to the Trust guidance on the Mental Capacity Act and be aware of any patient with an Advance Decision to Refuse Treatment. Enteral feeding tubes may be placed at DBHFT or at other trusts. Often patients with respiratory difficulties e.g. those with Motor Neurone Disease (MND) will have a radiologically inserted gastrostomy (RIG) placed in Sheffield as this does not require an endoscopic procedure (see 5.3.5)

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5.2 Consent

It is a general, legal and ethical principle that valid consent must be obtained before providing care and/or treatment to a patient. This principle reflects the right of patients to determine what happens to their own bodies and is a fundamental part of good practice. Before any treatment is given staff should ensure they have obtained valid consent from the patient. Where the patient lacks capacity to give valid consent a decision to treat will need to be made in the persons best interests, unless it is being provided under the provisions of the Mental Health Act 1983. For further guidance around consent staff should refer to the Trust Consent to Care and Treatment and Mental Capacity Act Policies.

5.3 Types of Enteral Feeding Tubes

Clinical staff must be aware of the type of enteral feeding tube that their patient has to ensure correct procedures are followed.

5.3.1 Percutaneous Endoscopic Gastrostomy (PEG) Tube

A Percutaneous Endoscopic Gastrostomy (PEG) is placed using an endoscope. It is a feeding tube approximately 12 inches long which passes through the abdominal wall directly into the stomach and is held in place with an air filled bumper. An external fixation device sits flush with the skin to hold the tube in place. It is intended for long term feeding (Manufacturers recommend they last for 2 years). It is usually the first tube placed.

5.3.2 Button Gastrostomy/Low Profile Feeding Device (LPFD)

An LPFD or button passes through the abdominal wall directly into the stomach and is held in place with a water filled balloon. The balloon requires weekly inflation with water and checking of placement with pH paper. The button attaches to a right angled extension set for pump feeding or a shorter bolus feeding/ decompression set for bolus feeding. These attachments twist and lock into place. It can be used as a replacement tube (after 12 weeks) as it does not require endoscopic placement. The LPFD (button) requires replacing every 3-4 months. These tubes are predominantly used for more active patients. They have a neater appearance and are less likely to become entangled in clothing. They are often therefore chosen for patients who may be at risk of pulling tube out. In this instance PEG protectors can be provided. MIC-KEY and AMT mini buttons are brand names of buttons.

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5.3.3 Balloon Gastrostomy Tube (BGT)

A BGT is a low profile skin level device which passes through the abdominal wall directly into the stomach and is held in place with a water filled balloon. This is the main type of replacement device used in the Trust. A PEG may be changed to a BGT after 12 weeks although if the tube becomes displaced a doctor can place a BGT at 4-6 weeks and does not require an endoscopy. The BGT needs replacing every 3- 4 months. The balloon requires inflating with cool boiled or sterile water every week & placement checking with pH paper.

5.3.4 Percutaneous Endoscopic Jejunostomy (PEJ)

This is a feeding tube inserted through the abdominal wall into the jejunum. These are secured in place in theatre with internal and external sutures. A PEJ tube is passed through the PEG tube into the jejunum. This extension tube is narrow and prone to blocking. If this happens it will need to be changed.

5.3.5 Radiologically Inserted Gastrostomy (RIG)

This is a feeding tube inserted through the skin directly into the stomach under x ray screening. They are usually removed after 3 months and replaced with an alternative feeding tube e.g. BGT, LPFD. RIGs are usually placed in patients with respiratory problems e.g. MND as they do not require an endoscope to be passed. The route and type of tube used will depend on the individual circumstances of the patient. Due to the method of initial placement the first type of tube is a PEG which is placed endoscopically. Subsequent replacement tubes e.g. BGT or button/ LPFD can be placed in an existing tract after 12 weeks. They do not require endoscopic placement but do need replacing every 3 – 4 months. At present The Emergency Care Practitioners (ECPs) or Nutricia Nurse carry out routine changes and emergency replacements as required.

5.4 Methods of Delivery

The Dietitian, in consultation with doctors and other health professionals, will decide on the feed type and method of delivery. Factors to be considered are:

Patient’s current and past nutritional status

Feeding environment

Reason for feeding enterally

Proposed time period of enteral feeding

Any complications present

Patient wishes and their social situation (consider who will administer feeds)

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A written regimen specifying feed type, rate of feeding, and additional water flushes will be provided by the Dietitian.

5.4.1 Infusion (Feed Delivered by Pump)

The use of a pump allows close control of the rate of delivery of the feed

A pump can be set to deliver feed at a rate of between 5 and 500 mls per hour. Feeds are usually commenced at a low rate (typically 50 ml/hr) and increased in increments to approx. 100 to 150 ml/hour after tolerance is demonstrated

It can be delivered continuously, just overnight or just during the day. Overnight feeding can be used as a ‘top up’ for patients taking some oral diet.

By adjusting the rate tolerance can be improved in patients with delayed gastric emptying, reflux or nausea and vomiting. This can reduce aspiration risk

5.4.2 Bolus Feeding (Without Pump)

Bolus feeding involves the delivery of specified volumes of feed, typically 100mls to 300mls over a period of 10-30 minute.

It can be administered up to 6 times a day depending on the patient’s individual feeding regime

Administration can be with a syringe using only the barrel as a funnel to allow the feed to infuse using gravity. The plunger from the syringe should not be used to push feed through, although sometimes a small amount of pressure is needed to direct thicker feeds in

Bolus feeding can also be delivered using bolus feed gravity sets

For most patients bolus feeding is the preferred option

If there are any signs of intolerance then another feeding method should be considered

5.5 Types of Feed

A wide variety of feeds are available. Sterile packs or plastic bottles of feed are preferable to those that need decanting as there is less risk of contamination. The Dietitian will determine the most suitable feed depending on the individual needs of the patient. Packs are generally used for pump feeding, plastic bottles for bolus feeding. Feed should be stored in a cool dry place, off the floor and away from direct sunlight. Standard whole protein feeds include Nutrison/Nutrison multi-fibre and Nutrison energy/Nutrison energy multi-fibre. High energy feeds are useful when fluid is restricted or to reduce feeding time. Most feeds are lactose, gluten and wheat free, and suitable for vegetarians. People with diabetes are usually given standard formulas but should be monitored frequently.

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5.6 Re-Feeding Syndrome

Re-feeding syndrome may occur when severely malnourished patients are fed enteral. There is a rapid fall in serum levels of phosphate, magnesium and potassium, along with altered glucose tolerance and an increased extracellular fluid volume. The resulting complications can include: respiratory failure, cardiac failure, cardiac arrhythmias, muscle wasting, seizures and coma. Severely malnourished patients (see below) require vitamin/mineral supplements prior to feeding and cardiac monitoring, as per NICE guidance. They must be cared for by health professionals trained to deal with such cases. These patients will require close monitoring of the bloods. NICE (2006) criteria for determining patients at risk of re-feeding problems: Patient has one or more of the following:

BMI <16 kg/m2

Unintentional weight loss >15% within the last 3 to 6 months

Little or no nutritional intake for >10 days

Low levels of potassium, phosphate or magnesium prior to feeding Or patient has 2 or more of the following:

BMI <18.5 kg/m2

Unintentional weight loss >10% within the last 3-6 months

Little or no nutritional intake for > 5days

A history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics

If a patient is assessed at risk of re-feeding syndrome refer to the dietitian before commencing enteral feed. Psychological Implications should be acknowledged through individualised care planning. Any communication with patients and carers should be accessible and appropriate to their needs.

5.7 Infection Prevention and Control Precautions

Enteral feeding is a common practice for those in hospitals needing artificial nutritional support and for those in the community needing long-term feeding. The National Institute for Health and Care Excellence (NICE, 2012) found that 30% of feeds were contaminated with a variety of micro-organisms, largely due to the poor preparation or poor administration of feeds and this

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has been linked to serious clinical infection. The research found that the rates of contamination were highest in home settings. These infection prevention and control precautions will reduce the risks of infection and to support Trust staff to deliver safe, best practice for the benefits of patients.

5.7.1 Hand Hygiene

Hands must be decontaminated in the following circumstances:

Immediately before every episode of direct patient contact or care, including aseptic procedures

Immediately after every episode of direct patient contact or care

Immediately after any exposure to body fluids

Immediately after any other activity or contact with a patient’s surroundings that could potentially result in hands becoming contaminated

Immediately after removal of gloves Healthcare workers should ensure that their hands can be decontaminated throughout the duration of clinical work by:

Being bare below the elbows

Removing wrist and hand jewellery when delivering direct patient care

Making sure that fingernails are short, clean and free of nail polish

Covering cuts and abrasions with waterproof dressings. For further guidance refer to the Trust’s Hand Hygiene Policy

5.7.2 Personal Protective Equipment

Staff must wear personal protective equipment if there is a risk of exposure to blood, bodily fluids, when caring for patients with infections or if clothing/uniform may be contaminated by direct contact with the patient.

These may include gloves, aprons, masks and goggles/visors.

Gloves and aprons should be used as single use items. For further guidance refer to the Trust’s Standard Infection Prevention and Control Precautions Policy.

5.7.3 Aseptic Technique

Use minimal handling and an aseptic (non-touch) technique to connect the administration system to the enteral feeding tube.

The system selected should require minimal handling to assemble, and be compatible with the patient’s enteral feeding tube.

Sterile equipment should always be used.

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For further guidance refer to the Trust’s Aseptic Technique and Aseptic Non Touch Technique Policy

5.7.4 Preparation and Storage of Feeds

Wherever possible pre-packaged, ready-to-use feeds should be used in preference to feeds requiring decanting, reconstitution or dilution.

The system selected should require minimal handling to assemble, and be compatible with the patient's enteral feeding tube.

Effective hand decontamination must be carried out before starting feed preparation.

When decanting or diluting feeds, a clean working area should be prepared and equipment dedicated for enteral feed use only should be used.

Feeds should be stored in a cool dry place, off the floor and away from direct sunlight and according to manufacturer's instructions.

5.7.5 Administration of Feeds

Only remove stored, ready to use or pre-prepared feed from the fridge half an hour before administration to allow it to come to room temperature.

Hands must be washed and single use apron and gloves donned before handling the feed or feeding equipment.

Before administering any feed the expiry date must be checked on the packaging.

The risk of contamination is often related to the manipulation of the system.

Minimal handling and an aseptic no-touch technique should be used to connect the administration system to the enteral feeding tube. Ensuring that open connectors do not come into contact with any potential contaminants e.g. clothing, bed clothes or other equipment.

Ready-to-use feeds can be administered up to a maximum of 24 hours.

Administration sets and feed containers are for single use and must be discarded after each feeding session.

Dispose of all equipment according to trust policy. Tubing, empty bags/containers/ should be discarded as offensive waste (tiger stripe bag). Any medicinal products should be discarded into appropriate waste bags. For further guidance refer to the Trust’s Waste Management Policy.

Unused feeds can be flushed down the domestic drainage system. 5.7.6 Syringes

Single use syringes must not be reused. All syringes should be ENFit i.e. for enteral/oral use and not compatible with IV cannula ports

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In hospital, used oral/enteral syringes should be discarded after each episode of use. Reusable syringes must not be used in hospital settings.

Following discharge, reusable oral/enteral syringes may be used: one syringe per week or 30 uses as per manufacturer’s instructions Reusable ENFit enteral syringes must be washed and dried after every use in accordance with the manufacturers recommendations. In between usage the syringes must be stored in accordance with the manufacturer’s recommendations.

5.7.7 Care of Insertion and Enteral Feeding Tube

There are a variety of feeding tubes available with differing care requirements. Follow manufacturers’ guidelines for care of the enteral feeding tube.

To prevent blockages, flush the enteral feeding tube before and after feeding or administering medications using single-patient-use (reusable) syringes according to the manufacturer’s instructions. Use: freshly drawn tap water for patients who are not immunosuppressed either cooled freshly boiled water or sterile water from a freshly opened container for patients who are immunosuppressed. In hospital sterile water should be used.

To prevent blockage, the enteral feeding tube should be flushed with water before and after feeding or administering medications. In hospital sterile water should be used. In a patient’s own home cool boiled water can be used.

Enteral feeding tubes for patients who are immunosuppressed should be flushed with either cooled freshly boiled water or sterile water from a freshly opened container. In hospital sterile water should be used. In a patient’s own home fresh cooled freshly boiled water can be used.

Sterile water or cooled boiled water should be used to inflate the balloon on buttons and gastrostomy tubes. It should be changed weekly using a no touch technique.

Where tubes have become accidentally dislodged, the removed tube should be discarded as offensive waste (tiger stripe bag) – faulty batches of tubes should be sent back to the manufacturer and an IR1completed.

5.7.8 Mouth Care

Good oral hygiene is essential for patients receiving nutritional support or who are nil by mouth. Saliva is normally produced when eating and this helps keep the mouth clean. Since saliva production is often reduced when receiving nutritional support the oral mucosa can develop sores. Artificial saliva can help if the mouth is dry. Patients should be encouraged to brush their teeth regularly (if able to do so) and use a suitable mouth rinse. Ensure lips are moistened.

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5.7.9 Education of Patients, Carers and Healthcare Workers

Hospital and Community staff should be trained on care of the tube and administration of enteral feeds as appropriate Patients and carers should be educated about, and trained in the techniques of hand decontamination, enteral feeding and the management of the administration system before being discharged from hospital.

Follow up training and on-going support of patients and carers should be available for the duration of home enteral tube feeding by the visiting Dietitian.

5.8 Stoma Skin Care 5.8.1 Peri-Stomal Skin Assessment General Principles

Peri-Stomal skin assessment should be:

Patient centred

Accurate and precise

Detect the presence of complications

Able to provide a framework to monitor resolution or deterioration

Evaluate the effectiveness of any treatment Peri-stomal skin assessment should take into account:

Exudate – colour, type, approximate amount, extent of strikethrough onto primary dressing

Odour – offensive, some, none.

Pain – site, frequency, severity, related to skin or PEG

Surrounding skin – dry, eczema, maceration, erythema, healthy

Colonisation/Infection – suspected, confirmed (specify organisms)

Hyper granulation tissue – present or absent. The details of the assessment and subsequent evaluations will be recorded in the patients’ records. Any change in skin or tubing should be documented and help sought from the endoscopy unit at DRI or the Homeward Nurse

5.8.2 Peri-Stomal Skin Management If signs of erythema are present apply Allevyn Ag (dressing can be cut to fit) around the tube to reduce the bacterial colonization and decrease exudates. Once the bacterial count is lowered the dressing changes can be undertaken as per the level of exudate.

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If Meticillin Resistant Staphylococcus Aureus (MRSA) MRSA is isolated at the tube site, the site should be dressed with Allevyn Ag. Specific reference to Infection prevention and control guidance should be made with regard to swab taking and repeat swabbing, however, when swabbing stoma sites please provide 2 separate swabs for culture and candida. If clinical infection is confirmed systemic antibiotics maybe required. If hypergranulation tissue is present then Allevyn Ag should be cut and applied around the site and rotated at each dressing change. If irritation or hypergranulation does not respond refer to a more senior colleague and if appropriate Clinical Nurse Specialist in Tissue Viability. Steroid cream 1% and +/- foam dressing is first line treatment for a granuloma. Referral to TVALS will depend on presenting factors.

5.8.3 Cleansing of Peri-Stomal Skin

Once established for a period of two weeks a routine of daily washing of the peri-stomal skin with water is all that is required. No dressing is required. If the patient prefers to have a dressing in situ then a non-filament gauze dressing can be applied and changed daily.

5.9 Administration of Medicines via Enteral Tubes

This section of the policy is to help support those who administer medicines via enteral feeding tubes. This guidance is required because crushing tablets may be at least unnecessary and at worst dangerous to the patient. In addition interactions may occur between medication and feeds which may render the medication ineffective, or may block the tube. See Appendix 6 for further information.

5.9.1 Legal and Professional Issues

Administration of a medicine not in accordance with its Summary of Product Characteristic, such as crushing the tablets is an unlicensed activity and may be harmful to the patient, and in the event of an untoward incident may expose the Trust to an unnecessary financial risk. The prescriber and health care professional who administers the drug are liable for any adverse effects resulting from crushing tablets or opening capsules. Whenever it may be necessary to administer a medicine by a method for which it was not intended, it must be considered carefully to ensure it is safe to do so. If there is any doubt the advice of a pharmacist must be sought.

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In community staff should contact the discharging hospital pharmacy for how the patient was managed prior to discharge if further guidance/ advice is required This section of the policy provides staff with guidance of current best practice relating to the administration of medicines via enteral tubes but is not intended to be an exhaustive list of options or to identify all problematic medication and does not remove the professional accountability of the practitioner. The National Patient Safety Agency recommends that a supply of oral/enteral syringes is available in all clinical areas that may need to measure and administer oral medicines in a syringe When patients or carers need to administer oral liquid medicines with a syringe, ensure that they are supplied with oral/enteral syringes 50ml Catheter tip oral/enteral syringes should be used to administer medicines. A smaller syringe may produce too much pressure and split the enteral tube.

5.9.2 General Considerations

The first thing to consider is does the patient need the medication. Is the oral route temporarily or permanently unavailable? If the oral route is temporarily unavailable can the medicine be stopped for a short time without significantly harming the patient? If it cannot be stopped consider alternative routes or formulations. Alternative routes may include:

Transdermal – for GTN, HRT or isosorbide mononitriate

Buccal or sublingual for GTN, for prochlorperazine

Rectal – for diclofenac, carbemazepine, paracetamol, domperidone

Nebulisation

Parental Using the feeding tube to administer medication should be considered as a last resort and whenever possible an alternative route should be used. The patient’s medication should in the first instance be reviewed by their doctor to consider the on-going need for all current medications and alternate presentations or routes of administration for medications considered necessary. Medication must be administered one at a time with 10-15mls water between each medication. A minimum of 30mls water must be flushed at the beginning and end of medications.

5.9.3 Preferred Formulations

Where possible to minimise the number and length of disruption to the

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administration of feed once daily products and medicines not requiring dosing on an empty stomach are preferred. Liquids or soluble tablets are the preferred formulation for administration of medication via feeding tubes. However, it should be noted that some liquid preparations are in fact suspensions of small granules and therefore not suitable for administering via enteral feeding tube e.g. lansoprazole suspension. Some liquid preparations contain sorbitol which can act as a laxative. In addition some soluble tablets may leave sediment. The cost of liquid preparations can sometimes be considered prohibitive; however the cost of replacing the feeding tube is far greater in terms of discomfort to the patient and financial implications to the Trust. Where modified release preparation is replaced by liquids more frequent administration of a lower dose will be necessary. Not all liquid preparations are suitable for undiluted administration via a feeding tube. High osmolality may cause diarrhoea. A viscous solution or suspension may block the tube and drugs such as diazepam may be adsorbed onto the plastic tubing. This can be reduced by diluting the medicines further with water before administration

5.9.4 Crushing Tablets

Before crushing tablets you must always check whether an alternative formulation is available. Where no commercial product is listed in the BNF you should consult the pharmacist who will check whether a suitable unlicensed product is available. Whenever the formulation is changed the medicine may require a dosage adjustment. For example: each Digoxin 125mcg tablet is equivalent to 100mcg of liquid preparation. This is due to the differing bioavailability of the products. Tablets you must NEVER crush:

5.9.5 Enteric Coated Tablets

Crushing enteric coated tablets may increase toxicity or reduce effectiveness. In addition the enteric coating is very hard to crush successfully and this may increase the risk of blockage if administered down a tube.

5.9.6 Modified Release Tablets

Modified release (M/R) tablets are designed to release their contents over an extended period, typically 12 to 24 hours. If the tablets are crushed the

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medicines will be absorbed in a much shorter period, perhaps 1-2 hours. This may lead to increased toxicity as a full day’s dose is absorbed in that 1-2 hours and then there may subsequently be a sub-therapeutic trough as the medicine is excreted. Modified release tablets are also described as:

Slow Release or SR

Extended Release or XL

Long Acting or LA

Retard

Slow or Slo

Perlonget 5.9.7 Buccal or Sublingual tablets

Buccal and sublingual tablets are designed to avoid the GI tract and first pass metabolism. Consequently crushing tablets and administering through the GI tract may be counterproductive as the drug may not be absorbed or may be removed through first pass metabolism. Conversely the buccal sublingual routes may provide an alternative where the oral route is not available.

5.9.8 Tablets that maybe toxic when crushed

When crushing tablets, powder will always be generated. A number of drugs will be potentially toxic to the person crushing the tablets by inhalation of the powder. In addition there is always the risk of sensitisation or anaphylaxis in susceptible individuals. Furthermore, if the device used for crushing is not properly cleaned the potential to contaminate other preparations exists. Tablets in this category include:

Cytotoxic drugs such as melphalan, busulphan, methotrexate.

Antibiotics such as penicillins, erythromycins

Prostaglandin analogues such as misoprostol (which is part of Arthrotec)

Hormone preparations The medicines listed are common examples and do not constitute an exhaustive list. If you are in any doubt consult a pharmacist before attempting to crush the tablets

5.9.9 Known Problems with Administration of Medicines via Enteral Tubes

Interactions with the Feed Interactions between enteral feeds and medication are important; always check with the Pharmacist prior to administering any newly prescribed

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medication for any possible drug interaction. Where possible give medication during a break in the feeding required to minimise this. It is essential for the multidisciplinary team and Patient to discuss and agree the optimum therapeutic treatment to suit the individual. Where medicines are advised to be administered on an empty stomach, this advice still applies. In these cases the feed should be stopped one hour before and stopped, in accordance with a clear risk assessment, for as long as possible prior to and after administration of medicines. Patient’s response to such medicines should be closely monitored (assessing physical signs and/or checking blood serum levels). It may be necessary for the prescriber to consider adjusting the dose of medicines whose bioavailability is reduced by food. Another interaction that may occur directly between the medicine and the feed is bezoar formation. Acid liquid medicines may also cause clumping of the enteral feed. Jejunal tubes Because the tip of the tube bypasses the stomach absorption may be impaired. Therefore when medicines are intended to be administered via a jejunal tube the absorption characteristics must be verified. Phenytoin The narrow therapeutic index of phenytoin makes the patient particularly vulnerable to variations in dosage. Phenytoin is known to interact with enteral feed. Therefore the following method of administration is recommended: a) Give phenytoin as a single daily dose b) Stop enteral feed two hours before administration of phenytoin and

recommence two hours after dosing

or

c) Dilute phenytoin suspension with at least equal parts (dilution up to 1:3 has also been recommended) or at least 20ml water (remember to shake the bottle before use).

d) Flush enteral tube with plenty of water before and after administration.

Ciprofloxacin Ciprofloxacin forms organic molecules that can trap certain trace elements in the enteral feed. This significantly reduces the absorption of the ciprofloxacin. In severe infection consideration should be given to the IV route.

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Stop enteral feed for one hour before and two hours after dose or administer higher doses or use IV treatment in severe infections. Liquid should not be diluted further with water. Use sterile water if dissolving tablets. Warfarin The Vitamin K content of the feed may antagonise the effects of warfarin therefore careful monitoring of the INR is required. This is particularly the case when feeds start, stop, or change. Sucralfate Sulcralfate may form bezoars causing the feeding tube to block. The manufacturers recommend stopping the feed 2 hours before and after administration. Consider ranitidine as an alternative.

5.9.10 Medicines which need to be administered on an empty stomach

Medicines such as penicillin antibiotics, proton pump inhibitors, and etidronate fall into this category. Where medicines are advised to be administered on an empty stomach, this advice still applies. In these cases the feed should be stopped one hour before and two hours after administration. In community settings feeds should be stopped for as long as possible prior to and after administration of medicines. However the patient’s response to such medicines should be closely monitored. It may be necessary for the prescriber to consider adjusting the dose of medicines whose bioavailability is reduced by food.

5.9.11 Administration via Enteral Feeding Tubes: Procedure

Check medication as per trust policy for Safe and Secure Handling of Medicines

Do not add medication directly to the feed.

Seek further advice for fluid restricted or paediatric patients, as flushing volumes may need to be reduced.

Clean hands with liquid soap and water. Put on disposable apron dry hands and put on non-sterile gloves as per 5.6.

The method of administration of each drug must be clearly written in the care plan so that it is clear to all clinicians.

5.10 PEG 5.10.1 Care of PEG Following Placement

It is important that staff are aware of the signs and symptoms which may occur up to 72 hours following the insertion of a PEG tube. The following signs require IMMEDIATE urgent medical attention.

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Pain during feeding (including medication delivery and water flushes)

Any pain or distress after procedure

New bleeding from the stoma site

Leakage of fluid around the tube. In the event of any one of these symptoms, the following actions MUST be taken:

Stop feeding/medication delivery immediately.

Seek immediate medical advice in order that the patient is examined and their symptoms assessed immediately.

5.10.2 Immediate Post Placement Care (up to 14 days)

Wash hands before and after caring for the tube

Leave the external fixation device in place for 10 days or as recommended during training provided by the Nutricia Homeward Enteral Nurse Specialist. If the device is digging into the skin contact the managing healthcare professional for review immediately

Clean the skin around the stoma site and under the external fixation device with sterile water or saline using sterile gauze (that does not shed fibres). This should continue daily for the first seven days. Ensure the skin is then dried thoroughly

Turn the gastrostomy tube through 360° after 10 days or as recommended during the training provided by the Nutricia Homeward Enteral Nurse Specialist (as manufacturers guidance varies depending on the type of tube used) to help prevent the tube adhering to the stoma tract and becoming embedded in the stomach wall

Report any inflammation, oozing or any changes from the site to the managing healthcare professional immediately. It is important not to use the tube until it has been reviewed.

5.10.3 Daily Care of PEG Tube

After 14 days post placement it is advised to care for the skin and tube as follows:

Wash hands before and after caring for the tube, open the external fixation device daily in order for the skin around the stoma site to be cleaned; note the tube position by observing the cm graduation mark where the tube exits the body

Clean the skin around the stoma site, the tube and under the external fixation device with mild soap solution and fresh tap water (using a cleaning cloth for this purpose only) and rinse thoroughly. Ensure the skin and external fixation device are thoroughly dried and check the tube is back in the original position. If there is a change in position of the tube do not use and contact the managing healthcare professional to confirm placement

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At least once per week, but no more frequently than once a day, insert the PEG tube into the stoma tract by 2-3cm and rotate the tube 360° to prevent the tube adhering to the stoma tract and becoming embedded in the stomach wall. Gently pull the tube back to its original position(advance and rotate)

If there is any discomfort, or you are unable to advance or rotate the tube, do not use and seek medical advice

Following care always replace and close the external fixation device so it lies approximately 2-5mm from the skin surface (the external fixation device may need to be loosened or tightened dependent on any weight loss/gain)

Flush the tube with water (type and volume as recommended by the managing healthcare professional) before and after the administration of feed or medication and 4-6 hourly if feeding is not in progress (except during the night) or as recommended by the managing healthcare professional, to prevent tube blockage

5.10.4 Additional Information on PEG

Avoid using creams and talcum powders as they can damage the tube material and may lead to irritation of the skin and give rise to infection. Creams can also reduce the effectiveness of the external fixation device and affect the tube material itself.

If the skin around the site becomes red or sore or there is oozing or bleeding from the site, contact the managing healthcare professional for advice. Only apply a dressing if advised to do so.

The patient can shower, bath and swim as normal if the stoma tract has been fully formed. Generally refrain from bathing for 2 weeks and swimming for 6 weeks.

5.11 Balloon Gastrostomy Tube (BGT) 5.11.1 Daily Care of Balloon Gastrostomy Tube (BGT)


Move the external fixation device to clean the skin around the stoma site with a mild soap solution and fresh tap water (using a clean cloth for this purpose only) and rinse thoroughly. Ensure the skin and fixation device are thoroughly dried – do this once per day. Replace the external fixation device so it lies approximately 2-5mm from the skin surface

Note the graduation markings on the tube where the tube exits the body, if there is a change in position of the tube do not use and contact the managing healthcare professional to confirm placement immediately

At least once a week but no more frequently than once a day, remove the external fixation device away from the skin surface and gently insert the tube into the stoma tract by 2-5cm and rotate the tube 360° to prevent the tube adhering to the stoma tract and becoming

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embedded in the stomach wall. Gently pull the tube back to its original position

If there is any discomfort or you are unable to advance or rotate the tube do not use and seek medical advice

Replace the external fixation device so it lies approximately 2-5mm from the skin surface (the external fixation device may need to be loosened or tightened dependent on weight loss or weight gain)

Flush the tube with water (type and volume as recommended by the managing Dietitian) before and after the administration of feed or medication or 4–6 hourly (except during the night) if feeding is not in progress or as recommended by the managing healthcare professional to prevent tube blockage

Check the position of the feeding tube by pH measurement before the first time tube feeding is started and also pre and post water changes i.e. weekly (see section below)

The BGT will need replacing every 3-4 months. At present this is done by either the Homeward Nurse or Emergency Care Practitioners (ECPs) at home or the Nutrition Nurse at DBHFT.

5.11.2 Checking Water in BGT

The fluid in the balloon ensures the tube is held in place. The water should be checked weekly, unless otherwise advised, to ensure that there is sufficient fluid in the balloon to hold the tube securely in place.

Attach an empty 10ml syringe onto the inflation valve of the BG tube

Gently draw back the plunger on the syringe until no more fluid comes out of the internal balloon

Check the volume of fluid withdrawn. Compare with the recommended volume advised for inflation by the manufacturer

If the volume of water withdrawn equals the recommended volume, re-inflate the balloon with a new syringe and the correct volume of fresh water

If the volume of fluid in the balloon is 1ml more or less than the manufacturer’s recommendation, tape the tube down securely and contact the managing healthcare professional or Nutricia Homeward Enteral Nurse Specialist for advice – do not use the tube.

5.12 Low Profile Feeding Device (LPFD)/ Button 5.12.1 Daily Care of Button


Lift the Button away from the skin approximately 2mm; clean the skin around the stoma site and under the Button with a mild soap solution and fresh tap water (using a clean cloth for this purpose only) and rinse thoroughly. Make sure the skin and button are thoroughly dried – do this once per day

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At least once a week, but no more frequently than once a day, rotate the tube 360° to prevent the tube adhering to the stoma tract

If the button is too tight or too loose contact the managing healthcare professional for further advice immediately

Flush the tube with water (type and volume as recommended by the managing healthcare professional) before and after the administration of feed or medication and 4–6 hourly if feeding is not in progress (except during the night) or as recommended by the managing healthcare professional to prevent tube blockage

Check the position of the feeding tube by pH measurement before the first time tube feeding is started and also pre and post water changes i.e. weekly (see below)

The BGT will need replacing every 3-4 months. At present this is done by either the Homeward Nurse or Emergency Care Practitioners (ECPs) at home or the Nutrition Nurse at DBHFT.

5.12.2 Checking Water in Button

The fluid in the balloon ensures the tube is held in place. The water should be checked weekly, unless otherwise advised, to ensure that there is sufficient fluid in the balloon to hold the tube securely in place.

Attach an empty 10ml syringe onto the inflation valve of the BG tube

Gently draw back the plunger on the syringe until no more fluid comes out of the internal balloon

Check the volume of fluid withdrawn. Compare with the recommended volume advised for inflation by the manufacturer

If the volume of water withdrawn equals the recommended volume, re-inflate the balloon with a new syringe and the correct volume of fresh water

If the volume of fluid in the balloon is 1ml more or less than the manufacturer’s recommendation, tape the tube down securely and contact the managing healthcare professional or Nutricia Homeward Enteral Nurse Specialist for advice – do not use the tube.

5.13 Checking Placement of BGT/Button by pH Measurement

Wash hands before and after checking the tube position. Attach extension set (if using a Button tube)

Ensure the clamp on the tube is closed before removing end cap (if present). Attach a 60ml enteral syringe to the end of the tube

Open the clamp on the tube (if present) and very slowly pull back on the syringe plunger until a small amount of fluid (at least 0.5–1.0ml) appears in the syringe

Detach the syringe from the tube, replace the end cap of the tube and close the clamp. Detach extension set (if using a Button tube)

Drop the fluid onto the pH indicator paper and wait for the strip to develop (follow manufacturer’s instructions).

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If the pH value is 1-5.5 it suggests the tube is in the correct position (the stomach). Flush the tube with water

If the pH value is more than 5.5, do not administer anything via the tube. Check the pH value again in 30-60 minutes. If the pH value remains above 5.5 contact the managing healthcare professional. It is very important that you do not administer anything including enteral feed, water or medication via the tube until certain the tube is in the correct place.

If it is not possible to obtain gastric aspirate for checking pH, try lying the patient on the left side, wait for 30 minutes, then try again

If able and the managing healthcare professional has advised it is safe to do so, sip a little oral fluid, wait five minutes and then try again to test the tube position

If it is still not possible to obtain any gastric aspirate do not use the tube and contact a healthcare professional for further advice

5.14 Flushing the Feeding Tube

Always flush the feeding tube before and after:

Each medication administration. A minimum of 30mls must be administered at the start and end of medications plus 10-15mls between each medication

Each feed whether bolus or pump administered. A minimum of 30mls is required but follow the feeding regimen

Flush 4–6 hourly (except during the night) if feeding is not in progress or as recommended by the managing healthcare professional to prevent tube blockage

How to flush: Provided the patient is not fluid restricted or that the Dietitian has not given specific fluid flushing volumes:-

Explain to the patient what you are going to do.

If the patient is having a feed via a pump and giving set, turn off the pump.

Clean your hands as per Trust Hand Hygiene Policy before and after the procedure.

Put on personal protective equipment i.e. gloves and apron.

Flush the tube using a 60ml ENFit enteral syringe before and after the administration of feed and medication, or 4–6 hourly (except during the night) if feeding is not in progress or as recommended by the managing healthcare professional to prevent tube blockage

Flush the tube with at least 30ml of water. If resistance is felt do not force the water into tube as this may damage the feeding tube.

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If the patient is on restricted fluids you will need to reduce the amount of fluid flushed through. Follow medical/ dietetic advice. If the patient is immuno-compromised or feeding into the jejunum, cooled freshly boiled water or sterile water should be used to flush the feeding tube (unless otherwise directed by the Local NHS Policy).

Observe the markings on tube check with placement measurement.

Do not excessively move the tube (more than ¼ inch or 6mm) in and out of the abdomen as this may dislodge the gastrostomy tube from the stomach.

Using a clean syringe pour 50 mls of water in a 60ml ENFit syringe.

Ensure the patient is sat in an upright position, or propped up with pillows to a minimum angle of 30 degrees, ideally 45 degrees

Close the clamp on the tube

Unfasten the large adaptor of the Y connector situated at the end of the gastrostomy tube.

Attach the syringe to the largest opening.

Unfasten the clamp.

Gently and slowly press the plunger down on the syringe until it is empty.

Close the clamp.

Remove the syringe.

Refasten the Y adapter.

Open the clamp.

Remove personal protective equipment.

Clean your hands as per trust protocol.

Document in the patient’s record.

Re-commence the feed 5.15 Feeding Pump Instructions

Equipment: feeding pump, stand (drip, Z, or Go Frame with carry bag), giving set, 60ml enteral syringe, feed, recommended water.

Wash hands before and after operating pump

Check the label of your feed to make sure you are using the correct product

Position at 45° during and at least one hour after feed

Check feeding tube position prior to administering anything down the tube (pH must be checked if it is a button/ BGT)

Flush the feeding tube using a 60ml enteral syringe with the recommended amount of water

Prepare and hang feed as demonstrated during training and follow the appropriate pump instructions

Program the pump as shown in the relevant pump instruction booklet or pump leaflet

If it is a Button then remove extension set once feeding regime complete.

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If the pump alarm sounds refer to the pump troubleshooting guide in the pump instruction booklet or pump leaflet. If the pump continues to alarm contact the Nutricia Homeward Enteral Nurse Specialist or out of hours advice line.

5.16 Bolus Feeding

Refer to the dietician’s regime for the:

Type of feed

Amount to be given

Number and timings of feeds How to feed:

Explain to the patient what you are going to do.

Check the feed to be administered

Clean your hands as per Trust policy before and after the procedure

Wear personal protective equipment i.e. gloves and apron.

Check feeding tube position, if applicable

Observe the markings on tube check with placement measurement.

Do not excessively move the tube (more than ¼ inch or 6mm) in and out of the abdomen as this may dislodge the gastrostomy tube from the stomach.

Ensure the patient is sat in an upright position, or propped up with pillows to a minimum angle of 30 degrees, ideally 45 degrees

Flush the feeding tube with the specified volume of water. Attach a bolus feeding set or an enteral feeding syringe without the plunger to the feeding tube

Slowly pour the amount of feed required into the syringe

Alter the height of the syringe slightly if the feed is running too quickly or slowly. If using a bolus feeding set adjust the roller clamp to enable feed to run quicker or slower

Ensure that the feed rate does not exceed 30ml a minute

Remove the bolus feeding set or syringe when the required amount of feed has been delivered

Flush the tube again and replace the end cap

Remove the plunger from a 60ml ENFit syringe

Close the clamp on the tube.

Unfasten the adaptor of the Y connector situated at the end of the gastrostomy tube.

Attach the barrel of the syringe to the largest opening on the Y adaptor.

Hold the gastrostomy tube in an upward position.

Gently pour the feed into the barrel of the syringe.

Unfasten the clamp on the tube.

The feed will go through the tube with gravity.

Refill the syringe until the correct amount has been administered.

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If the patient shows any signs of shortness of breath (more than usual), sudden pallor, cyanosis and /or sudden increase in heart rate stop the feed immediately and get a medical opinion.

Fasten the clamp on the tube.

Flush the tube the specified amount of water

Close the adapter on the Y connecter.

Leave the clamp open on completion.

Secure the tube in an upward position with tape or attach to the patients clothing.

Remove personal protective equipment.

Clean your hands as per Trust protocol.

Do not lay the patient flat for at least one hour following a feed to prevent nausea.

Document in the patient’s record. Any queries about the feed, rate or amount please refer to the Dietitian.

5.17 Emergency Enteral Feeding Regimen

If a patient is admitted to the ward when a Dietitian is not on duty, and if the Doctor authorises – start feed as per Emergency Enteral Feeding Regimen (Appendix 3).

5.18 Troubleshooting 5.18.1 The Tube Becomes Blocked

If there is resistance when flushing the feeding tube, do not force water into the tube:

Check the tube advances and rotates easily. If it does not advance or rotate easily, or you have not been trained, then there should be no attempt to unblock the tube until you have received further advice from the managing healthcare professional or Nutricia Homeward Enteral Nurse Specialist

If the tube advances and rotates easily, using a gentle pull and push technique, flush the tube using a 60ml enteral syringe using warm water or soda water. Do not use acidic solutions such as fruit juices or cola as they can curdle the tube feed

If a blockage still exists, gently squeeze the tube between the fingers along the length of the tube as far as possible

It can take 30 minutes or more to unblock a tube

If the blockage persists contact the managing healthcare professional or Nutricia Homeward Enteral Nurse Specialist for further advice

5.18.2 Accidental Tube Removal

Important: If the tube has been removed with the bumper completely intact or there are any signs of trauma to the stoma tract (such as

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bleeding), or if there are any signs of pain or distress, please seek urgent medical review.

The patient will need to have a new tube inserted as soon as possible, otherwise the stoma tract will start to heal and may completely close soon after the tube has come out

A PEG tube cannot be replaced at home. Contact the local hospital immediately. A doctor needs to confirm that the complete tube has come out and will need to be replaced in hospital.

Place a clean gauze dressing over the stoma site to prevent stomach contents leaking onto the skin or clothes

5.19 Discharge Planning for Community

Consideration needs to be given to who will be administering the feeds on discharge. If the patient/family is unable to manage the feeds it may be necessary to involve care agencies and/or district nurses. Please note not all care agencies are insured to administer feeds. Training for those agencies that are insured may need to be arranged by the Dietitian. The Dietitian will arrange equipment and ancillaries for home plus a feeding regimen tailored to the patient’s requirements and circumstances

6. TRAINING IMPLICATIONS

Staff groups

requiring training

How often should this

be undertaken

Length of training

Delivery method

Training delivered by whom

Where are the records

of attendance

held?

Staff who have an identified need with their line manager

Annually or can be CAST (Clinical Assessment Tool) assessment in the area to evidence competency is maintained.

½ day unqualified staff 1 day qualified staff

Simulation training plus further observations for each procedure to be completed by staff, with their supervisor until deemed to be confident and competent

RED Centre

Electronic Staff Record system (ESR)

Staff who have identified a need with their line manager

E-learning for Nutricia Pump

http://www.nutriciaflocare.com/

Print off copy of certificate Evidenced on Electronic Staff Record system (ESR)




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7. MONITORING ARRANGEMENTS

Area for Monitoring

How Who by Reported to

Frequency

Breaches in Policy

Via IR1 system

Multidisciplinary healthcare

professionals,

Care Groups

On ad hoc basis

8. EQUALITY IMPACT ASSESSMENT SCREENING

The completed Equality Impact Assessment for this Policy has been published on this Policy’s webpage on the Trust Policy Library website.

8.1 Privacy, Dignity and Respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

Indicate how this will be achieved

No additional requirements, other than those outlined within the policy have been identified.

8.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court Therefore, the Trust is required to make sure that all staff working with individuals who use our service is familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible

Indicate how this will be achieved

All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1)

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9. LINKS TO ANY ASSOCIATED DOCUMENTS

Hand Hygiene Policy, Clinical Policies, Infection Control

Aseptic technique and Aseptic Non Touch Technique, Clinical Policies, Infection Control

Standard Infection Prevention and Control Precautions Policy, Clinical Policies, Infection Control

Wound Management Policy, Clinical Policies, Wound Management,

Safe and Secure Handling of Medicines Policy, Clinical Policies, Medicines

Policy for the care and management of a patient requiring a nasogastric tube, Clinical Policies, General

Nutrition Policy, Clinical Policies, General

Waste Policy, Health and Safety Policies

Clinical Skills Training Package All of the above policies can be accessed via RDaSH Intranet

10. REFERENCES

Nutricia Limited (2013) Nutricia Nurse Patient/Carer Adult Training Policies and Procedures

Mersey Care NHS Trust April 2012 Enteral Feeding Clinical Guidance

NICE (2006) Nutrition support in adults; oral nutrition support, enteral tube feeding and parenteral nutrition Clinical Guideline 32

NICE (2012) Infection Prevention and Control of Healthcare Associated Infections in Primary and Community Care Clinical Guideline 139

NPSA (2010) Early Detection of Complications after Gastrostomy

Department of Health (2010) The Health and Social Care Act 2008: Code of Practice on the Prevention and Control of Infections and Related Guidance

Smyth J A (2010) The NEWT Guidelines for Administration of Medication to Patients with Enteral Feeding Tubes or Swallowing Difficulties North East Wales NHS Trust

11. APPENDICES

Appendix 1 - Definitions

Appendix 2 - Contact Details – Patient Information

Appendix 3 - Emergency Enteral Feeding Regimen for Adults

Appendix 4 - Medication Advice

Appendix 5 - Troubleshooting

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APPENDIX 1 Definitions

Bezoar A type of calculous or concretion of tightly packed collection of partially digested or undigested food that is unable to exit the stomach.

Buried bumper syndrome

A complication of PEG tubes where the internal disc becomes buried in the stomach lining.

Enteral feeding Feeding via a tube that can include any method of providing nutrition via the gastrointestinal tract.

Enteric Coated tablets

(Also abbreviated to EC or EN) are formulated to pass through the stomach intact before they begin to dissolve. The enteric coating may be being used to protect the stomach against local toxicity e.g. aspirin EC, or it may being used to ensure the medicine is released at the correct site for absorption or action e.g. bisacodyl

Exudate Accumulation of fluids coming from wounded tissue.

Hypergranulation Granulation tissue that is raised above the peri-wound area.

No-touch technique Avoiding direct contact of the hands with feed ingredients.

Oral/Enteral syringes

Syringes used to measure/administer liquid medication which are labelled oral/enteral and that cannot be connected to intravenous catheters or ports.

Osmolality The concentration of particles dissolved in a fluid.

Radiologically inserted gastrostomy (RIG)

This technique requires air insufflation of the stomach through an NG tube, puncture of the stomach externally and fixation of stomach to abdominal wall, then a tube is inserted by a push method.

Per-oral image-guided gastrostomy (PIG)

This technique requires air insufflation of the stomach through an NG tube and puncture of the stomach externally, then a guidewire is inserted and the oesophagus is canulated retrogradely to the oral cavity. Tube is attached to guidewire and then pulled back by guidewire until it is lodged in the abdominal wall, a pull method.

Peri-stomal skin The area of skin surrounding the surgically constructed opening in the abdomen. In this instance refers to Percutaneous Endoscopic Gastrostomy or Jejunostomy (PEG/PEJ).

Ready-to-use Feeds prepared and supplied by the manufacturer, that only require attaching to the feed tube.

Replacement gastrostomy tube

Same as the PEG tube but with a water filled balloon instead of a bumper. Last approximately 3 months

Single use For use on one occasion only.

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APPENDIX 2 Contact Details – Patients/Carers

Problem Contact Telephone Number

Tube Falls Out Emergency Care Practitioners (ECPs)

08448 706800

Wound Care Nutricia Nurse 08457 623644

Blocked Tube Nutricia Nurse 08457 623644

Spare Ancillaries Nutricia Co-ordinator 08457 623661

Training Dietitians 01302 796410

re-arrange appointments and planned gastro tube changes

Emergency Care Practitioners (ECPs)

08448 706803

01302 734834

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APPENDIX 3

Emergency Enteral Feeding Regime for Adults

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APPENDIX 4 Medication Advice N.B. This list is not exhaustive and any concerns should be raised with the prescriber and/or pharmacist.

DRUG FORMULATION AND ADVICE

Alendronate • No liquid preparation available

• Tablets should not be crushed – contact prescriber for alternative preparation

Aminophylline • No liquid formulation available.

• Patient could be changed to equivalent dose of Theophylline liquid- seek advice on dosing from pharmacy (for in-patients) or community pharmacist

• If Theophylline is substituted, it is advisable to stop feeds for one hour before and two hours after administration and to monitor plasma levels of the drug as Theophylline has a narrow therapeutic index

Amiodarone • Tablets may be dispersed in water and given immediately

• Bitter taste once dispersed therefore not suitable for oral administration (via PEG suitable)

Amlodipine • No liquid formulation available

• Disperse tablets in water and give immediately (light sensitive)

Antacids • Aluminium containing antacids may interact with feeds leading to the development of an oesophageal plug.

Aspirin • Soluble tablets available

Atenolol • Liquid formulation available

Azathioprine • Cytotoxic - tablets should not normally be crushed without appropriate precautions being taken. Consult ward pharmacist or Medicines Information Centre.

Baclofen • Liquid formulation available.

Balsalazide • Do not open capsules – the drug contain an AZO-DYE which stains skin, teeth etc. that it comes into contact with.

Bendro-flumethiazide • Tablets can be crushed and mixed with water

Bisacodyl • Suppositories available

Captopril • Crush tablets and flush with water, no commercially available liquid formulations. Specials manufacturing may be available if necessary, though this can be very costly.

Carbamazepine • Liquid formulation available, also suppositories for short term use.

• Dose and or frequency adjustments may be required if changing from alternative preparations.

• Ask ward pharmacist or Medicines Information Centre for advice.

Chlordiazepoxide • Open capsules and mix with water

Chlorphenamine • Liquid preparation available

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Ciclosporin • Liquid formulation available.

Ciprofloxacin • Liquid preparation available but too thick for tube administration and not recommended for dilution

• Disperse tablets in sterile water (ions in tap water chelate ciprofloxacin)

• Stop feed 1 hour pre and 2 hours post administration

• Bioavailability may still be reduced by 25%

Citalopram • Liquid available.

• NB there is no direct mg:mg dose equivalent between the solution and the tablets. Always ensure that the dose is converted to number of drops or mg using the conversion “8mg (4 drops) of the citalopram oral drops may be considered to be equivalent in therapeutic effect to 10mg citalopram tablets”.

• Mix with water before administering

Clarithromycin • Suspension available

Co-beneldopa (Madopar)

• Dispersible tablets are available but cannot be directly substituted as they have a faster onset of action than plain or CR tablets.

• Seek advice from ward pharmacist or Medicines Information Centre before changing tablet formulation

• Co-beneldopa may interact with the proteins in the enteral feed leading to potential enhanced absorption of levodopa. To minimise fluctuation ensure that co-beneldopa is administered at the same time(s) every day in relation to feeding.

Co-careldopa (Sinemet) • No liquid preparations available

• Seek advice from ward pharmacist or Medicines Information Centre

• Consider change to dispersible co-beneldopa preparation after discussion with prescriber

Codeine • Liquid available

Demeclocycline • Open capsules and disperse in water

Diazepam • Liquid preparation available

Digoxin • Liquid formulation available.

• Digoxin liquid has different bioavailability from tablets so dosage adjustment may be necessary; seek advice from ward pharmacist or Medicines Information Centre.

Dihydrocodeine • Liquid formulation available.

Diltiazem • No liquid formulation available, MR tablets should not be crushed, seek advice from ward pharmacist or Medicines Information Centre.

Dipyridamole • Crush tablets (Syrup available as “special”- very expensive)

• MR caps – convert MR 200mg bd to100mg tds of tablet and crush (NB 100mg strength not licensed for stroke)

Doxazosin • Crush ordinary tablets (not MR) and mix with sterile water (Ions in tap water chelate doxazosin)

Doxepin • Open capsules

Enalapril • Crush tablets (Bitter aftertaste)

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Erythromycin • Liquid formulation available.

Ferrous sulphate • No liquid formulation available, consider the use of ferrous fumarate, or alternative (e.g. Sytron) though dose adjustments may be required, see current version of the BNF.

Finasteride

Do not crush tablets.

• Seek advice from ward pharmacist or Medicines Information Centre

Flecainide • Special syrup may be available. If tablets crushed there may be a local anaesthetic effect to the oral mucosa

Flucloxacillin • Liquid formulation available

• Stop feed for half to one hour before and after administration; seek advice from dieticians for feeds administered continuously.

Fluoxetine • Liquid formulation available

Folic acid • Liquid formulation available.

Frusemide • Liquid formulation available.

Gabapentin • No liquid formulation available.

• Open capsules; dissolve contents in water for administration via enteral tube.

Gliclazide • Crush tablets

Hyoscine hydrobromide • No liquid formulation available.

• Seek advice from pharmacist or Medicines Information Centre regarding the use of alternative formulations or preparations. (Injection may be given orally).

Isosorbide mononitrate • Disperse low doses of tablets in water (Increased absorption and therefore increased dose when tablets dispersed) Do not crush tablets

• Do not crush MR caps/tablets

Lamotrigine • Dispersible tablets available

Lansoprazole • Suspension (sachets) available but not suitable for enteral tubes (liquid sticks to the tube). • Consider use of alternative proton pump inhibitor; seek advice from ward pharmacist or Medicines Information Centre.

• Lansoprazole fast-tabs are for administration either swallowed whole or dissolve under tongue. (Not suitable for dispersal in water and administered via feeding tube)

Lithium • Liquid formulation available Tablets are sustained release so total daily dose may need to divided and given at more frequent intervals and plasma levels monitored.

• Seek advice from ward pharmacist or Medicines Information Centre on changing from tablets to liquid formulations.

Lofepramine • Liquid formulation available.

Loperamide • Liquid formulation available.

Mebeverine • Liquid formulation available.

Mesalazine • Tablets should not be crushed. If colon only affected try a rectal preparation. Pentasa tablets disperse very quickly in water; however

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this leaves small beads in the liquid which must be swallowed intact.

Metformin • Liquid formulation available (as a Special preparation)

Metoclopramide • Liquid formulation available.

Metolazone • Dose may need to be reduced if tablets crushed

Metronidazole • Liquid formulation available.

Misoprostol • Tablets may be crushed and dispersed in water IMMEDIATELY before use

Moxonidine • Tablets may be crushed

Naftidrofuryl • Do not open capsule- powder is irritant and anaesthetic to mouth/throat mucosa.

Nicorandil • Tablets may be crushed

Nifedipine • Nifedipine is very short acting.

• If a long acting preparation (Tensipine, Adalat Retard, Adalat LA) is substituted with a short acting preparation then side effects e.g. hypotension may occur.

• Consider change to alternative calcium channel blocker and discuss with doctor. • Do not crush nifedipine tablets.

• Capsules may be used- discuss equivalent dose Vs tablets with ward pharmacist or Medicines Information Centre.

• If capsules are used, remove liquid from capsule using needle and syringe and flush liquid down tube using normal saline (not water).

• Liquid from the capsules is light sensitive and must be used immediately.

Nitrazepam • Liquid formulation available.

Nizatidine • Consider change to ranitidine.

Omeprazole • No liquid formulation available. • Dispersible tablets available.

Pantoprazole • Tablets must not be crushed. Change patient to alternative e.g. dispersible omeprazole tablets

Paroxetine • Liquid available

Penicillamine • No commercially available liquid formulation available.

• Hospital pharmacy may be able to formulate liquid preparation, discuss with pharmacy dept. • "Specials" manufacturing may be available from community pharmacists. Preparations have a short shelf life and are costly.

Penicillin V • Liquid formulation available.

• Absorption of liquid given enterally is unpredictable (30-80%).

• Stop feed for one hour before and for two hours after or administer higher doses.

• Consider alternative penicillin e.g. amoxycillin.

Phenobarbitone • Liquid formulation available.

• This drug is not thought to interact with enteral feeds.

Phenytoin • Phenytoin liquid (90mg) is approximately equal to 100mg phenytoin sodium capsules • Higher doses may be required when

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administering the drug enterally due to interactions • Dose should be prescribed as dose and volume

• Various approaches to minimising interaction of phenytoin with the feed have been documented e.g. 1. Give phenytoin as a single daily dose. 2. Stop enteral feed two hours before administration of phenytoin and recommence two hours after dosing. 3. Suspend feed between 10pm and 2.00am and give phenytoin as a single dose at midnight. Contact dietitian for further advice 4. Flush tube with plenty of water before and after administration. 5. Dilute phenytoin with at least equal parts of water.

• Optimum method of administration will depend on patient acceptability, patient location and availability of staff.

Prednisolone • Soluble formulation available.

Prochlorperazine • Liquid formulation available.

Procyclidine • Liquid formulation available

Propranolol • For patients taking long acting preparations seek advice from the ward pharmacist or Medicines Information Centre.

• No commercially available liquid formulation, may be manufactured in the hospital pharmacy or via "specials" manufacturing through community pharmacists, the expiry date will be relatively short and the costs high.

Ranitidine • Dispersible tablets available.

• Liquid may be used if tablets are unsuitable, but more expensive.

Salbutamol • Liquid formulation available.

• If changing from Sustained Release formulations (e.g. Volmax) give the total daily dose in 3-4 divided doses.

• Do not crush tablets as sustained release.

• If appropriate consider the use of inhaled or nebulised salbutamol.

Selegilene • Liquid formulation available.

Senna • Liquid formulation available.

Simvastatin • Tablets may be crushed

Sodium Valproate • Liquid formulation available

• If changing patients from long acting preparations seek advice form the ward pharmacist or Medicines Information Centre.

Spironolactone • Liquid available

Sucralfate • Avoid if possible.

• Liquid available but may block tube. Dispersible tablets also available but sucralfate binds to protein in feeds and has been associated with oesophageal bezoar formation. Feed needs to be stopped for at least one hour before and after dose (qds dosing means that feed stopped for at least 8 hours). Consider using alternative drug.

Sulphasalazine • Liquid formulation available.

Temazepam • Liquid formulation available.

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Theophylline • See under aminophylline.

Thiamine • Crush tablets.

Thyroxine • Crush tablets and disperse in water.

Topiramate • No liquid formulation available.

• Crush tablets and flush tube with water.

Tramadol • Dispersible tablets available.

Trimethoprim • Liquid formulation available.

Venlafaxine • Non m/r tablets may be crushed

Verapamil • Liquid formulation available (expensive).

• Do not crush M/R tablets

• Dose adjustment may be required if switching from controlled release or modified release tablets, seek advice from the ward pharmacist or Medicines Information Centre.

Vitamin B compound strong

• Liquid formulation available (Vigranon B) containing B group vitamins. (Not available on NHS) • 10ml of Vigranon B is approximately equal to two tablets of Vitamin B compound strong.

Vitamin E • Liquid formulation available

Warfarin • Tablets may be crushed or dispersed and flushed through with water • In the community liquid formulations are not commercially available and may be ordered through "specials" manufacturing though the shelf life will be comparatively short and the costs high

• Effects of warfarin may be antagonised by the vitamin K content of the enteral feed

• INR should be monitored closely and dose adjusted accordingly

• Further information on the interactions with this drug may be obtained from the ward pharmacist or the Medicines Information Centre.

• There is insufficient evidence to recommend stopping the feed for three hours in order to minimise the potential drug/feed interactions

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APPENDIX 5 Troubleshooting

DIARRHOEA

POSSIBLE CAUSE NURSING INTERVENTION

Contaminated feed/equipment Follow microbiological guidelines.

Check sterile handling of feed and equipment

GI infection e.g. Clostridium difficile, Enteropathic E coli

Stool sample. Reduce rate and consult Dietitian. Apply isolation precautions in hospital settings

Over rapid infusion of feed Reduce rate and consult Dietitian

Pharmaceutical e.g. antibiotics, laxatives, antacids, NSAID’s

Discuss with medical team.

Consult Pharmacy and Dietitian

Feed too cold Deliver feed at room temperature

Malabsorption e.g. pancreatic dysfunction, liver disease, coeliac disease

Consult Dietitian who may consider a peptide based feed

Hypoalbuminaemia Consult Medical staff

Inappropriate fibre intake e.g. long-term low residue feed.

Consult Dietitian who may consider a fibre feed

Diarrhoea is a relatively common problem in patients receiving an enteral feed but is seldom related directly to the feed.

CONSTIPATION


Inadequate fluid Ensure adequate fluid intake

Drug therapy Review drugs

Disease state Consider fibre feed or appropriate laxative. Consult Dietitian

NAUSEA OR VOMITING


Delayed gastric emptying Consult Dietitian and Doctor

Constipation See above

Drug therapy Check drug/nutrient interactions

Too rapid infusion rate Reduce rate

Contaminated feed Follow microbiological guidelines

Electrolyte imbalance Contact Doctor review blood profiles and correct levels

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DRY OR SORE MOUTH


Poor mouth care Good oral hygiene

ABDOMINAL DISTENTION


Delayed gastric emptying Reconsider choice of feeding route. Try pro-kinetic drugs.

Too rapid infusion rate Reduce rate (consult Dietitian)

GI obstruction Stop feed

Faecal impaction Contact team for assessment to ensure patient is not fully impacted.

REFLUX


Too rapid infusion rate Reduce rate (consult Dietitian)

Volume too large Consult Dietitian who may consider reviewing volume of feed and/ or administration rate

Poor position Keep head elevated at 30 degrees minimum while feeding and ½ hour after. (45-90 degrees may be necessary)

Delayed gastric emptying Consult Dietitian who may reconsider choice of feed

Decreased GI function Consult Dietitian. Consider drugs to alter gut motility. Assess for decreased bowel sounds, abdominal distension, nausea, vomiting.

Gastritis Discuss appropriate medication with team e.g.: H2 receptor antagonist

TUBE BLOCKAGE

POSSIBLE CAUSE ACTION REFERRAL TO

Failure to flush the PEG tube with water before and after feeding and medication causing food residue to stick to the tube

Try flushing the tube with warm water.

Gently manipulate the tube between your fingers squeezing the food towards the stomach.

If this does not resolve the problem refer to Homeward Nurse or Endoscopy on telephone Doncaster ext 6424

Increased abdominal pressure due to laughing,

Stop the feed/flush, allow time for the pressure to

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TUBE BLOCKAGE


coughing or straining/ thrusting

settle, restart the feed/flush

The patient is on a high fibre feed

Try flushing the tube with warm water.

Gently manipulate the tube between your fingers squeezing the food towards the stomach

Refer to the dietitian

The patient is putting food down not prescribed

Only put prescribed food down the tube

Refer to the dietitian

The patient is having crushed tablets put down the PEG tube

Try changing all medication to syrup or dispersible form. See the guidelines on medication via Enteral feeding tubes

Refer to the doctor/ pharmacist for medication review

TUBE DAMAGE


Wear and tear on the connectors leads to sticking

Replace the Y Connector Refer to Nutricia Nurse

Buildup of feed around the connector leads to sticking

Rinse the connector thoroughly with cooled boiled water / replace the Y connector

Refer to Endoscopy if persistent

Tubing is kinked or dented Change the position of the clamp regularly. Do not leave the clamp closed once the end connectors are sealed

SKIN/STOMA


Over granulation of the stoma site

Cut Allevyn Ag and apply around the site.

Tissue Viability CNS if problem does not resolve.

Stoma site inflamed, red Apply Allevyn Ag to the site. Change as necessary according to level of exudate.

Swab for culture and sensitivity. Refer to Endoscopy if negative result

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LEAKAGE AROUND STOMA SITE


The gastrostomy tube leaks around the stoma site

Ensure that the external fixator is secure and close to the abdomen, allowing for patient movement. Examine the tube for any slits or holes

Refer to Nutricia Nurse if the problem does not resolve

The gastrostomy tube leaks around the stoma

site

Ensure that the external fixator bar is secure and close to the abdomen, allowing for patient movement. Try re-inflating the balloon with sterile water the correct amount of water to be used is indicated on the flange of the tube

If the tube moves excessively seek advice from Endoscopy

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APPENDIX 6 Administration of Medicines Via Enteral Tubes - Further Information

STOP THE FEEDFlush the tube with at least 30ml of

water

Assemble medication and equipment needed e.g. 50ml enteral or catheter tipped syringe. Sterile water must be used in

Hospital. Cool boiled water may be used in the Community. Pestle and Mortar tablet crusher.

Prepare each drug separately.

Do you need to allow a break before administering the medicines?

Only on the Advice of

Prescriber/Pharmacist

Check appendix 1

SOLUBLE

TABLETS

Dissolve in

10-15 ml of water.

Administer down the enteral

tube.

LIQUIDS

Shake well.

Viscous (thick)

Liquids – dilute with an equal

amount of water immediately before

administration.

Administer down the enteral tube.

TABLETS

Crush uncoated and sugar

coated tablets using a

pestle and mortar or

suitable device

CAPSULES

Open capsules and tip

powder into medicine

pot.

Mix with 10-15ml of water to

produce a sediment free solution.

Administer down the enteral tube.

Using 10mls – 15mls of water rinse the tablet crusher/container, and draw up contents into the same syringe used to

administer medication and flush this down the enteral tube to ensures the full dose is given.

If more than one medicine is to be administered – flush between drugs with at least 10ml of water to ensure that the drug

is cleared from the enteral tube.

Flush the enteral tube with at least 30ml of water following administration of the last drug.

Clear away equipment and dispose of syringe as per manufacturers’ instructions.

RE-START THE FEED

Do you need to allow a break before restarting the feed?

Enteral Tube Feeding Policy - RDaSH NHS Foundation Trust · enteral feeding tubes 3 SCOPE The...

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