Enteral (Nasogastric) Feeding Procedure

Enteral (Nasogastric) Feeding Procedure 1. Purpose This Procedure outlines the process for the planning, administering and monitoring of Enteral Feed...
Author: Janis Barber
0 downloads 1 Views 212KB Size
Enteral (Nasogastric) Feeding Procedure 1.

Purpose This Procedure outlines the process for the planning, administering and monitoring of Enteral Feeding.

2.

Application This Procedure is to be followed by all WCDHB clinical staff members.

3.

Definitions For the purposes of this Procedure:

Enteral Nutrition is “defined as the delivery of a nutritionally complete feed (containing

protein/amino acids, carbohydrates+/- fibre, fat, water, vitamins and minerals) directly into the gut via nasogastric (NG) or entero cutaneous tube”1. Use of enteral feeding is associated with preservation of gut integrity, barrier and immune functions and reductions in septic complications.

4.

Resources Required This Procedure requires:

5.

i)

NG tube

ii)

Flocare Infinity feeding pump

iii)

Flocare Infinity Giving sets

iv)

Nutritional Feed- Nutrison Multifibre or alternative as per enteral nutrition prescription

v)

Patient’s Clinical Record

vi)

Sterile water

vii)

60ml irrigating syringes- for flushes, medication administration and aspirates

Process

1.00 Clinical Indications 1.01

OR

Enteral nutrition is indicated if: i) A patient is malnourished as defined by any of the following1: 1. A BMI < 18.5kg/m2 2. Unintentional weight loss of > 10% within the last 3-6 months 3. A BMI < 20kg/m2 and unintentional weight loss >5% within last 3-6 months ii) A patient is at risk of malnutrition, as defined by any of the following1:

Enteral (Nasogastric) Feeding Procedure Page 1 of 10 Document Owner: Dietitian WCDHB-DIET3 Version 6, Issued 02/04/15 Master Copy is Electronic UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD

Enteral (Nasogastric) Feeding Procedure 1. Have eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 or more days e.g. post stroke 2. Have a poor absorptive capacity and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism AND

AND 1.02 OR 1.03

Has inadequate (as deemed by Dietitian) or unsafe (as deemed by Speech Language Therapist) oral intake1 Has a functional and accessible gastrointestinal tract1 Enteral nutrition is contraindicated in patient’s with2: i) Major intra-abdominal sepsis ii) Total obstruction of GI tract or abdominal distension of unknown pathology Other Important Considerations: - The patient’s current oral intake - The length of time that intake has been or is likely to be inadequate - The patient’s current medical situation and current nutritional status (BMI, recent weight loss, nutrient deficiencies, electrolytes) - Whether enteral feeding is in the patients best interest in terms of both clinical outcomes and quality of life

NOTE: For patients requiring feeding for more than 6-8 weeks, a PEG is the technique of choice. For patients requiring feeding for short term< 6 weeks, a NG tube is technique of choice.

2.00 Staff Responsibilities: For the purposes of this Procedure:

Medical Staff are required to: -

-

-

In consultation with the Dietitian assess whether nutrition support is required for a patient and if necessary decide on the safest, simplest, most effective route for the patient e.g. oral nutrition support, enteral nutrition or parenteral nutrition In conjunction with the Dietitian gain consent for enteral feeding from patient and/or family Arrange for the collection and recording of monitoring data including: baseline bloods: urea, creatinine, electrolytes, calcium, magnesium, phosphate, glucose, albumin, protein, CRP, LFTs, INR, iron studies, serum folate and B12 Organise an X-ray to confirm nasogastric tube placement before enteral feeding commences

Enteral (Nasogastric) Feeding Procedure Page 2 of 10 Document Owner: Dietitian WCDHB-DIET3 Version 6, Issued 02/04/15 Master Copy is Electronic UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD

Enteral (Nasogastric) Feeding Procedure -

Document once placement is confirmed Medical monitoring of relevant and indicated biochemistry parameters and fluid management Daily review and if modifications are required to the feeding regime, discuss these with the Dietitian.

Nursing Staff are required to: -

Obtain the patient’s most recent weight and height, and weigh a minimum of bi weekly Refer to the Dietitian ASAP Insert the NG tube. Check house officer has checked and documented placement before initiating feeding Set up and change the giving set every 24 hours Administer feed as per feeding regime Ensure the feed is administered at room temperature Ensure feed only hangs for a maximum of 24 hours (or 8 hours if decanted) 3, 4 Flush NG tube with a minimum of 30mls q4h, pre and post medications and pre and post feeding 5, 6 Check gastric aspirates four hourly for the first 24-48 hours unless nasojejunal tube NOTE: up to 200mls of aspirate is acceptable and should be replaced and feeding continued; If more than 200mls is aspirated, 200mls should be returned and the additional discarded and feed withheld for one hour1. Monitor bowel motions. Complete fluid balance chart daily. To provide mouth cares if patient is NBM as per SLT recommendations. Ensure patient is at a minimum of 30-45 degrees for feeding if in bed and for 1 hour postfeeding.

Dietitian is required to: -

Assess the patient’s nutritional requirements and risk of re-feeding syndrome and decide on the appropriate feed, starting rate and additional nutritional supplements required. Provide the feeding regime and discuss this with the nursing staff. Prescribe feed and on the “Enteral Feeding Prescription” form. Prescribe additional supplements on the prescription chart. Liaise with pharmacy to ensure the supply of feed and supplements will be dispensed to the ward daily. Supply feeding pump to the ward. Regularly monitor patient including reviewing weight, bloods, bowels, fluid intake, and enteral nutrition intake.

Pharmacy Staff are required to: -

Dispense the feed as per the Dietitians enteral feeding prescription. Deliver the feed to the ward. Review and advise regarding medications and suitable routes of administration.

Enteral (Nasogastric) Feeding Procedure Page 3 of 10 Document Owner: Dietitian WCDHB-DIET3 Version 6, Issued 02/04/15 Master Copy is Electronic UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD

Enteral (Nasogastric) Feeding Procedure 3.00 Prior to Administering the Feed 3.01

The Dietitian needs to be contacted to estimate the patient’s nutritional requirements, determine the appropriate feed and develop the feeding regime. An accurate weight and height are required for this. The risk of re-feeding syndrome should also be considered as per WCDHB protocol.

3.02

The NG tube needs to be placed following the online Lippencott Nasogastric Insertion of Tube Procedure.

3.03

Enteral feeding tube should be at least 10 French, or 12 French if bolus feeding is likely. If a PVC drainage tube is used it can only stay insitu for up to 10 days.

3.04

The NG tube placement needs to be checked by x-ray prior to feeding. If any concerns regarding placement do not begin feeding and contact the medical team.

3.05

The Flocare Infinity feeding pump is situated in a cupboard outside the Pharmacy Department (Grey Base Hospital). The Dietitian will bring a pump to the ward or please contact the Duty Nurse Manager if it is after hours (outside 08:00-16:30 Monday-Friday).

3.06

The Flocare Infinity giving sets are available from stores. 1L Flocare bottles are available from stores if decanting is required. Syringes are available on the ward.

3.07

The feed should be at room temperature to avoid discomfort for the patient. Decanted feeds need to be removed from the refrigerator 30 minutes prior to starting the feed.

3.08

Check the enteral feed against the enteral feed prescription and expiry date of feed before commencing feeding. Write date and time of starting feed on ready to hang formula.

3.09

Once the tube is in situ and the placement has been checked via x-ray, the feeding regimen may be commenced. Document this in the clinical notes.

3.10

The head of the bed should be raised to 30-45 degrees while feeding to reduce the risk of aspiration and left at this angle for an hour after the feed has finished1.

4.00 Administering the Feed 4.01

Continuous Feeding Continuous feeding is defined as feeding at a slower rate using a pump over a 16-24 hour period4. Minimal handling and an aseptic technique should be used to connect the enteral feeding formula to the enteral feeding giving set and the patient enteral feeding tube.

Enteral (Nasogastric) Feeding Procedure Page 4 of 10 Document Owner: Dietitian WCDHB-DIET3 Version 6, Issued 02/04/15 Master Copy is Electronic UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD

Enteral (Nasogastric) Feeding Procedure 4.02

Process

-

Connect the enteral feeding giving set to enteral feeding formula Label enteral giving set with start date and time. (change every 24 hours) Label enteral feeding formula with start date and time (discard after 24 hours or 8 hours if decanted feed) Place drip chamber/enteral feeding giving set into the pump and prime the giving set with the enteral formula ensuring the drip chamber is not over filled Raise patient’s bed to 30-45 degree angle Flush enteral feeding giving set with 30mls sterile water Set enteral feeding pump to run at prescribed rate as per enteral feeding regime and commence enteral feed NOTE: The feeding regime will initially be started at a low rate and gradually increased until it is meeting the patient’s estimated daily nutritional requirements. The volume and rate may be increased or decreased depending on patient tolerance, fluid and energy requirements. Normally the regimen starts between 30-50ml per hour of feed and advances 10ml every 4 hours if the previous rate was tolerated and gastric aspirates are normal. This will be documented on the enteral feeding prescription by the Dietitian The tube needs to be flushed with at least 30ml of water before and after bolus feeds, after aspirates checked, 4 hourly during continuous feeding (or as specified by the Dietitian) and with 30ml before, between and after medication to avoid blocking the tube5, 6 Initially for patients not taking any food or fluid orally, stomach contents should be aspirated every 4 hours for the first 24-48 hours, to assess gastric emptying. If more than 200ml is aspirated, 200mls of the aspirate should be returned (the excess discarded) and the feed withheld for 1 hour. The aspirates should be rechecked in 1 hour and if they remain high, feeding stopped and the tube placement and bowel sounds should be checked. The Dietitian should be informed. This is when the use of prokinetics could be discussed with the medical team. NOTE: Small bowel tubes (e.g. nasojejunal tubes) should not be aspirated As the rate and volume of enteral feed increases, IV fluid infusion may need to be decreased. The patient should be meeting their full nutrient and fluid requirements within 48-72 hours, unless otherwise specified by the Dietitian

-

-

-

-

4.03

Bolus Feeding Bolus feeding is defined as formula delivered by gravity via a syringe over approximately 15 minutes4.

-

Minimal handling and an aseptic non-touch technique should be used to dispense the enteral feeding formula from the bottle to the syringe and to the patient enteral feeding tube.

4.04

Process

-

Bolus feeding is not suitable for a jejunally placed enteral feeding tube

Enteral (Nasogastric) Feeding Procedure Page 5 of 10 Document Owner: Dietitian WCDHB-DIET3 Version 6, Issued 02/04/15 Master Copy is Electronic UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD

Enteral (Nasogastric) Feeding Procedure -

Refer to bolus enteral feeding prescription developed by Dietitian for bolus feeding times, enteral feed volumes and flush volumes

-

Gravity method is preferred for large bore enteral feeding tubes e.g. gastrostomies

-

Syringe method is preferred for small bore enteral feeding tubes e.g. nasogastric

-

Shake feed well before commencing

-

Flush Nasogastric tube as per enteral nutrition feeding prescription

-

Place the tip of the syringe securely in the enteral feeding port of the enteral feeding tube (if gravity feeding remove plunger)

-

Measure indicated volume of enteral feeding formula in measuring jug. Pour into syringe in 60ml lots until total volume administered- document on fluid chart.

-

Repeat water flush using indicated volume on enteral nutrition prescription- document on fluid chart

-

Secure cap on end of enteral feeding tube

-

Maintain the head of the bed raised position at a 30-45 degree angle for one hour post feeding to minimise risk of aspiration

5.00 Monitoring All patients require monitoring for tolerance to the enteral feed. All staff are responsible To monitor, document and report abnormalities to the medical team and Dietitian. 5.01 5.02 -

Daily Fluid balance Nutritional intake from enteral and oral nutrition GI function e.g. bowel activity, nausea, vomiting, abdominal distension/pain, delayed gastric emptying, reflux Biochemistry urea, creatinine, electrolytes (until established on full rate) NG tube position before feed begins – pH less than or equal to 5 using pH paper Signs of gastric content aspiration: deterioration in respiratory function, tachypnea, tachycardia, SOB, productive cough, increased secretions, moist rales (gurgling), fever Twice weekly or as clinically indicated Body weight Hepatic secretory proteins e.g. albumin, transferrin Creatinine and urea

Enteral (Nasogastric) Feeding Procedure Page 6 of 10 Document Owner: Dietitian WCDHB-DIET3 Version 6, Issued 02/04/15 Master Copy is Electronic UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD

Enteral (Nasogastric) Feeding Procedure -

Electrolytes Blood glucose

5.03 -

Other Tests Trace elements will need to be monitored during prolonged enteral feeding

6.00 Medication Administration -

All patients need to be reviewed by pharmacy to determine which medications can be administered via the enteral route Stop enteral feed to administer each medication separately Flush the enteral feeding tube with at least 30mls before, between and after administering medication 5, 6 Administer medication via the medication port on the giving set using the dedicated syringe

7.00 Management of Complications 7.01

Altered Bowel Habit: Diarrhoea/Constipation

Consider the cause of altered bowel habits e.g. medications (specifically antibiotics), enteral feeding rate and patient’s clinical status. 7.02

Document bowel habits using Bristol stool scale. Specify frequency and volume in clinical notes Inform Dietitian for enteral prescription and fluid review Inform medical team for medications and fluid review If infective diarrhoea is suspected obtain faecal specimen for testing If patient is constipated administer laxatives as prescribed NOTE: Diarrhoea is usually secretory and is not an indication to discontinue enteral feeding Nausea Prevention: Maintain patient in the semi recumbent position (elevated head and upper body by 30-45 degrees) during and 1 hour post feeding and while administering medications Trouble Shooting:

-

Check aspirates. If > 200ml discuss prokinetic use with medical team Check patient is prescribed and being given prokinetics/antiemetics regularly

Enteral (Nasogastric) Feeding Procedure Page 7 of 10 Document Owner: Dietitian WCDHB-DIET3 Version 6, Issued 02/04/15 Master Copy is Electronic UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD

Enteral (Nasogastric) Feeding Procedure -

Check for and treat constipation Consult Dietitian- enteral feeding rate may need to be reduced temporarily

7.03

Vomiting

-

Stop Enteral Feed Check Aspirates Inform medical staff and Dietitian Check enteral feeding tube positioning prior to recommencing feeding

7.04

High Aspirates >200ml

-

Prevention: Maintain a 30-45 degree position during and after feeding and medication administration

-

Action: Inform medical staff and Dietitian of suspected aspiration If aspirate > 200mls, replace 200mls (discard excess) withhold feed for 1 hour. Recheck and recommence enteral feeding if aspirate< 200mls If more than two aspirates are >200mls inform medical team and Dietitian If delayed gastric emptying is limiting enteral feeding (oral prokinetics ineffective try IV prokinetics), then post pyloric feeding or parenteral nutrition should be considered Continuous enteral nutrition is favoured for patients with issues of delayed gastric emptying Turning a patient on their right side may improve gastric emptying Ensure patient is at 30-45 degree angle to aid gastric emptying

7.05

Abdominal Discomfort

-

Causes: Solution too cold Gastric distension Too rapid administration If acute pain/distension stop feed and inform medical team and Dietitian

7.06

Tube Blockage

-

Prevention: Request review of medications on commencing enteral feeding to ensure no potential tube blockage Flush with 30ml sterile water before, after and between medications Ensure regular flushing of enteral feeding tube every 4-6 hours as per enteral feeding prescription

Enteral (Nasogastric) Feeding Procedure Page 8 of 10 Document Owner: Dietitian WCDHB-DIET3 Version 6, Issued 02/04/15 Master Copy is Electronic UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD

Enteral (Nasogastric) Feeding Procedure Treatment: Massage tube, this may loosen blockage Use 15-30ml sterile warm water and a push pull action with a 50ml catheter tip syringe For blockages caused by enteral feeding formula a digestive enzyme preparation can be prescribed and ordered from pharmacy Use 15-30ml Clogzapper (this can be ordered via iPROC) and a push pull action with a 50ml catheter tip syringe NOTE: Do not use coca cola or other fizzy drinks to unblock enteral feeding tubes as this can damage the tube

8.00 Cessation of Enteral Feeding -

Follow the Dietitian’s enteral nutrition prescription for the transition from enteral to oral intake. The enteral feeding volume can be decreased as intake increases

-

Enteral feeding should not be withdrawn until the patient can consistently meet greater than 50% of their nutritional requirements via oral intake

AND 6.

7.

The patient can maintain adequate hydration orally Maintenance of food and fluid charts will be needed for the Dietitian to review to ensure this is an accurate decision process

Precautions and Considerations 

The Dietitian needs to be contacted for the estimated requirements and feeding regime including the appropriate feed to use



The NG tube needs to be placed following the WCDHB Nasogastric Insertion of Tube Procedure



Once the tube is in situ and the placement has been checked via x-ray, the feeding regimen may be commenced



If any changes to method or amount or feeding are planned please contact both the Dietitian and the SLT for full review first

References 1.

National Collaborating Centre for Acute Care. Nutrition support in adults Oral nutrition support, enteral tube feeding and parenteral nutrition. National Collaborating Centre for Acute Care, London; February 2006. 175p.

Enteral (Nasogastric) Feeding Procedure Page 9 of 10 Document Owner: Dietitian WCDHB-DIET3 Version 6, Issued 02/04/15 Master Copy is Electronic UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD

Enteral (Nasogastric) Feeding Procedure 2.

Dietitians New Zealand Inc. 2010 Clinical Handbook. Lyn Gillanders (Ed) Manor House Press.

3.

Preventing Microbial Contamination of Enteral Formulas and Delivery Systems (Hazard Analysis Critical Control Point (HACCP) in the Clinical Setting -- 63378/September 2003, Abbott Nutrition.

8.

4.

ASPEN Enteral Nutrition Practice Recommendations. JPEN Jan 2009.

5.

Kohn-Keeth C. How to keep feeding tubes flowing freely. Nursing.2000; 30:58-59.

6.

BAPEN. Administering Drugs via enteral feeding tubes a practical guide.

Related Documents WCDHB Nasogastric Insertion of Tube Procedure WCDHB Informed Consent Procedure WCDHB Clinical Documentation Procedure WCDHB Food and Fluid Chart WCDHB Enteral Nutrition Prescription WCDHB Weight Chart WCDHB Bristol Stool Scale

Version: Developed By: Revision

Authorised By:

History

Date Authorised: Date Last Reviewed: Date Of Next Review:

6 Dietitian Assocaite Director of Allied Health 2 April 2015 2 April 2015 3 April 2017

Enteral (Nasogastric) Feeding Procedure Page 10 of 10 Document Owner: Dietitian WCDHB-DIET3 Version 6, Issued 02/04/15 Master Copy is Electronic UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD