Trust Standard for the Assessment and Management of Physical Health Practice Guidance Note Enteral Tube Feeding Overview V01 Date Issued Planned Review PGN No: Issue 1 Aug 16 Issue 2 Nov 16 Aug 19 AMPH-PGN-02 Part of NTW(C)29 Trust Standard for the Assessment and Management of Physical Health Author/Designation Responsible Officer / Designation Gill Gallagher Clinical Nurse Manager Anne Moore - Group Nurse Director Contents Section Description Page No: 1 Introduction 1 2 Objectives 1 3 Types of Enteral Feed Tubes 1 4 Enteral Feed Tubes 2 5 Methods of Administering Enteral Feeds 2 6 Monitoring Enteral Tube Feeding 3 7 Complications of Enteral Tube Feeding 4 8 Home Enteral Tube Feeding 5 9 Termination of Enteral Tube Feeding 6 10 Staff Responsibilities 6 11, Social and Residential services, Learning Disability Directorate Appendix No: Appendices listed separate to Policy Description Appendix 1 Example of What to Write on Kardex Continuous Feeding Appendix 2 Appendix 3 Example of What to Write on Kardex Email to Doctors Example - PRN Sliding Scale of how to write on Karden Issue No: Issue Date 7 Review Date 1 Aug 16 Aug 19 1 Aug 16 Aug 19 1 Nov 16 Aug 19
1 Introduction 1.1 Enteral feeding means using the gastrointestinal tract for delivery of nutrients. This includes eating food, consuming oral supplement drinks and all types of tube feeding. 1.2 Whilst the majority of patients will be able to meet their nutritional requirements orally, there are a group of individuals who will require enteral tube feeding either on a short term or on a more permanent basis. 1.3 Across (the Trust/NTW) areas support service users nutritional needs by delivering enteral feeds via nasogastric (NG), gastrostomy and jejunostomy tubes. 1.4 This may include individuals presenting with any of the following; Anorexia Eating Disorders Aphagia Dysphagia Behavioural issues 2 Objectives 2.1 The purpose of this Practice Guidance Note is to provide clinical information to staff about enteral tube feeding to be read in conjunction with Practice Guidance Notes covering all aspects of enteral tube care, management and feeding. 3 Types of Enteral Feed Tubes 3.1 Nasogastric Nasogastric feeding is the most commonly used route and is suitable for short term feeding i.e. 2-4 weeks. Fine bore feeding tubes should be used whenever possible as these are more comfortable for the patient than wide-bore tubes. They are less likely to cause complications such as rhinitis, oesophageal irritation and gastritis. Polyurethane or silicone tubes are preferable to polyvinylchloride (PVC) as they withstand gastric acid and can stay in position longer than the 10 14 days lifespan of the PVC tube. 3.2 Gastrostomy A gastrostomy may be more appropriate than a nasogastric tube where feeding is to be medium or long term. A gastrostomy tube is inserted through the abdomen to deliver nutrition directly into the stomach. Benefits include being less likely to be displaced than an NG tube. Displacement of NG tubes will interrupt feeding and replacement can be uncomfortable. 1
3.3 A gastrostomy tube may be placed endoscopically (percutaneous endoscopically placed gastrostomy (PEG) or radiologically (radiologically inserted gastrostomy (RIG)) or surgically. They are made from polyurethane or silicone and are therefore suitable for short or long term feeding. There are, however, risks associated with placing a gastrostomy which must be considered. 3.4 Jejunostomy A jejunostomy tube is placed through the skin of the abdomen into the midsection of the small intestine to deliver nutrition. A jejunostomy or a jejunal extension to a gastrostomy should be used if a patient has undergone upper GI surgery or has severe delayed gastric emptying. A jejunostomy tube may be placed endoscopically (Percutaneous endoscopically placed jejunostomy (PEJ)) or radiologically (radiologically inserted jejunostomy RIJ) or surgically. 4 Enteral Tube Feeds 4.1 Commercially prepared ready to use feeds should be used. Available in liquid form, they have the advantage of being of known composition and are sterile when packaged. 5 Methods of Administering Enteral Feeds Feeding Regime Advantages Disadvantages Pump feeding can be used for all feeding routes Bolus feeding only suitable for gastrostomy feeding. Easily controlled rate. Can reduce GI complications. Reduced risk of re-feeding syndrome for susceptible patients e.g. patients with anorexia nervosa or who haven t eaten for a long period of time. Modern pumps now have a battery and can be portable. Some makes have a back pack which can be used when patients are out. Usually 4 6 bolus feeds per day then time free from feeding. Minimum equipment needed. Patient connected to the feed for a set period of the day and possibly night. May limit patients mobility if modern pumps are not available. May have an increased risk of GI symptoms. Each bolus should take on average 15 minutes. Any longer then gravity feeding could be considered and/or a review of the gastrostomy tube. N.B. Bolus feeding is unsuitable for NG or jejunostomy tubes 2
6 Monitoring Enteral Tube Feeding 6.1 In order to avoid complications and ensure optimal nutritional status, it is important to monitor the following in patients on enteral tube feeds: Where an NG tube is used correct site must be confirmed after insertion and prior to each feed Oral Intake Body Weight Urea and Electrolytes Blood Glucose Full Blood Count Fluid Balance Tolerance to feed e.g. nausea, fullness and bowel activity Bowel Chart Quantity of Prescribed Feed Care of Tube Care of Stoma Site Observe for signs of Infection 6.2 Frequency of monitoring should be decided by the Multi-Disciplinary Team (MDT) based on the individual s stability and nutritional risk. 7 Complications of Enteral Tube Feeding 7.1 The type and frequency of complications related to tube feeding depend on the access route, underlying disease state, the feeding regime and the patients metabolic rate. Complication Cause Prevention/Solution Aspiration Regurgitation of feed due to poor gastric emptying Displacement of tube Feed administered too quickly Medication to improve gastric emptying, e.g. metoclopramide. Check tube placement Ensure patient is in chair if possible or is sat up in bed at 45 degrees during feeding and for at least 30 45 minutes after 3
Complication Cause Prevention/Solution Nausea and Vomiting Related to disease/treatment. Medications Poor gastric emptying Rapid infusion of feed Patient re-assurance Anti-emetics Liaise with dietitian to review type of feed and method of administration Diarrhoea Medications e.g. antibiotics Bolus feeding Infection Avoid microbiological contamination of feed or equipment Suspend administration of laxatives Send stool sample to check for infection Keep stool chart Liaise with dietitian Fluid intake may need to be increased and monitored to prevent dehydration Anti-diarrhoeal agent (if infection is the cause of diarrhoea then antidiarrhoeal agents are not routinely recommended as diarrhoea is the body s way of eliminating infective agents from the gut.) Liaise with infection control nurse, doctor and pharmacist. A review of all medication is necessary as Sorbitol or Xylitol contained in some syrup s can have a laxative effect Constipation Inadequate fluid intake Immobility Use of opiates or other medication causing gut stasis Bowel obstruction Check fluid balance and correct if necessary Administer laxatives/bulking agents If possible encourage mobility If bowel obstruction suspected discontinue feed immediately Abdominal Distension Poor gastric emptying Rapid infusion of feed Constipation or diarrhoea Gastric motility agents Reduce rate of infusion If possible encourage mobility Treat constipation or diarrhoea 4
Complication Cause Prevention/Solution Blocked Tube Inadequate flushing or failure to flush feeding tube Administration of medication via the tube Prevent blockages by flushing with water before and after feeds in accordance with individuals feeding regime Refer to: UHM PGN 03 administration of medicines, section 13.1 crushing tablets and; Enteral feeding PGN s; Administration of medications and unblocking enteral feeding tubes for extra guidance 8 Home Enteral Tube Feeding 8.1 Some patients who are established on enteral tube feeding in hospital also require this to continue at home or in a nursing/residential home setting. A multi-disciplinary approach is needed for a successful leave/discharge; this should involve the patient and/or carer, dietitian, doctor, nurse, pharmacist, community nurse, general practitioner and community pharmacist when appropriate. The patient s circumstances and the ability to manage the feed will be assessed as part of the patient s leave/discharge planning. Adequate time should be allowed in the hospital setting for patient/carer to become fully accustomed to the techniques of the feed administration and care of the feeding tube, prior to leave/discharge. 8.1.1 Patients should also be given written information to reinforce the education they receive prior to leave/discharge. 8.1.2 Support in the form of the general practitioner, community nurse and community dietetic services should be established before leave/discharge. A multi-disciplinary leave/discharge meeting may benefit the patient and professionals involved. 8.1.3 In the circumstance where an NTW Community Team continues to be involved then there is a requirement that a physical health care plan is held in the patient s medical record detailing useful contacts and reviews in relation to the PEG site and feeding requirements. 5
8.2 If professional carers are to be used to provide care for the patient then it is necessary that they are able to manage the tube feeding as well. Trust staff must not assume responsibility for training and/or competency assessment with staff employed by any other agency or NHS Trust as this is the responsibility of their employer, however, the need to provide a safe handover of care, undertaken by means of risk assessments, care planning and practical demonstration of individual care may be required. Trust staff will need to be assured that receiving staff have been provided with training and have been competency assessed by their employer as part of this process. The MDT will be responsible for giving assurance on this and documenting in the records prior to discharge. 9 Termination of Enteral Tube Feeding 9.1 It is important to ensure that an individual is able to meet their nutritional requirements orally prior to termination of the feed. Ideally, the feeds should be reduced gradually, according to the dietary intake. It may be useful to maintain an overnight feed or reduced day time feed while the patient is establishing oral intake. 10 Staff Responsibilities 10.1 Within the Trust, enteral feeds must be managed as medication. Enteral feeds must be written on the medicine kardex by an authorised Dietitian and administered by qualified nursing staff who have successfully completed the relevant competency assessments. 10.2 Where a Dietitian is not available in person, an email detailing the format of the feeding regime to be written on the patient s kardex will be emailed to medical staff in order that they can copy requirements onto the kardex exactly as the Dietitian has directed, please see Appendix 1 for example e- mails. Sterile water flushes will be written in the comments box of the prescription. 10.3 In the rare event that prescriptions are required out of hours and dietitians are unavailable then a medic will be required to prescribe an enteral feed until the dietician is available. 10.4 Managers must ensure that staff are competent in administering fluids and medication via the enteral feeding tube either by bolus feeding or pump feeding as appropriate. Three yearly competency assessments (in line with medication administration competencies) are required. 10.5 Individuals will keep a copy in their portfolio, a copy will be held by the Ward Manager and a central copy will be kept in the Training Department. 6
11 Social and Residential Services Learning Disability Directorate 11.1 Within Social and Residential homes, enteral tube feed administration will be undertaken by suitably trained and competent staff, all services users care in relation to the feeding tube is monitored by PEG Nurse Specialist and/or Community/District Nursing Teams as part of an MDT approach. 11.2 Initial training and competency is assessed by the PEG Nurse Specialist and an annual competency assessment will be undertaken by S and R staff in conjunction with the Administration of Medication Assessment monitored by Team Leaders and Locality Managers. 11.3 All service users will have a comprehensive enteral tube feed care and risk management plan. 7