Tube Feed Management at Home for Adults Clinical Nutrition Services CEAC 0078 April 2017
Table of Contents To Obtain Tube Feeding Formula...2 To Obtain Tube Feeding Supplies... 3 Tube Feeding....4 Types of Feeding Tubes..4 Your Feeding Schedule...5 Your Water Flushes. 5 Getting Organized... 6 Proper Positioning During and After Your Feeding... 7 If You are Using a Pump. 8 If You are Using a Gravity Bag.. 9 If You are Using a Syringe....10 How to Stop Your Feeding...10 Cleaning Up After Your Feed...11 Medications and Your Feeding Tube........12 Mouth Care...13 Care of Your Tube Site.....13 Care of Your Feeding Tube...14 Concerns - Diarrhea, Constipation, Cramping......15 Concerns - Feeling Sick.... 16 When to Go to the Emergency Department......16 Call Your Health Care Provider if...........16 Important Phone Numbers/Notes......17 Notes.....18 Map to Nutrition and Food Services, Regina General Hospital.......19 2
To Obtain Tube Feeding Formula 3 days before picking up the product call the Nutrition and Food Services Department at (306) 766-4351 to order product. Hours of Service: Monday to Friday 8:00 a.m. to 4:30 p.m., except statutory holidays. Products can be purchased by the case only. Returns will not be accepted. Try to order 1 month s supply at a time. If there is a chance you may not require the product for an entire month, feel free to order smaller amounts. If you wish to have the product delivered, discuss arrangements for this service at the time you place your order. On Pick up Day Product may be picked up Monday to Friday, 9:00 a.m. to 3:00 p.m., except for statutory holidays. Go to the Nutrition and Food Services Department office at the Regina General Hospital. Parking is available in the parking stalls marked Meals on Wheels. See map on page 19. Payment for product may be made by Debit, Visa, or MasterCard. An employee is available to help you with loading of your nutritional product. When You Get Home Store your formula at room temperature, out of direct sunlight. 3
To Obtain Tube Feeding Supplies 1 day before picking up the product call the Distribution Department to order supplies at (306) 766-4569. Hours of Service: Monday to Friday 9:00 a.m. to 3:00 p.m., except statutory holidays. Feeding Supplies Information: 60 ml catheter tip syringes Order Number 311118 gravity feed bags Order Number 310056 feed bags for Covidien Kangaroo epump Order Number 311331 On Pick up Day Go directly to the Distribution Department at the Regina General Hospital during the hours of service listed above. Parking is available in the parking stalls marked Meals on Wheels. See map on page 19. The Distribution Department is down the hall from the Nutrition and Food Services Department, on the right hand side of the hallway. Note: If you are unable to pick up your supplies, courier services are available for a fee. Check the SaskTel Yellow Pages. 4
Tube Feeding Tube feeding is a way for you to meet all or some of your nutrition needs. A formula given through a tube replaces or supplements your normal diet when you are unable to eat or drink enough. Types of Feeding Tubes Tracheosophageal Puncture (TEP) catheter: passes through the trachea into the esophagus and down into the stomach. Gastrostomy Tube (G-Tube): passes through the skin into the stomach. Jejunostomy Tube (J-Tube): passes through the skin into the jejunum, the upper part of the small intestine. Combination Gastrostomy/Jejunostomy Tube (G-J Tube): This feeding tube has 2 openings - one that passes through the skin into the stomach and another that passes through the skin into the jejunum. Your feeding tube is a LifeART images copyright (2001) Lippincott Williams & Wilkins. All rights reserved. 5
Your Feeding Schedule The amount of formula you need each day is: Type of Formula Number of Containers per Day Suggested Feeding Schedule Time Type of Formula Amount of Formula Your Water Flushes Use drinking water at room temperature for your flushes. The amount of water you need each day is. Suggested Flushes Time Amount of Water 6
Getting Organized Note: If your feeding tube looks like it has moved do not start feeding. Call your health care provider immediately. 1. Wash your hands with soap and warm water. Image courtesy Microsoft Office ClipArt 2. Get your clean feeding supplies. You will need: 3. Get the formula you will need. See page 5 for type and amount of formula. Check the expiry date on the formula. If the formula has expired, throw it out. Use formula that is at room temperature. If you are using formula already opened from a previous feeding take it out of the refrigerator 1 hour before feeding to allow it to warm to room temperature. Note: If the formula has been in the fridge for more than 24 hours, throw it out. Do not use formula that has been frozen. Wipe the top of each can with a clean cloth. Shake the formula gently. 4. Flush the tube with water. See page 5 for amount. Fill a syringe with drinking water that is at room temperature. Attach the syringe to the feeding tube and slowly push the water into the tube. 5. Seal any partly used containers of formula with plastic wrap. Write the date and time that the container was opened on the container and place it in the fridge. Once a can is opened, it must be kept in the refrigerator and used within 24 hours. 7
Proper Positioning During and After Your Feeding Do not lie flat during a feeding or for at least 30 minutes after the feeding. You may: Sitting - be sure to sit upright. Image courtesy Microsoft Office ClipArt Reclined - be sure to stay upright by at least 30. A foam wedge may be purchased from a medical supply store, to ensure adequate elevation during your feeding. Photo courtesy RQHR Clinical Nutrition Services Department Walk - if you can, you may walk during your feeding. Image courtesy Microsoft Office ClipArt After your tube feeding is finished continue in one of the above positions for 30 to 60 minutes. 8
If You Are Using A Pump 1. Close the clamp on the feeding bag tube. Pour the formula for your feeding into the feeding bag. See page 4 for the type and total amount of formula to be used. 2. Hang the feeding bag on a pole or. 3. Hold the end of the feeding bag tube up. Open the clamp on the feeding bag tube. Let the formula go to the end of the tube. This gets rid of the air in the tube. Close the clamp. Some pumps have a setting to automatically fill the tube with formula. 4. Attach the tubing to the pump as shown by your nurse. Photo courtesy RQHR Clinical Nutrition Services Department 5. Set the pump at the rate suggested on the table below. The feeding rate and amount of formula needed will determine the length of time it will take your feeding to be completed. Feeding Rate (ml/hr) Length of Time for Feeding to Run 6. Do not use formula that has been in the bag for more than 12 hours. 7. During continuous feeds, flush your feeding tube with water every 4 hours to prevent it from clogging - see page 5 for amount of flushes. 9
If You Are Using A Gravity Bag 1. Close the clamp on the feeding bag tube. Pour the formula into the feeding bag. See page 5 for the type and amount of formula to use at each feeding. 2. Hang the feeding bag on a pole or. 3. Hold the end of the feeding bag tube up. Open the clamp on the feeding bag tube Let the formula go to the end of the tube as this gets rid of the air in the tube. Close the clamp. 4. Open the cap at the end of your tube. Put the end of the feeding bag tube into your tube. 5. Slowly open the clamp on the feeding bag tube. Photo courtesy RQHR Clinical Nutrition Services Department The food should run at a rate of about 20 to 25 minutes per 200 to 250 ml of product. If the feed is too slow, open the clamp more. If the feed is too fast, close the clamp a bit. The time it should take for your feeding to run is about: Feeding Amount of Time 10
If You are Using a Syringe 1. Remove the plunger from the syringe and set it aside as the plunger will not be used. You now have a hollow syringe. 2. Clamp off your feeding tube. 3. Open the port on your feeding tube and insert the narrow end of the syringe into the end of your feeding tube and lower the syringe to below the hips. 4. Pour formula into the hollow syringe until it is ¾ full. 5. Raise the connected feeding tube and hollow syringe to above your waistline. 6. Unclamp your feeding tube to let the formula flow through it. If the formula is running too quickly, lower the syringe or temporarily pinch or kink your feeding tube with your fingers to slow it down. 7. Repeat steps 1 through 6 until all the formula required for the feeding is used. See page 5 for type and amount of formula to be used at each feeding. 8. One feeding should take about 10 to 30 minutes. How to Stop Your Feeding 1. If using a pump or gravity bag: Close the clamp on the tube when your feeding is finished. Take the feeding tube out of your tube. Go to #2 for flushing instructions. If using a syringe: Disconnect the syringe from your feeding tube. Go to #2 for flushing instructions. 2. Flush with water. Fill a syringe with water. See page 5 for amount of water to be used. Use drinking water that is at room temperature for flushes. Attach the syringe to the tube and slowly push the water through the tube. Remove the syringe and put the cap back on your feeding tube. 11
Cleaning Up after Your Feed Cleaning of Feeding Bags Note: If you have a feeding pump do not disconnect the bag from the pump to clean it. 1. Rinse the feeding bag with clean cool water. Shake the bag back and forth several times to permit the water to reach all areas of the feeding bag. 2. Drain the water from the top of the bag, into the sink. Repeat this several times until the water is clear and you are sure all the formula has been rinsed out. 3. Run clean, cool water through the tubing several times until the water comes out clear and you are sure the tubing is clean. 4. Hang the feeding bag in a clean, dry place. Cover with a clean, dry towel. Note: The same feeding bag and tubing may be used for 24 hours of actual run time (feeding time). Do not use a dirty feeding bag. Cleaning of Syringes 1. Wash any syringes with cool, clean water after each use, until the water is clear. 2. You may scrub inside the syringe with a clean bottle brush, if needed. 3. Store syringes in a clean, dry place. 12
Medications and Your Feeding Tube Buying Medications for Your Feeding Tube Talk to your pharmacist or health care provider about all your medications (prescription, over the counter, supplements, herbal supplements) to be sure they can be given through your feeding tube. Remind your pharmacist or health care provider about your feeding tube, each time you need to take any new medicine or supplement. Buy medications that come in liquid form, when available. Taking Medications Through Your Feeding Tube 1. Wash your hands with soap and warm water. 2. Before you take your first medication, use a syringe to flush your feeding tube with 30 ml (1 ounce) of water. 3. Prepare each medication, one at a time, just before putting it in your feeding tube. Capsules: Open the capsule and place the contents in a paper cup. Dissolve completely in (at least) 30 ml (1 ounce) of warm water. Tablets or pills: Place the pill between the back of 2 spoons, or use a mortar and pestel, or other device to crush the pill very well. Place the contents in a paper cup. Dissolve completely in (at least) 30 ml (1 ounce) of warm water. Liquid medications: Place in paper cup and mix with 30 ml (1 ounce) of water. Never mix any medications with any liquid other than water. Once mixed in water, give each medication slowly with a syringe. Each medication must be given separately. 4. Between each medication, flush with 30 ml (1 ounce) of water. 5. After you have taken the final medication, flush your feeding tube again once with 30 ml (1 ounce) of water. 13
Mouth Care Good mouth care is important at all times, even if you are not eating. Brush your teeth at least 1 to 2 times each day. If you are unable to brush your teeth, rinse your mouth 1 to 2 times a day. Use 5 ml (1 teaspoon) baking soda in 500 ml (2 cups) of warm water to rinse. Dry Mouth Be sure to use the full amount of water for flushes each day, as recommended by the dietitian. See page 5. If you still have a dry mouth, use more water after each feeding. Contact your dietitian for a review of your water needs. Care of Your Tube Site Cleaning Your Tube Site Clean the skin around your feeding tube every day. Use soap and warm water or whatever your health care provider recommends. Dry well. A cotton swab may be used. Other Care of Your Tube Site Rotate your tube 360 each day. Exception: if you have a combination gastrostomy/jejunostomy feeding tube, do not rotate it. A dressing is not necessary unless there is fluid leaking around your feeding tube site. If skin is red, paint it using a cotton ball with a liquid antacid. If you have any questions about care of your tube site, ask your health care provider. 14
Care of Your Feeding Tube To prevent your feeding tube from clogging, always flush your tube with water: before and after each feeding before, between, and after each medication taken - see page 12 every 4 hours during continuous feeding. If Your Feeding Tube Becomes Clogged: 1. Stop your tube feeding immediately. 2. Attach an empty syringe to the feeding tube and gently pull back on the plunger. 3. If the tube does not unblock, remove the syringe and fill the syringe with warm water. 4. Attach the syringe to your tube and gently push the water into the tube. Do not force water into your tube. 5. Gently pull the plunger, drawing back into the syringe. 6. Repeat steps 2 through 5 several times, as needed. Note: If you are unable to unclog the tube, contact your health care provider. If your feeding tube clogs often, you may not be flushing properly. Ask your dietitian to review your flushing schedule. 15
Concerns Diarrhea To Prevent Diarrhea: Use formula that is room temperature. If formula was stored in the fridge, set it out at room temperature for 1 hour before you use it. Always wash your hands. Always use clean equipment for feedings. Follow sanitary rules for storage and handling of equipment. Never mix medication with formula. Do not hang the formula for more than 12 hours. If You are Experiencing Diarrhea: Take smaller feedings more often. Give your feedings more slowly. Change your feeding bag more regularly. A bag should never be used for more than 24 hours of feeding time ( run time ), even with proper cleaning. Tube feeding formulas are in liquid form, therefore, there is very little bulk going through your digestive tract. As a result, bowel movements will likely be more liquid. A few loose stools in a 24 hour period may be considered normal. Constipation To prevent constipation: Use more water for flushes after feedings. Dilute 30 ml (1 ounce) of prune juice with an equal amount of water. Add this mixture to your feeding tube times a day. Do not add directly to the formula. Ask your dietitian about a formula containing fibre if constipation does not go away. Cramping To Prevent Cramping: Use room temperature formula for feedings. If formula was stored in the fridge, set it out at room temperature for 1 hour before you use it. Give your feedings more slowly. Open the cap on your feeding tube to let gas out of your stomach. Walk around if you can. 16
Feeling Sick (e.g. nausea, gagging, and vomiting) If you are feeling sick: Take smaller feedings more often. Give feeding more slowly. Open the cap on your tube to let gas out of your stomach. Stay as upright as possible (at least 30 ) during your feedings. Remain as upright as possible (at least 30 ) for 30 to 60 minutes after feeding. Walk, if you can, after your feedings. Go to the Emergency Department: If your feeding tube comes out: If your tube goes into your stomach, it is important that the hole for your feeding tube does not close. This can occur shortly after the feeding tube falls out. Until you go to the Emergency Department, try temporarily reinserting your feeding tube or have someone else reinsert it. If you are unable to reinsert it, take it with you to the Emergency Department. If you have a tracheosophageal tube and cannot breathe during a feeding: Stop your feeding immediately and go to the Emergency Department. Call Your Health Care Provider if: Your feeding tube becomes clogged and you cannot unclog it following the instructions on page 14. Your feeding tube has moved from its normal position. Note: Do not start your tube feeding until your feeding tube has been returned to its normal position. You have diarrhea, constipation, cramping, or a sick feeling (e.g. nausea, gagging, vomiting) for more than 2 days after you have tried the guidelines on pages 15 and 16. You have a sore stomach and feel full for more than 1 day. You have a fever that is more than 101.3 F or 38.5 C. You have noticeable weight gain or loss. 17
Important Phone Numbers Health Care Provider phone # Nurse phone # Dietitian phone # Pharmacist phone # Speech Language Pathologist phone # Other Important Phone Numbers and Notes Number to order tube feeding formula..see page 2 Number to order tube feeding supplies..see page 3 18
Notes 19
Map to Nutrition and Food Services Department at Regina General Hospital 20
CEAC 0078 April 2017 21