Enteral Nutrition (Continuing Care)

Transcription

1 Approved by: Enteral Nutrition (Continuing Care) Senior Operating Officer, Addiction & Mental Health and Continuing Care, Edmonton; and Senior Operating Officer, Rural Services Corporate Policy & Procedures Manual Number: VII-C-100 Date Approved March 12, 2018 Date Effective Next Review (3 years from Effective Date) April 2021 NOTE: The first appearance of terms in bold in the body of this document (except titles) are defined terms please refer to the Definitions section. Purpose To provide best practice guidelines for management of residents receiving enteral nutrition. To reduce the risk of adverse events/complications and to improve safety for the resident receiving enteral nutrition. Policy Statement Prior to administration of enteral nutrition, the health care team will consult with the resident/alternate decision maker to confirm that the intervention aligns with the resident's wishes. Inclusive in this discussion is consideration of the resident's/alternate decision maker (ADM) Advanced Care Plan: Goals of Care Designation and other care options. When administering enteral nutrition, health care professionals at Covenant Health Continuing Care facilities and programs shall adhere to criteria identified in the A.S.P.E.N Enteral Nutrition Handbook and identified Infection Control standards. Enteral nutrition requires an order from an authorized prescriber and shall have an accompanying order for dealing with a blockage of the enteral nutrition access device. Applicability This policy and procedure applies to all Covenant Health continuing care facilities, staff, medical staff, students and any other persons acting on behalf of Covenant Health. Principles Adherence to the A.S.P.E.N Enteral Nutrition Handbook guidelines and process will promote optimal nutritional support and reduce the risk of adverse events while improving resident safety. Enteral nutrition is indicated: 1. For residents with a functional GI tract who are unable to meet nutritional requirements orally whose condition is stable. 2. Those with severe dysphagia or damage to the esophagus, stomach, or intestines who can receive long-term feeding via stomach or intestines. 3. Enteral nutrition is contraindicated when aggressive therapy is not warranted or not in line with the resident s Goals of Care; e.g.in terminal phases of illness such as end-stage dementia or cancer Residents may be transferred to a Continuing Care facility with stable enteral nutrition.

2 VII-C-100 Page 2 of 10 Procedure 1. The Registered Dietitian (RD)/Authorized Prescriber Ordering of Enteral Nutrition 1.1 The RD/authorized prescriber will confirm all enteral nutrition orders on residents admitted to a continuing care facility or program. 1.2 Nursing will follow all orders received upon resident transfer to the facility. 1.3 Upon completion of their assessment, the RD/authorized prescriber will document the following: the type of enteral formula schedule of enteral nutrition all flushes required to meet fluid requirements 2. Nursing Administration of Enteral Nutrition 2.1 Review medical chart for any transfer orders for residents transferred to the facility or for changes to current enteral nutrition regime. 2.2 Contact the RD/authorized prescriber for further assessment and follow up on the transferred or changed enteral nutrition orders. 2.3 Before initiation of the enteral nutrition, review the rationale and feeding process with the resident/alternate decision-maker. 2.4 Follow Infection Control Guidelines in regard to Point of Care Risk Assessment, Hand Hygiene, etc. 2.5 Intermittent feeds should be administered using the recommended closed system and a pump where available. Open system feeds can be administered using either a pump or gravity. 2.6 The head of bed must be elevated at least 30 degrees during intermittent feedings and for at least 60 minutes following the end of the feeding. If this is not possible, position the resident on his/her right side (unless contraindicated) to lessen the risk of aspiration. 2.7 Collect the appropriate supplies; e.g. administration set, formula, personal protective equipment (PPE). 2.8 Visually inspect the plastic bag or Tetra Pak container, for external damage and altered formula characteristics with the plastic bag. 2.9 Compare the formula name to the physician s order to ensure the correct formula is being administered and check the expiry date on the formula bag/ Tetra Pak.

3 VII-C-100 Page 3 of Label the bag with the resident name, date and time the bag was administered Closed System Procedure Shake the bag well Close the roller clamp on the administration (spike) set Place the bag on a flat surface and remove the purple cap from the formula bag Ensure that the feeding tube is secured to the access site and its patency has been maintained. Report any leakage around the tube to the RN/LPN Using clean aseptic technique, remove the spike cover from the administration set and insert the spike into the port of the formula bag. Turn it clockwise until tight and give it an additional ½ turn to secure the fit Before connecting the administration set to the enteral access site, flush the enteral tube to maintain site integrity. See point 5.0 Maintaining Enteral Nutrition Before connecting the formula bag and the administration set to the resident, expel all air from the administration set line When using the infinity pump system, it is not necessary to hang the formula bag from a pole. Gravity feeding is not possible with the closed system. (Hang the bag on the IV pole if using the Kangaroo pump.) Do not interrupt feeding administration for routine care unless specifically ordered. If the feeding must be interrupted, flush the tube to reduce the residue in the tube and decrease the potential for clogging Do not re-spike a bag, even with new tubing, if it has already been spiked. See manufacturer s guidelines for administration set changes along with formula hang time based on source of preparation Open System Shake the formula Tetra Pak well Sanitize the top and rim of the Tetra Pak with an alcohol swab

4 VII-C-100 Page 4 of Pour formula into the feeding bag, without touching the inside of the bag or formula. Partially-used formula Tetra Pak must be dated, refrigerated and used within 24 hours. Visually inspect the formula for any altered formula characteristic changes Before connecting the administration set to the enteral access site, flush the enteral tube to maintain site integrity. See point 5.0 maintaining enteral nutrition Hang feed for appropriate amount of time (see manufacturer s guidelines for hang time). Hang the feeding bag on an IV pole if using the Kangaroo pump Do not interrupt feeding administration for routine care unless specifically ordered. If the feeding must be interrupted, flush the tube to reduce the residue in the tube and decrease the potential for clogging. 3. Assessing Tolerance 3.1 Monitor for signs of enteral intolerance such as emesis, abdominal distention, constipation, diarrhea and complaints of uncomfortable fullness, abdominal pain or nausea if resident is awake and alert. 3.2 If aspiration is suspected, observe for clinical signs and symptoms such as an unexplained fever, rapid breathing, shortness of breath or wheezing. Follow-up with an appropriate assessment and notify prescriber. 4. Increasing Feeding Rate 4.1 Increase the feeding rate according to the prescriber s order and in consultation with the dietitian. 4.2 Residents with diarrhea will likely require a more gradual increase. 4.3 As enteral nutrition increases, other fluid inputs such as hypodermoclysis may need to be reassessed to achieve optimal fluid balance. 5. Maintaining Enteral Nutrition 5.1 Record enteral nutrition information on the relevant forms, such as the Resident Flow Sheet/Daily Assessment/Fluid Balance Record. If there are unusual circumstances, record these in the progress notes.

5 VII-C-100 Page 5 of 10 Feeding bags, tubing, and other equipment used to flush the feedings should be changed in accordance with the manufacturer s instructions and as per site specific process. 5.2 Flush with a minimum of 10 ml water every four hours if enteral nutrition is held. Water used to flush feeding tube should not be added to feeding bag. 5.3 Separate 60 ml syringes should be used for flushes and for medications. These should be labelled and dated. 5.4 Syringes should be cleaned after use with warm soapy water and rinsed. Syringes can be kept for up to 72 hours and should be disposed of sooner if necessary. 5.5 If enteral nutrition device becomes blocked, instill ml warm water. Let sit for 15 minutes and attempt to flush with water. Cola, cranberry juice or other acidic substances are NOT recommended due to their low ph and potential for coagulation of proteins in the formulas. 5.6 If tube remains clogged: implement prescriber s order for one capsule of pancrealipase (eg. Cotazym) and one 325 mg tablet of sodium bicarbonate crush the sodium bicarbonate and open the Cotazym capsule and mix these with ml of water instill the mixture into the feeding tube clamp for five minutes flush with water until clear repeat twice if needed If tube remains obstructed, check for mechanical obstruction (tube may need replacing) If tubes remain plugged, consider using ClogZapper packages (Reference #20-000) 5.7 For residents on intermittent feeds or when feed is off, use the same cap from the spike set to cover the tip of the feeding tube. When the tip is connected, tape the cap to the pump for future use. 5.8 The tube and skin around the stoma site should be checked at the time of each feed. If leaking is noted, the RN/RPN should check the position of the tube and/or the balloon for inflation. A 2x2 gauze pad under the tube will help to determine if there is further drainage at the site. If there is further drainage, change the balloon type tube or consult the attending physician regarding leakage and a non-balloon type tube.

6 VII-C-100 Page 6 of Medication and Enteral Nutrition: Procedure for Administering Medication 6.1 Enteral nutrition tubes should be flushed with a minimum of 30 ml of water by syringe (60 ml) before and after medications. 6.2 Do not add medications directly to the formula bag in either the open or closed enteral system. 6.3 Use a liquid preparation where possible. Medications that can be crushed must be crushed to a fine powder, and then mixed to a slurry in water before adding to feeding tube by syringe. Certain medications should not be crushed e.g. sustained-release, enteric coated or micro capsulated products (check with Pharmacy before crushing pills). 6.4 Each drug must be administered separately to avoid clogging and to prevent drug interactions (i.e. do not administer multiple drugs together) If more than one drug is to be administered: flush with 30 ml water before the first drug; flush with 5-10 ml water between each drug; flush with 30 ml water after last drug 6.5 Refer to Covenant Health policy #VII-A-75, Infusion Line and Tubing Verification. 7. Care of the Replaceable Gastrostomy Tube (i.e. Balloon) 7.1 RNs/RPNs may insert, reposition and remove the replaceable gastrostomy tube (balloon type) only. RNs/RPNs may not insert, reposition or remove other types of gastrostomy tubes. If these gastrostomy tubes are accidently removed or displaced, contact the attending physician. 7.2 If a replacement tube is not readily available, any foley catheter can be inserted to maintain the gastrostomy stoma until a replacement gastrostomy tube is available. Contact the attending physician and document if the foley catheter is to remain in situ longer than eight hours. Note: the foley catheter is temporary and shall not be utilized for any instillations. 7.3 A replaceable Gastrostomy tube should be left in situ until the stoma site is established, at least six months.

7 8. Insertion VII-C-100 Page 7 of See the manufacturer s instructions regarding the insertion of the replaceable gastrostomy tube and the balloon volume. 8.2 Inflate the balloon with sterile water or saline in accordance with the manufacturer's instructions. Do not use air. 8.3 Inspect the balloon. There should be no leaks and the balloon should inflate evenly. Deflate the balloon. If the balloon sticks to the tube, fill the balloon with 12 cc sterile water or saline then bend the tube while pressing on the balloon. 8.4 Cleanse the stoma area with soap and water. 8.5 Lubricate the tip of the tube with water soluble lubricant (i.e. Muko). Do not use petroleum jelly. 8.6 Gently insert the tube. Ensure the tube is advanced through the tract and into the stomach. 8.7 Hold the tube in place and inflate the balloon with half the volume of sterile water or saline in accordance with manufacturer's instructions. Gently pull the tube up and away from the abdomen until resistance is felt. The tube is now positioned against the stomach wall. Following this placement check, fill balloon to its maximum inflation. 8.8 Wipe any fluid or lubricant from the tube and stoma. 8.9 Check for wetness around the stoma. If there are signs of gastric leakage, check the tube position. Add fluid to the balloon in 1 or 2 cc increments as needed. Do not exceed manufacturer's recommendations Verify the tube is properly placed by injecting 10 cc of air in the feeding port and auscultating the stomach for a bubbling or gurgling of air Record the tube type, gauge, length and the balloon inflation volume on the resident chart. 9. Removal of the Tube Note: The balloon and tube may be a stained brown color from contact with gastric juices. This is normal and will not affect the function of the tube. When the tube becomes brittle, schedule a change. Non-balloon type tubes can be functional for one to two years.

8 VII-C-100 Page 8 of To Change/Replace the GastrostomyTube Balloon type tubes (eg. MIC, MICKEY, or BARD trifunnel) can be changed by an RN if they come out or there is drainage at the stoma site. The site will close within four to six hours. A foley catheter can be used in the interim to maintain patency of the site if equipment is not available when the tube comes out. Consult the attending physician and document same if the tube is to be replaced by a foley catheter for longer than eight hours For non-balloon type tubes (eg. Ponsky), changes are done by the gastroenterologist and need to be ordered and pre-booked through an endoscopy day unit. Should non-balloon type tubes come out unexpectedly, a foley catheter can be used to maintain patency of the site, however, the resident must be sent to an Emergency Department to have the tube replaced. Consult the attending physician if the non-balloon type tube comes out When changing a tube, ensure that the same lumen diameter and balloon size is used this is determined by the gastroenterologist Once the replacement tube has been properly inserted and placement confirmed, enteral nutrition can resume. 9.2 To Remove the Gastrostomy Tube: Attach a luer-tipped syringe to the balloon port and withdraw the fluid. Note the amount and color of the withdrawn fluid. If the amount withdrawn is less than what the balloon was inflated with suspect leakage from the balloon Gently remove the tube while bracing the stoma site with gentle pressure If resistance is noted, lubricate the tube and stoma with water soluble lubricant (Muko) and gently rotate the tube as it is pushed in one inch. Gently work the tube free. Never use force to remove a tube. If the tube still cannot be removed, consult the attending physician. Definitions Advance Care Planning means a process which encourages people to reflect and think about their values regarding clinically indicated current and future health care choices; explore medical information that is relevant to their health concerns; communicate wishes and values to those important to them, their alternate decision-maker and their health care team; and record those choices.

9 VII-C-100 Page 9 of 10 Alternate decision-maker means a person who is authorized to make decisions with or on behalf of the resident. These may include, specific decision-maker, a minor s legal representative, a guardian, a nearest relative in accordance with the Mental Health Act [Alberta], an agent in accordance with a Personal Directive, or a person designated in accordance with the Human Tissue and Organ Donation Act [Alberta]. Authorized prescriber means a health care professional who is permitted by Federal and Provincial legislation, her/his regulatory college, Covenant Health, and practice setting (where applicable) to prescribe medications. Enteral nutrition refers to the system of providing nutrition directly into the gastrointestinal tract bypassing the oral cavity. Enteral nutrition may be necessary because of decreased level of consciousness, and swallowing difficulties. Closed enteral nutrition system is a tube feeding formula that is available in sterile, ready to hang plastic bags. This is the recommended system. The benefits of a closed system include improved resident safety, decreased contamination risk, reduced tubing cost and formula wastage. The bag is spiked with an administration set, releasing the formula. Can only be used with a pump, no gravity feeds permitted. Open enteral nutrition system uses commercially sterilized cans that are poured into bags. The open system can be used with or without a pump. Family means one or more individuals identified by the resident as an important support, and who the resident wishes to be included in any encounters with the health care system, including, but not limited to, family members, legal guardians, friends and informal caregivers. Goals of Care Designation means a codified instruction that provides direction regarding general care intentions, specific health interventions, transfer decisions and locations of care, for a patient as established after consultation between the most responsible health practitioner, patient and when appropriate, alternate decision-maker. Goals of care designation order means the documented order for the Goals of Care Designation as written by the most responsible health practitioner Related Documents Covenant Health Policies Nutrition and Hydration Policy, #VII-C-105 Palliative Care Pathways, #VII-C-20 Advance Care Planning Goals of Care Designation, #VII-B-350

10 VII-C-100 Page 10 of 10 References A.S.P.E.N. (2010). Enteral Nutrition Handbook. Editors Boullata, J, Carney, L, Guenter, P. Fessler, TA. (June 2010). Fletcher, J. (2011). Nutrition: Safe Practice in Adult Enteral Tube Feeding. British Journal of Nursing 20(19): Simons, S and Remington, R. (2013). The Percutaneous Endoscopic Gastrostomy Tube: A Nurse s Guide to PEG Tubes. Pages 77 to 83. Framingham State University. The A.S.P.E.N. Adult Nutrition Support Core Curriculum. (2012). Chapter 10 (Overview of Enteral Nutrition); Chapter 11 (Enteral Formulations); Chapter 12 (Enteral Access Devices); Chapter 13 (Complications of Enteral Nutrition) accessed Nov. 16, al_nutrition_toolkit/enteral_nutrition_practice_recommendations/. Perry AG, Potter PA, Ostendorf WR. (2014). Enteral Nutrition, Clinical Nursing Skills and Techniques, Chapter 31 (pages 775 to 795). Previous Version Date(s) N/A