Date Issued Planned Review PGN No: Part of NTW(C)29 - Trust Standard for Assessment and Management of Physical Health Author/Designation

Transcription

1 Trust Standard for Assessment and Management of Physical Health Policy Practice Guidance Note Enteral Tube Care, Management and Feeding (Gastrostomy and Jejunostomy) V01 Date Issued Planned Review PGN No: Issue 1 Aug 16 Aug 19 AMPH-PGN-02.1 Part of NTW(C)29 - Trust Standard for 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 Practice Guidance Overview 1 3 Gastrostomy Tube Care 1-3days post op 1 4 Gastrostomy Tube Care 3 days plus post op 3 5 Gastrostomy Feeding Bolus Administration Procedure 5 6 Feeding via a Pump 8 7 Administering Medication via a Feeding Tube 10 8 Unblocking a Feeding Tube 13 9 References 14 1 AMPH-PGN Enteral tube care, management and Feeding (gastrostomy and jejunostomy)-v01-aug16 Part of NTW(C)29 Trust Standard for the assessment and management of physical health

2 1 Introduction 1.1 Feeding patients via a tube is classified as, and managed as, medicine within (the Trust/NTW). Therefore there is a need to standardise and assess practices to give assurance of high quality care and evidence of development training which will safeguard patients and staff against adverse incidents. 1.2 This Practice Guidance Note (PGN) has been written in collaboration with dietitians, pharmacists, medics and nursing staff. 1.3 Please read this document in conjunction with the Trust s NTW(C)29 Trust Standard for the assessment and management of physical health, Enteral Feeding PGN AMPH-PGN-02 Enteral Tube Feeding Overview. 2 Practice Guidance Overview Whenever possible pre-admission assessments must identify patients requiring enteral tube feeds in order that relevant equipment and feed is available for admission; All enteral feeds must be prescribed by a competent, approved dietitian or medic on the patient s medicine kardex to include a prescription for the sterile water flushes required PRN. Competent Qualified nurses only are to administer feed which must be recorded on the patients medicine kardex and fluid balance chart; NTW Medication Competency assessment, number 6, must be completed by qualified staff initially, prior to administering enteral feeds and 3 yearly thereafter as per policy or as necessary 3 Gastrostomy Tube Care days 1-3 post operatively 3.1 Immediate post op care instructions if required will be provided by Surgical Team Equipment 1 Access to handwashing facilities 2 PPE single use gloves and apron 3 Sterile dressing pack and gloves 4 Clean dressing trolley No: Action Rationale 1 Explain and discuss the procedure with the patient 2 Perform hand hygiene and apply PPE; single use gloves and aprons To ensure that the patient understands, and consents to, the procedure To minimise the risk of cross 1

3 No: Action Rationale 3 Observe peri-stomal skin and stoma site for signs of, irritation or excoriation 4 Note the number of the measuring guide on the tube closest to the end of the external fixation device. Loosen the tube from the fixation device and ease fixation device away from the abdomen. The external fixation plate should be subjected to very low traction, without tension to maintain contact of the stomach with the abdominal wall 5 Using aseptic non touch technique, clean the stoma site with normal saline. Dry thoroughly with gauze swabs. Rotate the gastrostomy 360o 6 Gently push the fixation Gently push the external fixation device against the abdomen checking the measurement guide Do not use bulky dressings, particularly under the external fixation device 7 Advise the patient and/or staff as appropriate not to use moisturising creams or talcum powder around the stoma site 8 Nursing staff must observe and monitor stoma site during each feed for signs of wound deterioration/ and manage appropriate To detect complications early and instigate appropriate treatment To ensure gastrostomy tube is reattached to the fixation device in the correct position To ensure the stoma site is thoroughly cleaned. Remove any exudates, to prevent and skin excoriation To prevent the tube adhering to the sides of the stoma tract To enable the gastrostomy tube to be reattached to the fixation device To encourage healing in the newly formed stoma site and prevent air to the stoma as this may cause To prevent and/or irritation to skin. The grease in creams can cause the external retention device to slip, allowing movement of the tube and increasing the risk of leakage and. Creams and talc s can affect the tube material, causing it to stretch or leak. Patients should be taught how to carry out this procedure for themselves 9 Dispose of all single use items in appropriate waste receptical 2

4 4 Gastrostomy Tube Care - 3 days plus post-operative Equipment 1 Access to handwashing facilities 2 PPE, single use gloves and apron 3 Disposable wipes 4 Dressing Trolley No: Action Rationale 1 Explain and discuss the procedure with the patient To ensure that the patient understands, and consents to, the procedure 2 Perform hand hygiene IPC- PGN and apply PPE, single use gloves and aprons IPC-PGN-02.1 To minimise the risk of cross 3 Observe peri-stomal skin and stoma site for signs of, irritation or excoriation To detect complications early and instigate appropriate treatment 4 Note the number of the measuring guide on the tube closest to the end of the external fixation device. Loosen the tube from the fixation device and ease fixation device away from the abdomen. The external fixation plate should be subjected to very low traction, without tension to maintain contact of the stomach with the abdominal wall To ensure gastrostomy tube is reattached to the fixation device in the correct position 5 Clean the stoma site with soap and water and disposable wipes. Dry thoroughly with disposable wipes. Rotate the gastrostomy 360 o To ensure the stoma site is thoroughly cleaned. To remove any exudates, to prevent and skin excoriation continued 3

5 No Action Rationale 6 Gently push the external fixation device against the abdomen checking the measurement guide Do not use bulky dressings, particularly under the external fixation device To prevent the tube adhering to the sides of the stoma tract To enable the gastrostomy tube to be reattached to the fixation device To encourage healing in the newly formed stoma site and prevent air to the stoma as this may cause 7 Advise the patient and/or staff as appropriate not to use moisturising creams or talcum powder around the stoma site To prevent and/or irritation to skin. The grease in creams can cause the external retention device to slip, allowing movement of the tube and increasing the risk of leakage and. Creams and talc s can affect the tube material, causing it to stretch or leak. Patients should be taught how to carry out this procedure for themselves. 8 Nursing staff must observe and monitor stoma site during each feed for signs of wound deterioration/ and manage appropriately 9 Dispose of all single use items in the appropriate waste receptacle NB It may be relevant for some patients with long term PEG tubes in situ to be referred for a change to a button PEG. In this instance there will be specific practice guidance and management instructions, relevant to the particular button used, supplied by the Specialist Team. This must be included in the patients care plan. 4

6 5 Gastrostomy feeding bolus administration procedure 5.1 Please note Enteral feeding via a Percutaneous Endoscopically placed Jejunostomy (PEJ) must always be done via a feeding pump, never bolus. No: Equipment Rationale NB: At no point should three way taps or Syringe tip adaptors be used (NPSA safety alert 19, March 2007) 1 Prescribed feed and required amount of sterile water to be administered NB Sterile water must be used for all feeds. Sterile water once opened must be labelled with the patients details the date and time of opening. It must be discarded after 24 hours. 2 Enteral feed syringe These have purple plungers to clearly identify that they are for enteral feeding use only. Single patient use only. NB: Single patient use syringes must be discarded after 24 hrs, therefore they also need to be labelled with name, date and time of allocation. Single patient use equipment must be stored in a lidded container marked with the patient s name Each time and as appropriate the syringes must be discarded and the lidded container must be washed with hot soapy water and dried 3 Managers must ensure that there is a supply of enteral feeding syringes available on the ward if they undertake enteral feeding 4 Feeding tube extension if feeding via button gastrostomy 5 Access to hand washing facilities to wash hands. Apply personal protective equipment single use gloves and apron IPC PGN 02.1 To promote safety in Enteral Feed administration To prevent To prevent risk of wrong route with liquid administrations. National Patient Safety Agency (safety alert 19, March 2007) To ensure syringes are not used past manufacturers recommendations of usage To enable delivery of enteral fee via button To prevent cross 6 Clean Dressing trolley To prevent cross continued 5

7 No: Procedural Actions Rationale 1 Explain and discuss the procedure with the patient To ensure syringes are not used past manufacturers recommendations of usage 2 Ensure patient is comfortable 3 Ideally the patient should be upright in a chair or sitting up in bed at 45 degrees prior to commencement, during feed and at least 30 minutes afterwards 4 Any interventions e.g. toileting, positional changes should be complete prior to feed administration and not during unless unavoidable 5 Ensure feed type and quantity match prescription on the patient s medicine kardex. Check expiry date. Document administration on medicine kardex and fluid chart 6 Decanting or diluting feed should be avoided unless absolutely necessary, in which case single use jugs must be used. Pre-packed commercially prepared feeds should be used and administered directly from the bottle. Measurements are made on the side of the bottle to accommodate this. When only part of the bottle is used the remainder can be stored in the fridge for later use. The bottle must be labelled with name date and time and stored in the fridge until the next time, it must be used within 24hours or discarded 7 Ensure feeds must be at room temperature for administration. They must be stored in the treatment/clinic room or an agreed locked store room that is cleaned to the same standards as that of food products. If they have been stored in the fridge then they must have been removed for 30 minutes prior to administration To prevent aspiration To avoid movement immediately after feed and prevent any vomiting or aspiration To ensure patient safety To minimise the risk of cross To prevent abdominal cramps 8 Gently shake bottle in preparation continued 6

8 No: Procedural Actions Rationale 9 Wash and dry hands and apply PPE prior to decanting or commencing procedure. IPC PGN-04.1 hand Hygiene PGN To minimise the risk of cross 10 Expose the gastrostomy tube only from clothing/bedding. Observe for any fresh bleeding or external leakage of gastric contents prior to commencing feed. If these are observed Do Not administer feed until patient has been referred to and examined by the appropriate medical team. To maintain patient dignity To ensure correct placement of tube prior to feeding and review for potential complications prior to feed administration. 11 Close the gastrostomy clamp prior to removing the end stopper/bung To prevent leakage of gastric contents 12 Connect the feeding tube extension (if button gastrostomy in situ) or the extended gastrostomy tube to the enteral feeding syringe without touching the inside of the gastrostomy tube To minimise the risk of cross 13 Pour 5 10 mls of measured sterile water (or the appropriate amount as indicated by the dietitian) into the enteral feeding syringe and release clamp To flush feeding tube To allow administration 14 Fill syringe with enteral feed immediately after sterile water, without a break 15 Continue to administer prescribed amount of feed in the same way as above. Ensure feeding tube is held at a height that prevents feed administration being too quick. A feed should take approximately minutes to administer. Any pain on feeding or prolonged, severe pain requires termination of feed and immediate referral to appropriate medical team. 16 Administer remaining amount of required sterile water To reduce air intake during feed administration Administering feed too quickly can cause the patient to go into shock Pain may be an indicator of tube displacement or complication. To flush tube upon completion continued 7

9 No: Procedural Actions Rationale 17 Close clamp when all fluid is administered, remove enteral feeding syringe and replace end stopper/bung. Release clamp To prevent leakage of gastric contents 18 Replace feeding tube under clothing /bedding as necessary To maintain patient dignity 19 Advise patient to rest for at least 30 minutes if possible. (Horizontal resting is not advised to minimise risk of aspiration) To aid digestion 20 Remove apron and gloves and perform hand hygiene. IPC- PGN To minimise the risk of cross 21 Clear away equipment dispose of single use items in accordance with local policy. Waste Management Policy NTW(O) 24 None disposal equipment, if necessary, must be cleaned and dried appropriately. Extension sets must be dried on the outside and hung in protective outer coat e.g. in elephant oxygen tubing to air dry 22 Elephant tubing must be renewed weekly and extension sets monthly, therefore they must be labelled with name, date and time To minimise the risk of cross 23 Document on fluid balance chart; type, amount of feed and water administered 8

10 6 Feeding via a Pump 6.1 Follow steps 1-9 of bolus administration procedure and add feed pump to equipment list NB Enteral feeding pump and compatible giving set. Enteral feeding system devices must be purchased with the recommended connector combinations. (NPSA safety alert 19, March 2007) No: Procedural Actions Rationale Follow steps 1 9 of Section 5 - bolus administration procedure and then: 10 Expose the gastrostomy tube only from clothing/bedding. Observe for any fresh bleeding or external leakage of gastric contents prior to commencing feed. If these are observed Do Not administer feed until patient has been referred to and examined by the appropriate medical team. To maintain patient dignity To ensure correct placement of tube prior to feeding and review for potential complications prior to feed administration. 11 Connect the feed bottle to the giving set, without touching the inside of the bottle or giving set and run feed through to the end of the tube using the wheel clamp of the set. This should be done over a kidney bowl in case of spillage. The giving set must be labelled with name, date and time and change giving set every 24hours To minimise risk of cross 12 Connect the feeding system to the pump system and set to one side, ready to connect later, ensuring tip of giving set is not contaminated To minimise risk of cross 13 Without touching the inside of the gastrostomy tube or the tip of the extension set, connect the feeding tube extension if applicable to the end of the giving set To prevent leakage of gastric contents continued 9

11 14 Attach enteral feeding syringe to enteral feeding tube. Pour 5 10 mls of measured sterile water (or the appropriate amount as indicated by the dietitian) into enteral feeding syringe and release clamp To minimise risk of cross 15 Attach feeding system to tube To flush feeding tube 16 Pump must be set (in accordance with manufacturer s instructions) to required feeding rate/volume as specified in the patients care plan Any pain on feeding or prolonged, severe pain requires termination of feed and immediate referral to appropriate medical team. To allow administration Pain may be an indicator of tube displacement or complication. 17 After feed is completed and/or between bottles administer specified amount of sterile water through the tube via syringe To flush tube and prevent blockage To enable adequate fluid intake if continuous feeding 18 Close clamp when all fluid is administered, remove enteral feeding syringe and replace end stopper/bung. Release clamp To prevent leakage of gastric contents Follow steps of bolus administration procedure 10

12 7 Administering medication via a feeding tube Equipment list; No: Equipment Rationale 1 Purple enteral feeding syringe To prevent risk of wrong route with liquid administrations. (NPSA safety alert 19, march 2007) 2 Single use Medicine pot/pots To prevent cross and cross contamination 3 Feeding tube extension if feeding via button PEG To enable delivery of medication via button 4 Sterile water as appropriate. Water must be fresh and kept covered To reduce the risk of 5 Tablet crusher if tablets are being administered. NB tablets should be crushed as a last resort and this must be instructed following pharmacy advice and documented in notes by a doctor or pharmacist who must take overall responsibility Crushed tablets are considered as off licence once crushed, effects may differ therefore the prescribing practitioner or pharmacist must take responsibility in instructing that medications are administered in this format 6 Hand washing facilities 7 PPE: single use gloves and apron continued 11

13 Procedure; No: Procedural Actions Rationale 1 Check whether patient can take medication orally and if medication is necessary If patient can take the medication orally (or no longer requires the medication) it reduces the risk of tube blockage 2 Consider whether an alternative route can be used, e.g. Buccal, sublingual, transdermal, topical, rectal or subcutaneous If an alternative route can be found it removes the risk of tube blockage by medication 3 Check drug is absorbed from the site of delivery. 4 A pharmacist must always be contacted for advice where there are no explicit directions for administration on the inpatient medication chart. This includes which preparation to use and how to administer the individual medications Some liquids may block feeding tubes whilst some tablets are dangerous (as well as unlicensed) if crushed. The pharmacist will advise on which preparation to give and how to prepare and administer it. This advice will be written by the pharmacist on to RiO records at the next available opportunity and must be transcribed on to the service user s inpatient drug chart before administration 5 Perform hand hygiene 6 Apply PPE: single use gloves and apron To minimise cross- and protect the practitioner from gastric/intestinal contents 7 Stop administration of the enteral feed (bolus or pump) and flush the tube with at least 30ml of sterile water using a purple enteral feeding syringe Some medications interact with enteral feeds, rendering them non-therapeutic. Seek pharmacist advice if new medications are prescribed alongside feeding regimens. Never add medication directly to the enteral feed To clear the tube of enteral feed as this may cause a blockage or interact with medications. Some regimens may have to be stopped for up to two hours before and after medications. Also to ensure the patient s nutritional requirements are met in the time around medicine administration continued 12

14 No: Procedural Actions Rationale 8 Prepare each medication to be given separately Soluble tablets should be dissolved in 10-15mls sterile water Liquids should be shaken well. Thick liquids should be mixed with an equal amount of sterile water If volumes of less than 10ml are required the dose should be measured in a 10 ml single use oral syringe Tablets (after following step 4 and information in equipment section) must be crushed using tablet crusher and mix with 10 15ml sterile water 9 The plunger of the enteral syringe should be removed and the barrel connected with the enteral tube. The medication should then be administered via the barrel of the 50ml syringe 10 Rinse the tablet crusher (if used) with 10ml sterile water, draw up in a 50ml syringe and flush this through the tube via the enteral syringe barrel Some medications are not designed to be crushed. These include; a) Modified-release tablets; absorption will be altered by crushing, possibly causing toxic side effects b) Enteric coated tablets; the coating is designed to protect the drug against gastric acid c) Cytotoxic medicines; this will risk exposing the practitioner to the drug 11 If more than one medicine is to be administered, flush between drugs with at least 10ml of sterile water to ensure that the drug is cleared from the tube 12 Flush the tube with at least 30ml sterile water following the administration of the last drug 13 If the patient is on a fluid restriction, or for a paediatric patient, consult the dietitian and pharmacist about the quantity of water to be given before and after medication To avoid interaction between different medications and to ensure solubility To ensure the whole dose is administered and to avoid medicines blocking the enteral tube To Ensure the patient does not exceed their fluid restriction or requirements 13

15 8 Unblocking a Feeding Tube Equipment 1 Access to hand washing facilities 2 2 PPE single use gloves and apron 3 50ml purple enteral feeding syringe 4 Sterile water 5 Carbonated water e.g. soda water No: Procedural Actions Rationale 1 Perform hand hygiene with soap and water To prevent cross contamination 2 Apply PPE, single use gloves and apron 3 Always flush the enteral tube before and after administration of feed and medication with at least 30ml of sterile water 4 Frequency of flushing may need to be increased to keep jejunostomy tubes patent. Please liaise with dietitian) 5 If the tube is blocked try to administer 50ml warm water down the enteral tube and leave for 30 minutes. To obtain lukewarm water (40-45 o C) put (120ml) of sterile water into 40 mls boiled water To avoid the tube blocking Sterile water must be used for jejunostomy tubes as water is bypassing the protective acidic environment of the stomach To dissolve any medication or soften any feed plugs in the tube To prevent hot water being administered via the feeding tube 6 Flush tube with 50ml sterile water To remove blockage 7 If unsuccessful try to administer 50ml carbonated water, e.g. soda water, via the enteral tube and leave for 30 minutes To dislodge blockage 8 Flush tube with 50ml sterile water To remove blockage 9 If tube is still blocked consider use of proprietary product designed to unblock tube. Follow manufacturer s instructions To break down plug. Such products contain digestive enzymes which may break down a protein plug but they may not unblock a tube blocked with medication 10 Do not use a smaller syringe than 50ml. To avoid the tube being ruptured with the high pressure of a smaller syringe No: Procedural Actions Rationale 11 If all of the above are unsuccessful then the enteral tube will need to be replaced. To ensure continued enteral access for the administration of feed, fluids and medication 14

16 9 References Infection Prevention Society (2010) Quality Improvement Tools. Available at: National Evidence Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England (2014). Journal of Hospital Infection, 86S1 Department of Health (2007) Saving Lives: a delivery programme to reduce healthcare associated including MRSA revised edition, HMSO, London. 15