Enteral Feeding Adults2

NOTTINGHAM UNIVERSITY HOSPITAL NHS TRUST
CLINICAL GUIDELINES
Title of Guideline: Enteral Feeding in adults
Date First Issued: July 2009
Version: 21
Latest Re-Issue Date: September

2009
Review Date: September 2011
Main Author and Job Title:
Local Contact including job title

and Ext. No.
Dr Tim Bowling
Consultant in Gastroenterology
Dr T Bowling
QMC Campus
Ext 63862
Document Derivation:
Consultation Process:
Nutrition Steering Committee
subgroup on complex nutrition
Heads of (relevant) Services
Ratified by:
Distribution:

Clinical Effectiveness Committee
All Clinical Directorates
Plans for training on/implementing

guideline:
Plans for audit of guideline:

Verification and documentation of NG
tube position
PEG/RIG complication rates
Given vs prescribed feed
This guideline has been registered with the Trust. However, clinical
guidelines are guidelines only. The interpretation and application of clinical
guidelines will remain the responsibility of the individual clinician. If in doubt
contact a senior colleague or expert. Caution is advised when using the
guidelines after the review date.
CONTENTS
Page
Abbreviations
Members of Writing Group
Introduction
SECTION 1: POLICIES, STANDARDS & AUDIT PROPOSALS
Enteral feeding policy for adults

Standards of Service
Audit proposals
References
7
9
10
10
SECTION 2: GUIDELINES, PROCEDURES AND CARE PATHWAYS
11
When and how to refer to the Nutrition Support Team

Requests for Teaching and Training
Route of feeding
Nasogastric
Indications/contraindications
Placement and verification of position
Bridles
Wide-bore tubes
Nasojejunal
Indications/contraindications
Placement
Tubes available
Gastrostomy/jejunostomy
Types of stoma
Tubes available
12
14
15
17
18
18
24
25
26
26
26
26
27
27
28
Administering feed
Gastric feeding
29
29
Commercially-prepared feed using a pump
By pump and reconstituted powdered feed

By pump and use of reservoir bottle
Jejunal feeding
Commercially-prepared feed by pump
Reservoir bottle
Tube/patient care
Nasogastric feeding
Feeding by NG tube
Flushing
Administration of medicines
Gastrostomy feeding
Post-insertion care
Feeding via gastrostomy
29
30
33
35
35
37
40
40
40
41
41
43
43
44
2
Care of stoma and tube

Removing and replacing gastrostomies
Accidental removal of gastrostomies
Medicines through gastrostomies
Jejunal feeding
50
52
52
53
54
Complications of enteral feeding

Insertion related
Tube related
Feeding related
Diarrhoea
Constipation
Nausea, vomiting, regurgitation
61
61
61
61
61
63
63
Management of unexpected discontinuation of enteral feeding
65
Procedure for discharging patients on home enteral feeding
66
APPENDICES
1
Adult critical care enteral feeding
68
Wide bore nasogastric tubes
77
Starter regimes when dietitians unavailable
86
Nutrition team assessment of potential gastrostomy patients
88
Care pathway for patients with suspected/confirmed stroke
91
Procedure for replacing balloon gastrostomy
96
Procedure for fitting button gastrostomy
98
ABBREVIATIONS
CNC
CNNS
HEFT
MUST
NG
NJ
NUH
NSC
NST
S&LT
Clinical Nutrition Consultant

Clinical Nutrition Nurse specialist
Home Enteral Feeding Team
Malnutrition Universal Screening Tool
Nasogastric
Nasojejunal
Nottingham University Hospital
Nutrition Support Team
Speech & Language therapy
The members of the working group for this document have been:
Kathryn Blount
Clinical Lead Dietitian
Tracey Buchanan
Clinical Nutrition Nurse Specialist
Janet Crowe
Ewan Forbes
Specialist Dietitian
Zoe Hooley
Azma Malik
Gastroenterology & Nutrition clinical pharmacist
Hannah Meanwell
Specialist Dietitian
Sian Rajakaruna
Principal Speech & Language Therapist
Kathy Teahon
Clinical Nutrition Consultant
INTRODUCTION
These guidelines are about enteral feeding in adults. This is the administration of nutrients
directly into the intestinal tract via a tube. The indications, broadly speaking, are for those
patients who have a functioning gut but unable to take any or adequate nutrition in by mouth.
There is considerable overlap between the services described in this guideline and the dietetic
and ward services for nutritional care. All patients should be nutritionally screened by ward
staff and those deemed at nutritional risk, for whatever reason, should be referred to the ward
dietitian for further assessment. The nutrition support team, either as a whole or an individual
from the team (usually the nurse) can be asked to review any patient by any member of the
attending multi-professional team. The key remit of the nutrition team is to determine the
need for artificial nutritional support and to facilitate such an intervention when required.
These guidelines will take the reader through the essential background, evidence and
practicalities of enteral nutrition.
Other related/relevant Trust guidelines:
Intravenous or parenteral feeding
Prevention and Management of Refeeding Syndrome: Guidelines for Adults
Feeding in critical care (also included as an appendix here)
Passing and Checking the Position of a Wide Bore Nasogastric Tube (also included as an
appendix here)
SECTION 1
POLICIES, STANDARDS & AUDIT PROPOSALS
ENTERAL FEEDING POLICY FOR ADULTS

I.
The nutritional status of all inpatients will be assessed and monitored using the
national Malnutrition Universal Screening Tool (MUST) or a clinically appropriate
adaptation approved by the Nutrition Steering Committee.
II.
The nutritional status of appropriate outpatients and day-care patients will be assessed
and monitored using the modified MUST or a clinically appropriate adaptation.
III.
Patients assessed to be at nutritional risk with swallowing difficulties and for whom
first line guidance is not appropriate, or those who are consistently failing despite
dietetic support, will be referred for consideration of artificial feeding.
IV.
A multidisciplinary Nutrition Support Team will be available in working hours to

support, advise on and review the care of patients with complicated nutritional needs.
V.
Decision support, via the Trusts Clinical Ethics committee, will be available for staff
when there is difficulty in making or implementing a decision about the
appropriateness of feeding
VI.
VII.
VIII.
The best route for enteral feeding will, in usual circumstances be determined
following the NUH Choosing a route for enteral feeding algorithm.
The most appropriate tubes and stomas for use in particular circumstances will be
determined following the NUH guideline Choosing an enteral feeding tube or
stoma. In this circumstance appropriateness refers to: licence for use, availability
and competence in the trust for insertion, care and maintenance.
If the clinical circumstance results in a variance from the Choosing a route for enteral
feeding or the Choosing an enteral feeding tube or stoma guidelines the variance
and the reason for it will be clearly documented in the patients record.
IX.
All tubes and stomas used for enteral feeding will be appropriate for that use and will
be placed by staff who are competent to do so.
X.
The clinical assessment and care of tubes and stomas used for enteral feeding will be,
by staff who are competent to do so.
XI.
A full range of dietary formulae will be available in stock to meet the usual needs of
patients in the Acute Hospital setting. Non-stock formulae can be obtained on a named
patient, evidence based, basis.
XII.
Dietary regimens will be prescribed and monitored by dietetic staff ,who are
appropriately experienced in the relevant area of clinical care. For Out of hours
there will be Starter Regimen guidance available.
XIII.
Dedicated & standardized prescription charts will be used for the prescription of
enteral feeds
XIV.
Guidance will be available (via the intranet, the dietitians and nutrition support team)
on the identification and management of common clinical problems which can occur
during feeding such as: Problems with tubes & stomas, Re-feeding syndrome,
7
Diabetes, Unexpected discontinuation of feeding, Constipation, Diarrhoea, Vomiting

and Mouth-care
XV.
XVI.
XVII.
XVIII.
XIX.
XX.
XXI.
When patients are transferred into the Trust with feeding tubes or stomas already in
place, the appropriateness, integrity and position of these tubes and stomas will be
confirmed before use.
Consent will be obtained for feeding and for the insertion of all tubes and stomas
following Trust guidelines
Patient information will be available for all usual types and routes of enteral feeding
Teaching, Training and Competency assessment, packages will be available for
relevant staff for the insertion, care and maintenance of tubes and stomas used in
enteral feeding.
Teaching, Training and Competency assessment, packages will be available for
relevant staff in the identification and management of the common clinical problems
which can occur during feeding.
Teaching, training and competency assessment and evidence thereof will be the
responsibility of the individual directorates.
Regular audit of service standards will be performed and the service will be reviewed
in response to this. Such audits will be the responsibility of individual directorates to
perform and provide evidence thereof.
STANDARDS OF SERVICE
I.
The MUST, or a clinically appropriate adaptation approved by the Nutrition Steering

Committee, is in use for all inpatients and relevant Outpatient and Day-care patients
II.
Patients requiring nutritional intervention are identified early and referred

appropriately to the Dietitians and/or Nutrition Support Team and are seen within two
working days
III.
The relevant route of feeding is implemented for all patients, where clinically
appropriate, according to the sub-speciality guideline and achieved within three
working days
IV.
The tubes and stomas in use are in line with the NUH guidelines and appropriate for
the clinical needs of the patient
V.
VI.
VII.
VIII.
IX.
X.
XI.
The care and maintenance of all tubes and stomas is in accordance with the guidelines
The dietary regimens prescribed and administered via tubes and stomas are in
accordance with the guidelines for all patients
All patients being enterally fed are appropriately monitored as detailed in the relevant
guideline/care pathway
Nutrition support team advice and guidance is available during working hours and
relevant out of hours guidance is available
For all patients, in whom, there is difficulty making or implementing a decision about
the appropriateness of enteral feeding, decision support is available, is easily accessed
and is accessed.
Enteral feeding records are accurate, available and up-to-date for all patients
The service standards are regularly audited by the relevant Directorates
AUDIT PROPOSALS
Each directorate in the Trust should be able to demonstrate compliance with the above service
standards. Regular audit is essential. We recommend a three yearly audit cycle, auditing one
or two of the audits detailed below every year. The audit templates will be made available.
The recommended main audits are:
1. A Directorate audit of individual patient documentation associated with insertion and
checking of nasogastric and nasojejunal feeding tubes
2. An audit of the Directorates nutritional screening and management of outpatients
3. An audit of the Directorates staff training and competency profile in nutritional
screening and in the management of feeding tubes and stomas
4. An audit of the Directorates use of patient information on enteral feeding
5. An audit of the time from decision of route for feeding to the establishment of the
route
REFERENCES
NICE 2006 Nutrition Support for Adults Oral Nutrition Support, Enteral Tube feeding and
Parenteral Nutrition
St Marks & The Burdett Institute of Gastrointestinal Nursing (2005) Adult Enteral Nutrition
Guidelines
De La Torre AM (2001)
Nutrition 4 (6A) 1379-1384
Guidelines for Nutrition Support in the elderly. Public Health
Stroud M (2003) Guidelines for enteral feeding in adult hospital patients GUT 2003 52 Suppl
VII
Raykher A
2007 Enteral Nutrition Support of Head & Neck Cancer patients Nutrition in
Clinical Practice Vol 22: 68-73
10
SECTION 2
GUIDELINES, PROCEDURES AND CARE
PATHWAYS
11
WHEN TO REFER TO THE NUTRITION SUPPORT TEAM (NST)

There are many reasons to refer patients to the NST. Referrals can be made for clinical assessment,
advice, support and teaching. As such, referrals will vary in their degree of urgency. The team consists
of a nurse specialist, dietitian, clinical nutrition consultant, clinical chemist and pharmacist. Usually
patients identified as being at risk nutritionally are first referred to the dietitians, often as a result of the
screening process. Patients who have problems with feeding tubes, stomas or parenteral feeding lines
should normally be referred to the nutrition nurse specialist in the first place. Other members of the
NST can always be contacted (see below for details).
Which patients to consider for referral
Patients who have been identified by MUST to be at nutritional risk, who have already been
seen by the ward dietitians and in whom there is concern either about the appropriateness or
the choice of route for feeding
Patients who have been identified as needing a feeding gastrostomy (by either endoscopic,
radiological or surgical method)
Patients who have gastrostomy or jejunostomy, tube or stoma related problems (retention,
blockage)
Patients who have NG tube related problems (initial placement, retention, blockage)
Patients who have NJ tube related probems (initial placement, retention, blockage)
Please note
The NST also deal with patients on parenteral nutrition (see the parenteral nutrition
guidelines)
Problems with feeding or infusion pump problems are usually dealt with by the equipment
library staff but the nutrition nurse specialists can also offer support
How to refer
All referrals must be made on NotIS
For PEG Assessment the order code is PEG
For all other referrals the order code is CNNS
If there is an urgent need the nurses can be bleeped on (City campus Bleep 80 6993 or Queens campus
Bleep 80 6417), however when there is a need to bleep the referral should be confirmed on NotIS
Helping the NST to provide an efficient sustainable service

So many patients have nutrition related problems that the NST, and especially the nurses workload is
often very great. To ensure the most efficient service possible it is helpful if the ward based teams
follow the care guidelines detailed throughout this document. Only after reviewing and following the
guideline should the patient be referred.
General guidance:
Selection of patients for enteral feeding
When and who to contact for help
Use of syringes to administer flushes, feeds and medication via oral and enteral route in adults
(guideline in preparation)
For Patients with NG tube related problems the relevant guidelines are:
Passing & checking position of fine bore NG tubes (page 18)
Care of a patient receiving enteral feeding via NG tube (page 40)
Ongoing care of patients on NG tube feeding (page 40)
12
For Patients with NJ tube related problems the relevant guidelines are:
Care of a patient receiving jejunal feeding (page 54)
For patients with feeding gastrostomy or jejunostomy problems the relevant guidelines are:
Care of patients being fed through a gastrostomy (page 43)
Care of a patient receiving jejunal feeding (page 54)
For feed & pump problems please refer to:
Administration of feed using a feeding pump & commercially prepared feed in a pack (page
29)
Administration of feed using a feeding pump & reconstitution of powdered feed (page 30)
Administration of feed using a feeding pump & feed decanted into a reservoir bottle (page 33)
For patients with TPN related problems please refer to:
Guideline Care of patient receiving TPN (this is a separate guideline)
WHEN YOU NEED HELP: WHO TO CONTACT & HOW

Problem
High risk patients
identified on MUST
Feed prescription
Patients on enteral feed &
issues of tolerance
Difficulty with NG tube
insertion or care
To refer for gastrostomy

(irrespective of method of
insertion)
Problems with the care &
maintenance of
gastrostomy or
jejunostomy
DIABETES- Patients who

are feed enterally and have
diabetes If they are on oral
hypoglycaemic agents or
insulin they made need a
total change in their
treatment whilst being
enterally feed to ensure
optimum blood glucose
control.
Problems giving drugs
down tubes or stomas
Discharge on enteral feed
Uncertainty about route or
Who
Ward dietitian
How
Ward based referral
Ward dietitian
Ward dietitian
Ward based referral

Ward based referral
Nutrition support team nurse

Out of hours the CNU nurses on
QMC campus (62119) or the Hogarth
ward Nurses on NCH campus (55152)
can offer guidance but cannot offer an
outreach service
NotIS referral or if urgent bleep

80 6417 (QMC campus)
80 6993(NCH campus)

Out of hours the Clinical Nutrition
Unit nurses on QMC campus (62119 )
or the Hogarth ward Nurses on NCH
campus (55152) can offer guidance
but cannot offer an outreach service
Referral to the diabetes team
NotIS referral or if urgent bleep

80 6417 (QMC campus)
80 6993(NCH campus)
Your ward pharmacist
Ward based referral
Ward dietitian
Nutrition Support consultant
Ward based referral

NCH Campus: NotIS referral
NotIS referral (code = PEG)
Notis referral DIAB
13
appropriateness of feeding
(Acute gastro & choose Dr Teahon

QMC Campus: Dr Bowling, call
63862 or bleep 80-0240
(if either is not available they will
have organised cover)
If urgent bleep
84-1170-(QMC campus);
800275(NCH campus)
REQUESTS FOR TEACHING & TRAINING

Teaching and training can be divided into two groups Formalised Teaching and Training and As
Required Teaching and training
Formalised:
Formalised Teaching and Training How to pass and Check a Fine Bore Nasogastric tube. There will
be two Study sessions a year, one based at either campus. Details will be forwarded to ward managers,
please check with your ward manager before booking onto a session. To book a place email Jackie
Gaskil or ring on Extn. 57348 with your details.
As required:
Tube and stoma care teaching and training can be provided to ward areas by contacting the Nutrition
Nurse Specialist via e-mail or by leaving a message on Extn. 56754 or 61036. Please note a minimum
of 4 staff will be required.
TPN teaching and training can be provided to ward areas by contacting the Nutrition Nurse Specialist
via e-mail or by leaving a message on Extn. 56754 or 61036. Individual teaching and training can be
provided on request.
14
Figure 1: Algorithm for nutritional support
Patient assessed using MUST relevant for the clinical setting and is unable to maintain
nutritional requirements with oral intake
Prognosis is assessed to
be < 4 weeks
Unsure
Yes
No
Feeding usually
inappropriate. Follow
Feeding is in line with

Unsure
Persistent vegetative state
patients known wishes
Ethics in Feeding guideline
Yes
Yes
No
No
Yes
Small intestine is
No
functional & can be
Reduced oral intake due
accessed and used
to dementia
Yes
Follow Ethics in Feeding guideline

No
Reduced oral intake will last

<6 weeks
Follow Parenteral Nutrition Pathway
Yes
No
Seek formal opinion from nutrition

support team re gastrostomy or
Gastric emptying is (and

predicteded to remain) normal
without vomiting or severe
GORD
jejunal feeding
No
Yes
NG tube
There is a large gastric residue
Gastric emptying is normal
or one develops
without vomiting or GORD
Yes
Single lumen NJ, or

double/triple lumen
NJ with NG/sump
No
Jejunostomy or
Gastrostomy
Gastro-jejunostomy
15
ROUTE OF FEEDING
The algorithm on page 15 outlines guidance for the selection of patients for enteral feeding in its
broadest sense. It should be combined with the text below, and support from NST should be sought if
there is any concern. In brief:
Nasogastric (NG) feeding will be considered:
Who cannot maintain nutrition by oral means

In whom feeding is appropriate and in line with their wishes
Whose small intestines are functioning
Who have normal gastric motility or respond to prokinetic agents
Who are known not to be at excessive risk of vomiting or gastro-oesophageal reflux
Who are estimated to require feeding for six weeks or less
Nasojejunal (NJ) feeding will be considered:

Who have or are predicted to develop abnormal gastric motility or who are known to be at
excessive risk of vomiting or gastro-oesophageal reflux
Who are estimated to require feeding for six weeks or less
Gastrostomy feeding will be considered:

Who have normal gastric motility
Who are known not to be at excessive risk of vomiting or gastro-oesophageal reflux
Who are estimated to require feeding for longer than six weeks
Who do not have contra-indications such as ascites, CAPD, peritoneal shunts,
hepatosplenomegaly, portal hypertension, morbid obesity (these contra-indications are relative
but the decision on feeding and route of feeding for these patients should involve one of the
nutrition support consultants)
Jejunostomy feeding will be considered:
Who have abnormal gastric motility or who are known to be at excessive risk of vomiting or
gastro-oesophageal reflux
Who are estimated to require feeding for six weeks or longer
Who do not have contra-indications such as ascites, CAPD, peritoneal shunts,
hepatosplenomegaly, portal hypertension, morbid obesity (these contra-indications are
relative but the decision on feeding and route of feeding for these patients should involve one
of the nutrition support consultants)
(Note : patients undergoing oesophago-gastric surgery will sometimes have peri-operative
jejunostomies inserted to aid immediate post operative feeding)
16
Best practice notes on choosing feeding route

Gastrostomy formation has a low mortality (approaching 0%) and a high technical success rate (90%)
in properly selected patients. In unselected patients the 30 day mortality for gastrostomy is 25 - 30%
(Grant et al 1998, Sanders et al 2000). Patients with loss of swallow because of dementing illness have
a 54% 1 month mortality and a 90% 1 year mortality (Sanders 2000)
Gastrostomies may be of value for palliation (gastric decompression, drug administration)
When commencing tube feed in the "unsure" group, do so in the context of well defined outcome
measures & for a well defined time period
In patients who lack capacity to make decisions, the decision to or not to site a gastrostomy is that of
the responsible physician but communication with all involved is essential. Clinicians involved in this
decision should be fully aware of the Mental Capacity Act and IMCA services
NASOGASTRIC FEEDING
INTRODUCTION
Nasogastric tube (NG) feeding remains the most common and the simplest method of providing
relatively short-term artificial nutritional support for intervals of 4 6 weeks. The decision to start
tube feeding, which type of tube to use, the type of feed and diet and the feed regimen should be a
team decision involving doctor, nurse, dietitian, speech and language therapist and patient. Unless
specifically required/requested, the NST would not normally be involved in these decision. The role of
the ward team is crucial, but it is often the nurse who administers the feed and observes the patient for
signs of improvement and/or complications. Therefore excellent communication between the nurse
and the other members of the team is essential.
The feed can be given intermittently and it is common practice to give a break of at least 4 hours each
day. During the rest period, the tube is usually flushed with fresh freshly drawn drinking tap water.
How often and how much depends on the individual patient. Always refer to the individuals
feeding regimen provided by the dietitian or, if unavailable, consult the dietitian.
For most people, eating is an enjoyable and social experience as well as a physiological necessity. A
patient who is tube fed may no longer be able to eat and drink orally and enjoy his/her food. If this is
so, nurses have a responsibility to help the patient come to terms with this situation and endeavour to
help the patient not feel isolated.
Routine mouth care is vitally important for the patient unable to eat or drink; mouthwashes and oral
mouth care should be offered (Hamilton, 2000). (See Guidelines Care of the Mouth).
A fine bore tube can be passed by a health care professional who has been assessed as competent to
perform the procedure. Staff should only start a feed when the tube position has been
documented as correct (see below).
Nasogastric feeding via a wide-bore tube, e.g. a Ryles tube is possible but is not recommended as:
It is uncomfortable for patients
Has increased risk of complications (reflux & aspiration)
Can impair normal swallowing
Can cause nasal and oesophageal erosions.
Feeding via a wide bore tube usually only takes place in critical care and some other specialised areas
and each will have area specific guidelines. Widebore tube feeding in Critical Care should only be
considered in the early stages of enteral feeding if it is necessary to aspirate the contents of the
stomach to check for gastric emptying (Rollins, 1997). In ENT wide bore tubes may be used to
maintain the patency of the tracheo-oesophageal puncture for voice rehabilitation. The decision to feed
via a wide bore tube should be made by the specialist team.
17
If feeding via a fine bore nasogastric tube is anticipated to last longer than 4-6 weeks, referral for
gastrostomy placement should be considered
INDICATIONS FOR NG FEEDING

1. Physical problems such as:
Facial / jaw trauma under guidance from specialist team
Dysphagia as a complication following stroke
Inflammation of the mouth / throat e.g. following radiotherapy
Unconsciousness
2. Depressed appetite caused by:
Severe systemic illness
3. Hypercatabolic states such as:
Major sepsis
Burns
Major trauma / surgery
4. Other patients unable to meet their nutritional needs via the oral route
CONTRAINDICATIONS FOR NG FEEDING

1. Physical injuries or deformities such as:
Confirmed or suspected basal skull fracture (in such cases an orogastric feeding tube should
be passed by an anaesthetist)
Laryngectomy unless under guidance/approval of ENT department
2. Gastro intestinal such as
Stasis (gastric stasis or ileus)
Obstruction
3. Withdrawal or refusal of consent (see also Trust Guideline on Informed consent)
PASSING AND CHECKING POSITION OF NG TUBES
Although the decision to insert a fine bore nasogastric tube is often made by the multiprofessional
team, the procedure must only be carried out following formal consent and only be performed by a
health care professional who can demonstrate relevant theoretical knowledge and who has been
assessed as competent in the procedure in accordance with the Working in New Ways Policy and
Guidelines
Types of NG tube
There are many different types of fine bore nasogastric tube available. If unsure, the medical team,
nutrition team or Clinical Nutrition Unit (as appropriate) will advise which type of tube to use. Please
see Guidance on the feeding tubes & stomas currently in use at Nottingham University Hospital It is
important that all tubes and stomas in use are licensed for this purpose, that the correct attachments are
available and that those caring for them are competent/ trained to do so. Most fine bore nasogastric
tubes are single use only and should be left in situ for a maximum 4-6 weeks.
Guide Wire
All fine bore nasogastric tubes will have a guide wire to aid with the insertion.
Always read the manufacturers instructions regarding the guide wire. Prior to insertion of the tube,
pull the guide wire in and out by about 5cm to ensure that it moves freely and then replace. The fine18
bore tubes used in Nottingham University Hospitals Trust require the guide wire to be removed prior
to x-ray or aspiration to ascertain the tube position. This ensures that the tube is not displaced
following subsequent removal of the guide wire. To remove the guide wire, refer to the
manufacturers instructions. Some tubes may have a lubricated coating, which is activated by water.
Other tubes may require further lubrication with a water-soluble jelly prior to insertion before the wire
can be removed.
Guide wires should not be reused or reinserted into the tube as this can cause perforation of the tube.
Syringes
Please see separate guidance: Syringes for Oral & Enteral Use Note that syringes used in hospital
for enteral feeding are single use only.
EQUIPMENT NEEDED FOR FEEDING TUBE PLACEMENT
Fine bore nasogastric (NG) tube
Hypo-allergenic tape or commercial attacher
50ml purple enteral syringe
Drinking straw and glass of water (if patient can swallow safely)
Measuring jug and freshly drawn drinking tap water
pH paper
Lubricating gel
Disposable non-sterile gloves
Disposable apron
Table 1: Passing an NG Tube

Principle
Rationale
1.
Passage of the tube may be more difficult or

contraindicated.
Check patients notes and enquire if the patient

has a known nasal obstruction e.g. old fracture /
polyp / previous operation.
If an obstruction is present or suspected, discuss
with medical staff before proceeding.
2.
Ask the patient to sniff with one nostril and then

the other or to blow their nose. If needed, clean
the nostrils before commencing the procedure.
To check if the nostrils are clear and to identify any

obstruction which may hamper the procedure.
3.
Arrange a signal by which the patient can

communicate if she/he wants to stop the
procedure, for example, by raising their hand.
To give the patient a sense of control, gain their cooperation and to ensure the safe passing of the tube.
4.
Sit the patient in an upright position, with head

well supported and with the chin 90 to the neck,
unless contra-indicated.
The patients natural inclination is to move

backwards away from the tube.
To close the glottis, protecting the airway
(McConnell, 1997).
5.
Prepare tape or commercial attacher.
To facilitate procedure.
6.
Wash hands and put on apron.
To prevent cross infection and protect clothing.
7.
Prepare the tube by making sure that the guide

wire moves freely (some manufacturers
recommend that the wire is lubricated ,always
check the manufacturers instructions).
Promote easy removal of guide wire.
19
8.
Check the distal end of the tube to ensure that the

guide wire is not protruding.
Wire could cause trauma to the nasopharynx and

oesophagus.
9.
Measure the length of tube required by placing the

end of the tube at the patients xiphisternum and
measure the distance from here to the bridge of
the nose and then from the nose to the earlobe.
Note the mark on the tube.
To ensure the appropriate length of tube is passed

into the stomach.
10.
Put on gloves. Dip the distal end of the tube into

the water or water soluble jelly. Give mouth care
or offer the patient a drink if able to swallow.
To lubricate the tube and oesophagus, making

insertion easier.
11.
Calmly insert the distal end of the tube into the

clearest nostril and slide slowly along the floor of
the nasopharynx.
To facilitate passage of the tube by following the

natural anatomy of the nose.
12.
As the tube passes down into the nasopharynx,

ask the patient to start sipping water and
swallowing (if able).
A swallowing action closes the glottis, enabling the

tube to pass into the oesophagus and reduces the risk
of it entering the trachea.
13.
Advance the tube at a speed acceptable to the

patient, until the pre-determined mark is reached.
To gain patients co-operation.

To ensure correct length of tube is inserted.
14.
Gently remove the guide wire, if indicated in the

manufacturers instructions.
With some tubes removing the guide wire could

displace the tube; therefore it is necessary to remove
the wire before the final checking of the tubes
position.
Difficulty in removing the guide wire could indicate
a wrongly placed tube.
15.
Anchor the tube securely in position. If possible,

a commercial attacher should be used.
Document the exact position (length) of the tube,
at the nostril, in the appropriate record. The mark
on the tube at the end of the procedure should be
at the patients nostril.
To secure the tube and determine tube position.
16.
Document the procedure in the patients record

detailing date, time, confirmation of consent, any
difficulties during insertion, how the position of
the tube was confirmed, the length mark of the
tube at the patients nostril and how the tube was
secured
To conform to good clinical governance
Checking NG tube position (Figure 2)

Checking the position of the tube is a shared responsibility between the nursing and medical staff.
There are two methods of determining tube placement, namely:
Aspiration
Radiography
PLEASE ALSO SEE APPENDIX 2: USE OF WIDEBORE TUBES
20
Aspiration (Table 2 and Figure 3)

Aspiration and pH testing of the aspirate is a reliable method when determining tube position.
Please refer to NPSA Alert 05-2005 Reducing Harm by Misplaced Nasogastric Tubes. Aspirate
should be pH 5.54 or below to commence feeding. There are no known reports of pulmonary aspirates
at or below this figure. The range of pH 0-5.54 balances the risk between increasing the potential
problems for clinical staff e.g. removing tubes that are actually in the stomach, increase use of x-ray,
with the as yet, unreported possibility of feeding at pH 5.5 4 when the tube is in the respiratory tract.
Best Practice
Use of pH Paper
Only pH paper should be used to obtain an accurate pH reading via aspiration.

Litmus paper is not sufficiently sensitive to distinguish between gastric acid and bronchial
secretions.
Radiography
It is generally accepted that the most reliable method of checking the position of the tube is with the
use of radiography as fine bore NG tubes are radio-opaque. However, this method can result in
excessive exposure to x-rays and delay to nutritional support. It should also be remembered that
although radiography has been recognised as the gold standard for determining tube position
(Neumann et al, 1995), it can only confirm the tube position at the time of x-ray. For these reasons the
best practice is to check position of nasogastric tubes by the pH method using radiography only when:
Patient on critical care (see Appendix 1)
Gastric aspirate cannot be obtained on at least two occasions (as above) (El-Gamel & Watson,
1993)
When the gastric aspirate is above pH 5.54 (as is often the case for patients on proton pump
inhibitor medication)
There is significant doubt that the aspirate obtained is gastric (as above)
In high-risk patients where there is any concern that the tube may be in the bronchial tree, e.g.
unconscious, sedated or intubated patients and patients with tracheostomies.
Auscultation for determining feeding tube placement should not be used. Auscultation alone is
not reliable in the checking of the tubes position, as vigorous peristalsis can be mistaken for air
entering the stomach. Insufflation of air into the tube can be misleading because auscultation over
the stomach can register sound transmitted through a tube that has been passed into the main
bronchus (Sobotka, 2000 p83). NPSA Alert 2005 CL NPSA 05-2005
The information in the document was originally developed by the National Nurses Nutrition Group
(NNNG) and further developed in collaboration with the Medicines and Healthcare products
Regulatory Agency (MHRA), the National Patient Safety Agency (NPSA), NHS clinicians, risk
managers and other leading experts in the field. The Patient Safety Research Programme at the
University of Birmingham has commissioned additional research to assess these methods further. This
advice may therefore be revised following the outcome of this work. www.npsa.nhs.uk/advice
21
Table 2: Checking tube position: Aspiration

Principle
1.
Using a 50ml syringe purple enteral syringe (BAPEN 2003)
aspirate some fluid from the tube and test it on pH paper.
Always check the expiry date on the pH paper prior to

using.
If there is any doubt, confirmation of the pH reading should
be made with another health care professional.
Rationale
To establish the position of the tube.
Aspirate should be pH 5.5 or below to
commence feeding. There are no known
reports of pulmonary aspirates at or below
this figure. (NPSA Safety Alert 2005).
pH indicator strips can measure this
accurately. (Metheny et al, 1989,
Neumann et al, 1995, Colagiovanni,
1999)
To rule out subjective analysis.
A smaller syringe may produce too much
pressure and split the tube (BAPEN2003)
2.
Use only a 50ml purple enteral syringe and dispose of

according to local guidelines. The safest syringe size for
flushing or aspirating is a 30-50ml syringe.
3.
Record in patients notes

date and time tube passed
number of attempts made to pass
the type of tube used
the nostril used
the exact position of the tube (referring to the
distance mark at the nostril)
method used to check tube position, give details of
Ph of aspirate obtained.
any difficulty in passing the tube
To maintain records and to maintain

patient safety.
4.
Commence feeding only after the position of the tube has

been confirmed by aspiration or radiology.
If radiology is used a doctor should record the image
position of tube in patients medical records
To maintain patient safety.
Figure 3: What to do if aspirate is not obtained

Advance or withdraw tube
10-20 cm and retry
Change patients position

and retry
Put the indicator and syringe

below the level of patients
stomach to obtain syphon
effect.
If no aspirate obtained, wait 30-60 minutes and retry
If still no aspirate obtained, consider radiography
22
FIGURE 2: REDUCING THE HARM CAUSED BY MISPLACED NG FEEDING TUBES:

ADVICE FOR HEALTHCARE STAFF
Confirming the correct position of nasogastric feeding tubes in ADULTS
Check if on acid inhibiting medication
Check for signs of tube displacement and measure tube length
Reposition or repass tube if required
Aspirate using 50ml syringe and gentle suction
Aspirate obtained (0.5-1ml)
Aspirate not obtained
DO NOT FEED
1
If possible, turn adult onto side
Inject 10-20ml air into the tube using syringe
Wait for 15-30 minutes

Test on pH strip or paper
DO NOT FEED
1
Advance tube by 10-20 cm

Try aspirating again
pH > 6 or above4
pH 5.54 or below

DO NOT FEED
1
Leave for up to one hour

Try aspirating again
pH 5.54 or below
pH > 6 or above4
DO NOT FEED
1
2
Call for advice

Consider replacement/repassing of tube and/or checking
position by x-ray
Process to feed
CAUTION: If there is ANY query about position and/or the clarity of the colour change on the
pH strip, particularly between ranges 5 and 6, then feeding should not commence.
23
Best Practice
Flushing the Tube
Fine bore feeding tubes require regular flushing. If the feed is turned off, the tube is at risk of
blocking. Always ensure the tube is flushed after a feed is turned off, before and after administration
of feed or medication. Always following the instructions for flushing on the feeding regimen.
Best Practice
Checking And Re-Checking The Tube Position
Before the feed commences, administration of medications and before flushing the intra-gastric tube
position of the tube must be confirmed and documented. The tube position should also be confirmed
on each nursing shift. The registered nurse should document (Colagiovanni, 1999) how the tube
position has been checked and its distance at the nose each time the tube is used. In addition to the
above, the tubes position should be checked:
If the patient has episodes of vomiting, retching or coughing
After any oro-pharyngeal suction
If there is any change in the length of tube
At any signs of respiratory distress
If an aspirate cannot be obtained OR is above 5.54 and the tube has not moved since last (+)
check was made, it will be acceptable to commence the feed after having had a second review
by another competent practitioner
If in any doubt about the position of the tube, do not use and seek expert/medical advice.
As it is difficult to distinguish between gastric and other aspirate, visible characteristics of the
aspirate should never be used as a method for checking the tube position
Best Practice
Visible Checking of the Tube
Check and record the distance of the tube at the nose and compare with previous records. This should
be recorded at least once in 24hrs and also before commencing a new feed or administering drugs
(Cannaby et al 2002). Fixation tape should be checked, at least daily, to ensure that it is secure and
intact. Replace as necessary.
Best Practice
Health and Safety
If there appears any respiratory distress, stop the feed and check the tube position. If necessary, call
for help.
During feeding, nurse the patient at a 45o angle to reduce the risk of reflux and aspiration
NG BRIDLES
Bridles are loops which go through each nostril around the posterior aspect of the nasal septum and are
then secured to the feeding tube in front of the nose. They are intended as a method of securing
feeding tubes so that they are not easily displaced. They should be used only when standard methods
of securing feeding tubes have failed.
There are two main types of bridle:
Catheter-based, which are usually inserted by surgeons or anaesthetists when the patient is
ventilated.
Magnet based, which is a commercially available bridle kit. These can be inserted at the
bedside. There is currently only one product available and instructions for use are in the
packet insert. However these must only be inserted by those who are competent to do so and
have had the relevant training.
Indications for NG bridles:
Short-term (< six weeks) feeding in patients who frequently displace their tubes
Post operatively in upper GI surgery to ensure that tubes stay safely across an anastomosis
(but these tubes are then not usually used for feeding purposes)
24
In critically ill patients where intubation has been difficult and there is a high risk of
displacement
In general, their use outside of critical care would usually be at the discretion of the Nutrition Nurse
Specialist
WIDE-BORE TUBES (See Appendix 2)

The term wide-bore tube is often used synonymously with the Ryles tube. There are, however, 2
types in common use. The Ryles tube is a single lumen unvented tube used for gastric aspiration and
sometimes temporary feeding and administration of medicines in critical care. A Salem tube is a
double lumen tube used for venting the stomach, again mainly used in critical care.
While it is possible to use such tubes for feeding, it is not recommended, because
It can be very uncomfortable for the patients
Has increased risk of complications
Can cause oesophageal erosions
If a patient is discharged from critical care with such a tube in place, but which is only required for
feeding, this should be exchanged for a fine-bore tube.
For further information on wide-bore tubes, please refer to the Trust Guideline Passing and Checking
the Position of a Wide Bore Nasogastric Tube (also included in this document as Appendix 2).
REFERENCES
BAPEN (2003) Administering drugs via enteral feeding tubes - a practical guide London: BAPEN
Cannaby N, Evans L, Freeman A (2002) Nursing care of patients with nasogastric feeding tubes
British Journal of Nursing Vol. 11 No. 6 pp. 366-372
Colagiovanni L (1999) Taking the tube Nursing Times Vol. 95, No. 21 pp. 63-71
El-Gamel A, Watson D (1993) Transbronchial intubation of the right pleural space: A rare
complication of nasogastric intubation with a polyvinylchloride tube a case study Heart and Lung
May/June pp.224-225
McConnell (1997) How to determine gastric pH Nursing Times Vol. 27 No. 8 pp. 126
Metheny N, Reed L, Worseck M, Clark J (1993) How to aspirate fluid for small bore feeding tubes
American Journal of Nursing Vol. 93 No. 5 pp. 86-88
Neumann M, Meyer C, Dutton J, Smith R (1995) Hold that x-ray: Aspirate pH and auscultation
prove enteral tube placement Journal of Clinical Gastroenterology Vol. 20 No. 4 pp. 293-295
Nottingham Acute Trusts (2003) Working in New Ways Policy and Guidelines Nottingham: NAT
Sobotka L (Ed) (2000) Basics in clinical nutrition 2nd Edition Prague: Galen
25
NASOJEJUNAL (NJ) FEEDING

Nasojejunal tubes are not commonly used and the indication for use and tube selection will normally
be under the supervision of the Nutrition Support Team. NJ tubes can single-lumen or multi-lumen. A
double lumen tube can be used when gastric stasis necessitates the need for aspiration of the stomach
while feeding distally, and a triple lumen tube will allow, feeding as well as gastric aspiration and
decompression.
Indications for NJ feeding
Feeding a functioning gastrointestinal tract when the stomach needs to be by-passed, i.e.
where there is a mechanical or obstructive gastric outflow obstruction
Pancreatitis
Risk of aspiration with intragastric feeding
Contraindications as for NG feeding
Placement
Nasojejunal tubes can be positioned in three main ways:
1. By the bedside in patients who have normal gastric emptying and in whom there is no
vomiting. This is a rare situation, but can occur in patients pre-treatment, such as bone marrow
transplantation or cystectomy when post-treatment vomiting or gastric stasis can be predicted.
In this situation a Bengmark tube is used and passed, as for an NG tube. Spontaneous passage
into the jejunum should be confirmed radiologically. We do not currently use magnetic tube
trackers in the Trust.
2. Endoscopically (preferred method in ventilated patients and in those who need their tubes
passed in Theatre). In this situation tubes are passed either:
a. Through the scope (Cook or Freka Nasojejunal tubes)
b. Over a guidewire (Cook Nasojejunal or Trilumina tubes)
c. Endoscopically by differential friction (usually a Bengmark tube)
3. Radiologically (preferred method in patients who are immunosuppressed) The tubes used will
be Bengmark, Cook or Freka Nasojejunal tubes)
Following insertion the procedure report should detail:
Method of insertion
The type of tube used (Manufacturers name and batch number)
Which jejunal position has been achieved and how this has been or should be confirmed
How the tube has been secured at the nose or cheek
At what level the tube has been secured at the nose or cheek
If there is more than one port, how these can be identified
Any variance to standard insertion protocol and the reason for it
NJ tubes in use at NUH

The tubes available for NJ feeding in NUH have three characteristics:
1. They are licensed for this purpose
2. There is competence in the Trust for insertion, care and maintenance
New tubes will only be introduced when all three of these criteria have been achieved and when the
relevant guidelines have been updated. The Nutrition Steering Committee will need to ratify any
requests for new tubes.
The following tubes are currently in use:
Flocare Nutricia Nasojejunal (Bengmark)
Cook Nasojejunal single lumen
Freka (Fresenius) nasojejunal single lumen
Freka (Fresenius) nasojejunal double lumen
Trelumina Nasojejunal (Fresenius)
26
GASTROSTOMY AND JEJUNOSTOMY FEEDING

A gastrostomy or jejunostomy is a tube with an external catheter exiting from a stoma on the
abdominal wall, and allows the patient to be fed enterally. Patient selection for gastrostomy and
jejunostomy will normally be with advice from the Nutrition Support Team.
The indications for gastrostomy and jejunostomy feeding are the same as for NG and NJ feeding
respectively (pages 18 and 26), and are usually the route of choice when the anticipated need for
nutritional support is prolonged (ie>4-6 weeks). There are, however, a number of relative
contraindications to insertion, including
morbid obesity (technically difficult to access the stomach)
uncorrected coagulopathy
portal hypertension & ascites
active gastric ulceration or malignancy
gastroparesis
Peritoneal dialysis
Previous partial gastrectomy
Although some of the relative contraindications may preclude endoscopic insertion, radiological or
surgical insertion is often feasible (see below).
All patients referred for consideration of stoma feeding will be assessed by the nutrition nurse
specialist (see appendix 4).
Types of stoma
a) Gastrostomy tubes
These may be placed endoscopically (PEG), radiologically (RIG) and occasionally at laparoscopy or
by open surgical technique. The type of procedure performed is dependent on the patients diagnosis
and condition. The patients medical team and the nutrition support team will decide on which method
of stoma formation to use. In general the method chosen depends on the issues detailed in the
following 3 points:
Percutaneous Endoscopic Gastrostomy (PEG)
This method is used providing that the patient is fit enough to undergo gastroscopy and does not have
obstruction of the oesophagus.
Percutaneous using ultrasound and xray screening techniques (RIG radiologically inserted
gastrostomy)
A gastrostomy can be placed in X-ray by using ultrasound and/or X-ray screening techniques. This
allows the structures in the abdomen to be identified to locate the stomach and avoid damage to other
organs such as transverse colon or liver.
Surgical
Gastrostomy insertion during a laparotomy under general anaesthetic is often performed at the same
time as another surgical procedure or when the percutaneous methods have failed (eg large hiatus
hernia).
b) Jejunostomy tubes
As with gastrostomies, these can be placed endoscopically, but more often surgically.
PEGJ
These are extension tubes placed through a pre-existing PEG. Technically straightforward to insert but
maintaining intubation into jejunum is difficult to maintain.
PEJ
This is a direct endoscopic puncture into the jejunum. It required deep intubation beyond the
duodenojejunal flexure and is technically difficult to achieve. These are done only occasionally.
Surgically placed jejunostomy
Following tube insertion the procedure report should detail:
27
Method of insertion
The type of tube used (Manufacturers name and batch number)
How position of the tube has been confirmed
How the tube is secured internally
How the tube has been secured at the skin
At what level the tube has been secured at the skin
If there is more than one port, how these can be identified
Any variance to standard insertion protocol and the reason for it
Gastrostomy and jejunostomy tubes in use at NUH

The tubes available for gastrostomy and jejunostomy use in NUH have three characteristics:
1. They are licensed for this purpose
2. There is competence in the Trust for insertion, care and maintenance
New tubes should only be introduced when all three of these criteria have been achieved and when the
relevant guidelines have been updated. The Nutrition Steering Committee will need to ratify any
requests for new tubes.
The following tubes are currently in use:
Gastrostomy tubes:
o 9 & 15 French Freka tubes (can be placed endoscopically or radiologically)
o 12, 14, 16 and 20 French Corflo balloon replacement
o 12 French Tilma loop retaining (can be placed radiologically)
o 15 French Freka balloon replacement
o Skin level devices (buttons) for better cosmesis
Jejunostomy tubes:
o Freka gastrostomy with a jejunal limb
o 9F Freka gastrostomy in the jejunum
o Freka needle catheter jejunostomy
o Mickey cuffed jejunostomy
o 9 French Freka surgical jejunostomy
28
ADMINISTERING FEED
A) NASOGASTRIC FEEDING
Nasogastric feeding is usually administered via a pump as this ensures feeding at a slow steady rate
with greater accuracy. A pump also assists passage of a viscous solution through a fine-bore tube.
Pumps should only be used by health care professionals who have the relevant knowledge and
competency in their use and care.
Commercially prepared feed should normally be used as it reduces the risk of infection (Anderton,
1995). Feed packs should be stored unopened at room temperature as feeds that are warmed are more
likely to become contaminated with harmful pathogens (Jones, 1982). Details of the feed to be used
for your patient will be given on enteral feeding regimen prepared by the dietitian. (Emergency starter
regimen is available in appendix 3 if required)
i) ADMINISTRATION OF FEED USING A FEEDING PUMP & COMMERCIALLY

PREPARED FEED IN A PACK
EQUIPMENT
Feeding regimen
Prescribed feed pack
Infinity flocare Feeding pump and stand
Suitable giving set
pH paper
Jug and freshly drawn drinking tap water (Sterile for immunosuppressed patients)
Table 3: Administering commercially-prepared feed using a pump
Principle
Rationale
1.
To avoid errors in administration.
2.
3.
4.
5.
6.
7.
8.
9.
Check the feed against the prescribed regimen

and patient details. Check the presentation and
expiry date.
Wash hands
To minimise the risk of cross infection
Check the position of the tube (see page 21).

To prevent aspiration and feeding using a displaced
If in any doubt that the tube is not in the
tube.
correct position do not use, and inform medical
team.
Wash hands again or use alcohol hand rub.
To minimise the risk of cross infection.
Unscrew or open the feeding end of the NG
tube. Attach the 50ml purple enteral syringe
syringe, gently and slowly flush the tube using
up to 50 ml of freshly drawn drinking tap
water (or amount indicated on the feeding
regimen). Use sterile water for
immunosuppressed patients.
Shake pack of feed and then hang on the drip
stand.
Check the expiry date on the giving set, open
packaging and take out, holding each end.
Screw giving set tightly to the feed pack and
spike taking care not to touch the sterile foil
end of the feed pack.
Squeeze the drip chamber to half fill with feed
To prevent tube blockage.

Use 30-50 ml syringe as it is possible to rupture
fine-bore tubes by using excessive force with a
smaller syringe (BAPEN 2003, Shaw, 1994).
To distribute the contents throughout the solution.

To ensure sterility.
To facilitate the procedure and reduce risk of
leakage and of contamination
To facilitate the procedure.
29
10.
11.
12.
13.
14.
15.
16.
Open the pump door and place the giving set

in the pump and then close the door.
Turn the pump on. Then press the CLR button
Now you need to set the rate of the infusion
and then the total volume to be infused. First
set the rate to be infused:
Check the feeding regime for the intended rate
of feed. Press the (+) or (-) buttons to set this
rate, in mls per hour on the pump
Now set the total volume to be infused:
Press the DOSE = VOL button and the pump
will read CONT, then press the (+) to set the
volume to be infused
Press the FILL SET button to prime the giving
set
Remove the cap from the giving set. Connect
the end of the giving set to the nasogastric tube
and then press START/STOP button to
commence feeding
Document the procedure in the patients record
to include:
How position of feeding tube was confirmed
Date & time new feed was commenced
To power pump and clear previous settings

To ensure that the patient gets the prescribed
regimen
To commence feeding
To conform to good governance practice
ii) ADMINISTRATION OF FEED USING A FEEDING PUMP & RECONSTITUTION

OF POWDERED FEED
EQUIPMENT
Feeding regimen
Appropriate prescribed feed
Feeding reservoir bottles and additive labels
Infinity Flocare pump & stand
Suitable giving set
Jug and freshly drawn freshly drawn drinking tap water (sterile water for immunosuppressed
patients) for flush
pH paper
Sterile jug and sterile water (if mixing feed)
Whisking device
Alcohol 70% spray
Paper towel
Alcohol wipe
Table 4: Preparation and reconstitution of powdered feed (must take place in the ward kitchen
away from any food.)
Principle
Rationale
1.
Prepare equipment needed. Check the feed

against the prescribed regimen and patient details.
Check the presentation and expiry date.
30
2.
Wash hands and clean the whisk in hot soapy

water and rinse. Dry with a paper towel.
To avoid cross infection.
3.
Wash hands and clean the work surface with 70%

alcohol and allow the work surface time to dry
(Anderton, 2000).
4.
Clean the top of the feed pack with an alcohol

wipe and allow to dry.
To avoid cross infection
5.
Open the feed and sterile water and pour into a

jug (ensuring you have calculated the amount of
feed and water needed for the 24hr period).
Discard any unused water. Bottles of sterile
water are single use only. Once opened the
water is no longer regarded as sterile. Do not
replace cap. Do not re-use.
Mix together in the jug with whisking device
according to the manufacturers instructions.
To facilitate the procedure
6.
Remove the lid from the reservoir bottle (ensure

the inside of the lid and reservoir is not touched).
Pour the feed into the reservoir and replace the lid
firmly.
Repeat this procedure until you have filled
enough reservoir bottles for 24 hrs.
7.
Discard any unused feed and water and the jug

(MDA, 2000).
To ensure opened feed and water is not used

again
8.
Record the
date and time;
feed type;
volume
feed expiry time
patients name and number
on the additive labels and fix to all the reservoir
bottles.
For monitoring purposes
9.
Store the additional filled reservoir bottles in the

fridge.
10.
Take the feed to be used to the patient.
11.
Check the position of the tube. (See Guidelines

for Passing and Checking a Fine Bore NG
Tube).If in any doubt that the tube is not in the
correct position do not use and inform medical
team.
To prevent aspiration and feeding using a

displaced tube.
12.
13.
Wash hands again or rub with alcohol hand rub.

Unscrew or open the feeding end of the NG tube.
Attach the 50ml purple enteral syringe and gently
and slowly flush the tube using up to 50 ml of
freshly drawn drinking tap water (or amount
indicated on the feeding regimen).
Use sterile water for immunosuppressed patients.

Use 30-50 ml syringe as it is possible to
rupture fine-bore tubes by using excessive
force with a smaller syringe (BAPEN 2003,
Shaw, 1994).
31
14.
Check the expiry date on the package of the

giving set prior to opening.
Open packaging of the giving set.
15.
Hang the reservoir bottle on the drip stand.

Hanging will be considered carefully when the
dietitian is planning the feeding regime ideally
reservoirs of reconstituted or decanted feed
should only hang for 4 hours. This may be
extended to a maximum of twelve hours (for
example, overnight) in response to client or carer
needs.
Attach the giving set to the reservoir taking care
not to touch the sterile end of the reservoir or
giving set.
16.

spike taking care not to touch the sterile foil end
of the feed pack.
To facilitate the procedure and reduce risk of

leakage and of contamination
17.
18.
Open the pump door and place the giving set in

the pump and then close the door.
19.
20.
Now you need to set the rate of the infusion and

then the total volume to be infused. First set the
rate to be infused:
Check the feeding regime for the intended rate of
feed. Press the (+) or (-) buttons to set this rate, in
mls per hour on the pump
Now set the total volume to be infused: Press the
DOSE = VOL button and the pump will read
CONT, then press the (+) to set the volume to be
infused
Press the FILL SET button to prime the giving set

regimen
22.
Remove the cap from the giving set. Connect the

end of the giving set to the nasogastric tube and
then press START/STOP button to commence
feeding
To commence feeding
23.
Document the procedure in the patients record to

include:
How position of tube was confirmed
Time new feed commenced
24.
Remove next feed from refrigerator our before

it is required
To allow the feed to come to room

temperature and prevent abdominal
discomfort.
21.
32
iii) ADMINISTRATION OF FEED USING A FEEDING PUMP & FEED DECANTED

INTO A RESERVOIR BOTTLE
EQUIPMENT
Feeding regimen
Appropriate prescribed feed e.g. can, bottle
Feeding reservoir bottle and additive label
Flocare Infinity pump and stand
Suitable giving set
Jug and freshly drawn drinking tap water (Sterile water for immunosuppressed patients) for
flush
pH paper
Alcohol wipe
Table 5: Administration of feed using a feeding pump and reservoir bottle
Principle
Rationale
1.

and patient details. Check the presentation and
expiry date.
2.
Wash hands
3.
Check the position of the tube. (See Guidelines

for Passing and Checking a Fine Bore NG
Tube).
If in any doubt that the tube is not in the correct
position do not use and inform medical team.
To prevent aspiration and feeding using a

displaced tube.
4.
5.
Wash hands again or rub with alcohol hand rub.

Unscrew or open the feeding end of the NG tube.
Attach the 50ml purple enteral syringe and gently
and slowly flush the tube using up to 50ml of
freshly drawn drinking tap water (or amount
indicated on the feeding regime).
Use sterile water for immunosuppressed patients.

6.
Clean top of feed pack/can with alcohol wipe
To prevent cross infection
7.
Fix a completed additive label to the reservoir,

indicating feed, volume, date and time.
To allow the contents to be checked and

ensure the feed is only hung for 24 hrs.
8.
Shake the container of feed.
To mix the contents of the feed.
9.
Fill the reservoir with the correct volume of feed

and replace the lid.
10.
Open packaging and close the roller clamp.

Check the expiry date on the package of the
giving set prior to opening.
To ensure the volume is administered

according to the feed regime and facilitate
the procedure.
11.
Hang the reservoir on the drip stand. Ideally

reservoirs of reconstituted or decanted feed
Use 30-50 ml syringe as it is possible to

rupture fine-bore tubes by using excessive
force with a smaller syringe (BAPEN 2003,
Shaw, 1994).
33

example, overnight) in response to client or carer
needs.
Attach the giving set to the reservoir taking care
not to touch the sterile end of the reservoir or
giving set.
12.

spike taking care not to touch the sterile foil end
of the feed pack.
To facilitate the procedure and reduce risk

of leakage and of contamination
13.
14.

15.
16.

rate to be infused:

regimen
17.

Press the DOSE = VOL button and the pump will
read CONT, then press the (+) to set the volume
to be infused
18.
19.

end of the giving set to the nasogastric tube and
feeding
To commence feeding
20.
Document the procedure in the patients record to

include:
How position of tube was confirmed
Time new feed commenced
21.
Remove next feed from refrigerator our before

it is required
To allow the feed to come to room

temperature and prevent abdominal
discomfort.
34
B) JEJUNAL FEEDING
ADMINISTRATION OF COMMERCIALLY PREPARED FEED USING A FEEDING
PUMP
Details of the feed to be used for your patient will be given on enteral feeding regimen prepared by
the dietitian. (see appendix 3 for emergency starter regimen if required)
ONLY USE STERILE WATER AND STERILE JUGS WHEN DEALING WITH
JEJUNAL TUBES
Table 6: Administering commercially prepared feed via jejunal tube
Principle
Rationale
Commercially prepared Feed in a Pack

i)
Equipment Required:
Feeding regimen
Appropriate feed pack, check pack size to be
used
Feeding pump
Drip stand
Suitable giving set
50ml purple enteral syringe x 2
Sterile Jug
Sterile water
1.
Check the feed against the prescribed regimen and

patient details. Check the feed type, presentation,
volume and expiry date.
2.
Wash hands
To remove germs and prevent cross

infection
3.
Check the position of the tube prior to each time

the tube is used. Check the visual length of the
tube and compare with other visual checks. If
markings are available check actual length. If in
any doubt the tube is not in the correct position
Do Not Use. Check with medical team or the
Nutrition Support team.
To prevent aspiration or when gastric

feeding is contraindicated.
4.
Wash hands again or rub with the alcohol hand

rub.
To minimise risk of infection
5.
Always flush the jejunal tube prior to feeding (and

repeat after feeding)
ONLY USE STERILE WATER.
Draw up 15-50ml water into a 50ml purple enteral
syringe (see feeding regime to check amount of
flush required)
Unscrew or open the feeding end of the jejunal
tube. Attach the 50ml purple enteral syringe and
gently and slowly flush the tube.
To prevent the tube from blocking and

ensure patency of the tube.
35
6.
Shake pack of feed.
To distribute the contents throughout the

solution. This is especially important if the
feed contains fibre.
7.
Hang pack on drip stand.
8.
Obtain giving set; check the expiry date on the

package prior to opening. Open packaging and
take out giving set, holding each end.
To ensure the giving set is sterile
9.
Unscrew and remove the protective cap from the

pack, ensure you do not touch the sterile foil end.
Whilst keeping the feed still by holding the purple

connector above the sterile end on the pack of
feed, push on the purple end of the giving set and
screw on.
Hold the purple end of the giving set that has been
screwed onto the feed and with the other hand
push up sharply the giving set allowing the
internal spike to break the foil seal.
9.
10.

11.
12.

rate to be infused:
13.

Press the DOSE = VOL button and the pump will
read CONT, then press the (+) to set the volume
to be infused
14.
15.

end of the giving set to the jejunal tube and and
feeding
16.
Flush feeding tube at the end of feeding, before

and after medication; refer to feeding regimen for
flushing instructions.
Use sterile water only.
To prevent blocking tube.
To ensure that the patient gets the

prescribed regimen
36
17.
Commence a fluid balance chart and document

accurately input and output.
To ensure adequate hydration.
Please weigh twice weekly if possible, or more

frequently if indicated by medical staff.
To monitor nutritional status or signs of

over/under hydration.
18.
Prior to commencement to feeding ensure that

base line blood monitoring has been undertaken.
Repeat at regular intervals as required by
members of the team.
To maintain normal metabolic state.
19.
Check bowel movements daily by observation, or

by asking the patient about the frequency and
nature of stools. If any increased frequency,
commence a stool chart and inform the Dietitian.
To maintain normal bowel function.
Table 7: Administering feed decanted into a reservoir via jejunal tube

Principle
Rationale
ii) Feed decanted into a reservoir

Equipment Required:
Feeding regimen
Appropriate feed e.g. can, sachet, bottle
Reservoir bottle
Additive label
Feeding pump
Drip stand
Suitable giving set
Sterile jug and sterile water if mixing feed (refer to
guidelines for preparing powdered feed)
Sterile Jug
Sterile water
1.

and patient details. Check the feed type,
presentation, volume and expiry date.
2.
Wash hands
3.
Check the position of the tube prior to each time

the tube is used. Check the visual length of the
tube and compare with other visual checks. If
markings are available check actual length.
To remove germs and prevent cross

infection
To prevent aspiration or when gastric
feeding is contraindicated.
If in any doubt the tube is not in the correct

position Do Not Use. Check with medical team
or the Nutrition Support team.
4.
Wash hands or use alcohol rub
To reduce risk of infection.
5.
Always flush the jejunal tube prior to feeding

(and repeat after feeding )
To prevent the tube from blocking and

ensure patency of the tube.
37
ONLY USE STERILE WATER.

Draw up 15-50ml water into a 50ml purple
enteral syringe (see feeding regime to check
amount of flush required).
Unscrew or open the feeding end of the jejunal
tube. Attach the 50ml syringe and gently but
slowly flush the tube.
6.
Remove the lid from the reservoir taking care not

to touch the inside of the lid or reservoir
7.
Pour in the amount of feed required and firmly

close the lid.
8.
Fix the completed additive label to the reservoir,

indicating type of feed, volume, date and time
and patients name and hospital number.
To allow other nurses/Dietitians to check

contents.
9.
Hang reservoir on drip stand.
10.
Obtain giving set; check expiry date on package

prior to opening. Open packaging and take out
giving set, holding each end.
Hang the reservoir containing feed on the drip
stand
Package is within expiry date.
12.
Attach the giving set to the reservoir; ensure you

do not touch the inside of the connection on the
giving set and reservoir. Screw on.
13.
14.

15.
16.

regimen
rate to be infused:
17.

Press the DOSE = VOL button and the pump
will read CONT, then press the (+) to set the
volume to be infused
18.
Press the FILL SET button to prime the giving

set
end of the giving set to the jejunal tube and then
press START/STOP button to commence feeding
11.
19.
38
20.
Turn on the pump and set at the required rate, as

recommended by the Dietitian. Set the volume to
be infused using the dose key on the pump.
Always ensure mls/hr and volume to be infused
are set on pump prior to feeding. A second
person should check the rate, volume and type of
feed.
To ensure correct administration.
21.
Flush feeding tube at the end of feeding, before

and after medication; refer to feeding regimen for
flushing instructions.
Sterile water only
To prevent blocking tube.
22.
Commence a fluid balance chart and document

accurately input and output.
To ensure adequate hydration.
Weigh twice weekly if possible, or more

frequently if indicated by medical staff.
To monitor nutritional status or signs of

over/under hydration.
23.
Prior to commencement to feeding ensure that

base line blood monitoring has been undertaken.
Repeat at regular intervals as required by
To maintain normal metabolic state.
24.
Check bowel movements daily by observation, or

by asking the patient about the frequency and
nature of stools. If any increased frequency,
commence a stool chart and inform the Dietitian.
39
TUBE CARE AND MANAGEMENT

NG TUBE
Table 8: On-going (tube) care of patients on NG feeding

Feeding
Principle
1.
2.
The position of the tube and the length of tube

at the nostril must be re-checked every time
feeding is commenced and each time the tube
is used to administer medication. It should
also be checked by the nurse taking over the
care of the patient at the start of the shift. This
process should be clearly documented. See
page 18 on passing and checking position of
NG tube.
Flush feeding tube before and after feeding,
before and after medication and as per feeding
regimen.
Rationale
The tube can become dislodged, increasing the risk
of aspiration.
Establishing the correct position of the tube in the
stomach is essential to the safety of the patient, as
intrapulmonary feeding or aspiration owing to a
poorly positioned tube can have serious
consequences (Cannaby et al, 2002).
To prevent blocking NG tube and to maintain
hydration.
3.
The giving set and reservoir (if used) must be

labelled and changed every 24 hours and any
remaining feed discarded. Decanted feeds
example, overnight) in response to client or
carer needs.
To reduce the risk of infection (Anderton, 1995).
4.
Document input & output accurately on a fluid

balance chart
Weigh patient twice weekly if possible, or as
indicated by the dietitian or medical staff.
Prior to commencement of feeding ensure that
baseline blood monitoring has been
undertaken: (urea & electrolytes, magnesium,
calcium, phosphate & glucose). Repeat at
regular intervals as required by members of the
team
Record bowel movements daily. If any change
to usual pattern, commence a stool chart and
inform the Dietitian and/or medical team.
Observe the patient for signs of complications
(e.g. new breathlessness, coughing, fever or
regurgitation or vomiting) throughout the
duration of the feed. If signs of complications
or distress are seen, stop the feed and seek
medical advice.
Inform the Dietitian of any problems involving
the feed, equipment etc.
Change the tape, which secures the tube at the
nostril as required. A commercial attacher
should be used where possible.
Assist the patient to clean mouth and nostrils.
To ensure accurate records
5.
6.
7.
8.
9.
10.
11.
To monitor nutritional status.

To establish baseline biochemistry and identify
abnormalities which need monitoring.
To monitor and maintain patient safety

To reduce risk of accidental removal or
displacement of the tube.
To promote comfort.
40
Flushing the Tube

Principle
1.
Only use 50ml purple enteral syringes to flush
the tube and discard after single use.
Rationale
A smaller syringe may produce too much pressure
and split the tube (BAPEN, 2003).
2.
Tubes should be flushed with freshly drawn

drinking tap water before and after feeding,
administration of medication and as indicated
on the feeding regimen.
Re-use of single use only items contravenes

Medical Devices Regulations (MDA, 2000).
3.
Sterile water should be used if the patient is

immunocompromised (Taylor and GoodinsonMcLaren, 1992).
To reduce the risk of infection (Anderton, 1995).
Medicines (Refer to Separate Guideline on The use of syringes to administer flushes, feeds and medication
via the oral and enteral route in adults currently in preparation)
Principle
Rationale
1.
Tubes should be flushed with at least 15ml of

freshly drawn drinking tap water (Adams,
1994) before and after each individual
medication.
If more than one drug is to be administered they

should be administered separately and the tube
should be flushed with water between each one
(Colagiovanni, 2000) to prevent the tube blocking.
Inadequate tube flushing is the most common cause
of tube blockage (BAPEN 2003)
2.
Medication should ideally be in liquid form.
To reduce risk of blocking the tube.
Some thick liquid medications may require

diluting in an equal amount of water before
administration.
Some liquids are viscous and this may block the

tube.
3.
4.
All medications should be given separately.

If medicines are only available as a tablet,
check with the pharmacist that they can be
crushed. Do not administer crushed tablets that
have not been completely dispersed in water.
Liquids or soluble tablets are preferred
formulations to be administered via a feeding
tube.
Some medicines react with feed, affecting the
efficacy of the drug. Always check with the
pharmacist before administering any
medication down an enteral feeding tube.
Where possible give dose during the feed rest
period.
Best Practice
Tablets that have not been completely crushed can

block feeding tubes, as can preparations that are
incompatible when mixed with enteral feeds
(Marcuard and Perkins, 1988)
To maximise drug efficacy.
FLUSHING THE TUBE
Tubes which are not flushed immediately before and after feed and/or medication have a much higher risk of
blocking (Brennan Krupp and Heximar, 1998; Adams, 1994).
41
Best Practice Medication

Although the use of unlicensed medication or medication via unlicensed routes is not encouraged,
there are many occasions when it the only option. It is vital, however, to first seek the advice of a
pharmacist to identify other routes of administration or, if unavoidable, the best possible preparation
for nasogastric administration. (Refer To Separate Guideline On The use of syringes to
administer Feeds, Flushes and Medication via the oral and Enteral route in adults
Best Practice Medicines
Medications which must not be crushed include:
Enteric Coated (EC). The coating is designed to resist gastric acid to protect the drug and/ or reduce
gastric side effects.
Modified/slow Release (MR, SR,LA,XL). These are tablets or capsules that are specifically designed
to release the drug over a long period of time. Crushing these will cause all the drug to be released at
once and may cause toxic side effects.
Cytotoxics
and hormones. These should not be crushed due to the risk of exposure from the powdered drug.
Some Problem Drugs: Phenytoin, Digoxin and Carbamazepine Blood levels may be affected by
feeds; these should be checked regularly. It may be necessary to increase the dose. It is often helpful to
write a feed regimen which gives a two hour break pre and post the dosing of phenytoin
Antacids The metal iron in the antacid binds to the protein in the feed and can block the tube.
Consideration of an alternative may be necessary.
Penicillins Feed may reduce the absorption, a higher dose may be needed. If possible stop the feed 1hour before and 2 hours after administration.
Other antibiotics Levels of antibiotics such as Ciprofloxacin tetracyclines and rifampacin can be
significantly reduced by feed.
REFERENCES
Adams (1994) Administration of drugs through a jejunostomy tube British Journal of Intensive Care
Vol. No. pp. 10-17
Anderton A (1995) Reducing bacterial contamination in enteral tube feeds British Journal of Nursing
Vol. 4 No 7 pp 368-376
Anderton A (2000) Microbial Contamination of Enteral Tube Feed: How can we reduce the risk?
London: Nutricia Clinical Care
BAPEN (2003) Administering drugs via enteral feeding tubes - a practical guide London:
Brennan Krupp K and Heximer B (1998) Going with the flow Nursing. Vol. 28 No. 4.
Cannaby N, Evans L, Freeman A (2002) Nursing care of patients with nasogastric feeding tubes
British Journal of Nursing Vol. 11 No. 6 pp. 366-372
Colagiovanni L (1999) Taking the tube Nursing Times. Vol. 95, No. 21 pp. 63-71
Colagiovanni L (2000) Preventing and clearing blocked feeding tubes Nursing Times Vol. 96 No 17
pp. 3-4
Jacobs S, Chang R W, Lee B, Bartlett F W (1990) Continuous Feeding - A Major cause of
Pneumonia in the Ventilated ITU Patient Journal of Parenteral and Enteral Nutrition. Vol. 14, No 4,
pp 353-356
Jones E (1982) Nursing Aspects of Tube Feeding Nursing Vol. 12 No. 4 pp34-47
Hamilton H (2000) Total Parenteral nutrition - a practical guide for nurses London:
Marcuard and Perkins (1988) Clogging of feeding tubes Journal of Parenteral and Enteral Nutrition
Vol. 12 No.4 pp. 403 - 405
Medical Devices Agency (2000) The re-use of medical devices supplied for single-use only MDA
DB9501 London: HMSO
Rollins H (1997) A nose for trouble Nursing Times Nutrition Supplement. Vol. 93 No 49
Shaw J (1994) A worrying gap in knowledge - Nurses knowledge of enteral feeding practice
Professional Nurse July, pp. 656-661
St Georges Healthcare Trust (2000) Procedure for the insertion and placement of Naso-Gastri Tubes:
Adult Fine-Bore London: St Georges
42
Tait, (2001) Going Nasogastric Current thinking in Nasogastric Techniques Complete Nutrition
Vol 1 No. 2
Taylor S, Goodinson-McLaren S M (1992) Nutritional Support - A Team Approach. London: Wolfe
Publishing
Ward V, Wilson J, Taylor L, Cookson B, Glyns A (1997) Preventing Hospital Acquired Infection.
Public Health Laboratory Service, London.
GASTROSTOMY TUBE
CARE OF A PATIENT WITH A PERCUTANEOUS ENDOSCOPIC GASTROSTOMY
(PEG)
Table 9: IMMEDIATE CARE POST-PROCEDURE
Principle
Rationale
1.
Follow instructions for care of the patient as

indicated in the post-operative sheet.
To ensure safe recovery.
2.
Wash hands and apply non-sterile gloves.
To reduce the risk of cross infection.
3.
Check stoma site for swelling, bleeding and

leakage.
Check the fixation device is in the correct
position (procedure report) and remains
secure.
Do not open or adjust fixation device for the
first 48hrs.
Record position of the tube using the
graduated markings
To detect for haemorrhage or signs of infection.
4.
To ensure the tube is in the correct position.
5.
Check and record blood pressure, pulse and

temperature as requested on the post-operative
sheet.
To detect early signs of sepsis / peritonitis.
6.
Patient should remain nil by mouth for 4

hours post procedure or longer if indicated in
the procedure notes. Sterile water at 50mls per
hour via gastrostomy is then used for first 4
hours. If there are any adverse symptoms or
signs during the water infusion (excess pain,
fevers etc) then medical advice should be
sought
To reduce the risk of peritonitis
43
FEEDING VIA GASTROSTOMY

The dietitians will normally have prescribed a starter regimen (see appendix 3 for emergency starter
regimen if required). Ensure that this is available and used. Feeding will usually start at 8 hours after
the procedure providing there are no signs of peritonitis or organ damage.
Table 10: Pump feeding using agreed feeding pump and giving set
Principle
Rationale
1.i)
Commercially prepared feed in a pack, requirements:

Feeding regimen
Appropriate feed pack, check pack size to be used
Feeding pump
Drip stand
Suitable giving set
Label for giving set
Jug
Freshly drawn drinking tap water for flushing
1.
Check the feed against the prescribed regimen and patient

details. Check the feed type, presentation, volume and
expiry date.
2.
Wash hands.
To prevent cross infection.
3.
Check the position of the tube by looking at the graduated

markings on the tube or the visual length of the tube and
compare this with the information recorded following
insertion regarding tube position, if available.
To prevent feeding the patient when

the tube is displaced and to avoid
aspiration.
If in any doubt aspirate some gastric contents and check the

pH level with pH paper. The pH should be 5.5 or below.
Only pH Paper should be used to

obtain an accurate reading following
aspiration. Litmus paper is not
sufficiently sensitive to distinguish
between gastric acid and bronchial
secretions.
If there is still any doubt that the tube is not in the correct
position, do not use. Check with medical staff or the
4.
Always flush the gastrostomy tube prior to feeding (and

repeat after feeding).
Use freshly drawn drinking tap water or sterile water for
immunosuppressed patients. In some hospital areas sterile
water may need to be used for all patients (check local
policy)
Draw up, or measure out, 15-50ml water (see feeding
regimen to check amount of flush required).
Flush the tube using either low pressure or free flow
technique (see best practice box ).
To maintain a patent tube.
44
5.
Check feed labels to ensure feed type and expiry dates are
correct.
To ensure correct feed is given
Shake pack of feed.
To distribute the contents throughout

the solution. This is especially
important if the feed contains fibre.
6.
Hang pack on drip stand.
7.
Obtain correct giving set, check the expiry date on the

package prior to opening. Open packaging and take out
To ensure the giving set is safe to use

and to facilitate the procedure.
8.
Unscrew and remove the protective cap from the pack of

feed, ensure you do not touch the now exposed sterile foil
end.
Whilst keeping the feed still by holding the purple
connector above the sterile end on the pack of feed, push on
the purple end of the giving set and screw on.
Hold the purple end of the giving set that has been screwed
onto the feed and with the other hand sharply push up the
giving set allowing the internal spike to break the foil seal.
9.
10.
Open the pump door and place the giving set in the pump
and then close the door.
11.
To power pump and clear previous

settings
12.
Now you need to set the rate of the infusion and then the
total volume to be infused. First set the rate to be infused:
Check the feeding regime for the intended rate of feed.
Press the (+) or (-) buttons to set this rate, in mls per hour on
the pump
Press the DOSE = VOL button and the pump will read
CONT, then press the (+) to set the volume to be infused

prescribed regimen
13.
14.
15.
Remove the cap from the giving set. Connect the end of the
giving set to the gastrostomy tube and then press
START/STOP button to commence feeding
To minimise air entry, thus reducing

the risk of gastric distension and
patient discomfort.
To commence the feed
16.
Flush feeding tube at the end of feeding, before and after

medication; refer to feeding regimen for flushing
instructions.
To prevent blocking the tube.
45
17.
Commence a fluid balance chart and document accurately

input and output. Prior to commencement of feeding ensure
that base line blood monitoring has been undertaken (urea
and electrolytes, magnesium, calcium, phosphate and
glucose). Repeat at regular intervals as required by
To monitor metabolic and hydration

state.
18.
Monitor bowel movements daily by observation, or by

asking the patient about the frequency and nature of stools.
If abnormal, commence a stool chart and inform the
Dietitian and/or medical team.
To monitor normal bowel function.
19.
Inform the Dietitian of any problems involving the feed,

equipment etc.
To maintain patient safety
20.
Document all interventions and variances in the patients

record
In accordance with good clinical

governance
Best Practice
FLUSHING THE TUBE
To flush the tube using low pressure technique:

Draw up the required volume of freshly drawn drinking tap water (sterile water is often used as routine
in hospitals if there is concern about tap water, please check local guidelines. Always use sterile water
for immunosuppressed patients). Open the port or cap on the gastrostomy tube. Attach the 50ml
syringe and gently and slowly depress the plunger to flush the tube.
To flush the tube using free-flow technique:
Remove the plunger from a 30-50ml syringe. Open the port or cap on the feeding tube, attach the
syringe barrel and fill with the required amount of water, open the clamp and allow the water to go
through the tube.
Principle
1 ii)
Rationale
Feed Decanted into a Reservoir....

Equipment Required
Feeding regimen
Appropriate feed e.g. can, sachet, bottle
Reservoir bottle
Additive label
Pump and stand
Pump giving set or other if indicated
Label for giving set
Sterile jug and sterile water if mixing feed (refer to
guidelines for preparing powdered feed)
Jug and fresh drinking tap water for flushing (sterile
water for immunosuppressed patients)
1.

expiry date.
46
2.
Wash hands
3.

To prevent aspiration.

pH level. The pH should be 5.5 or below.
4.
Always flush the gastrostomy tube prior to feeding (and

repeat after feeding).
To ensure the tube remains patent.
Using freshly drawn drinking tap water or sterile water

(according to local guidelines) and measure out, 15-50ml
(see feeding regimen to check amount of flush required).
5.

technique (see best practice box).
Wash hands again or use alcohol rub.
6.
Before putting in the reservoir check the expiry date, type of

feed and duration against the feeding regimen and add feed
to reservoir.
To facilitate the procedure and to

prevent errors in administration.
7.
Obtain correct giving set, check the expiry date on the

package prior to opening. Open packaging and take out
Attach and screw on the giving set to the reservoir
To ensure the giving set is safe to use

and to facilitate the procedure.
8.
Hang reservoir on drip stand.
9.
Screw giving set tightly to the feed pack and spike taking
care not to touch the sterile foil end of the feed pack.
To facilitate the procedure and reduce

risk of leakage and of contamination
10.
11.
Open the pump door and place the giving set in the pump
and then close the door.
12.
13.
Now you need to set the rate of the infusion and then the
total volume to be infused. First set the rate to be infused:
Check the feeding regime for the intended rate of feed. Press
the (+) or (-) buttons to set this rate, in mls per hour on the
pump
14.

Press the DOSE = VOL button and the pump will read
CONT, then press the (+) to set the volume to be infused
15.
To power pump and clear previous

settings

prescribed regimen
47
16.
Screw giving set tightly to the feed pack and spike taking
care not to touch the sterile foil end of the feed pack.
To facilitate the procedure and reduce

risk of leakage and of contamination
17.
Remove the cap from the giving set. Connect the end of the
giving set to the gastrostomy tube and then press
START/STOP button to commence feeding
To facilitate the procedure and to

commence the feeding regimen
18.

input and output. Prior to commencement to feeding ensure

state.
19.
Check bowel movements daily by observation, or by asking

the patient about the frequency and nature of stools. If
abnormal, commence a stool chart and inform the dietitian
and/or medical team.
To monitor bowel function.
20.

equipment etc.
21.

record

governance
Table 11. Bolus Feeding

Principle
Rationale
Equipment Required
Feeding regimen
Appropriate feed e.g. bottle, can or cartons
Clean jug (to measure feed)
Jug and fresh drinking tap water for flushing
1.

expiry date.
2.
Wash hands.
3.

To prevent aspiration.

pH level. The pH should be 5.5 or below.
48
4.
Flush feeding tube before and after feeding, before and after
medication and as per feeding regimen.
To reduce risk of tube blockages
Using freshly poured drinking tap water draw up, or

measure out, 15-50ml (see feeding regimen to check amount
of flush required).
technique (see best practice box).
5.
With low profile device (buttons) an administration set is

required.
To select the correct feeding set for

type of feeding required
Select the correct administration set and this will be a bolus

set for bolus feeding.
The administration set must be primed with freshly drawn
drinking water. Open the clamp and attach the syringe
containing the water to the administration set. Gently and
slowly insert the water by pushing the plunger on the
syringe until the administration set is full.
Close the clamp.
Attach the administration set to the button, reattach the
syringe containing water and flush the button.
6.
Shake pack or bottle of feed. Measure the amount of feed

required into a jug or pour directly into syringe
To distribute the contents throughout

the solution. This is especially
important if the feed contains fibre.
7.
Administer the feed using either low pressure or free flow

technique as explained in the best practice boxes
8.
Continue until the procedure is complete, ensure the clamp

is closed and remove the syringe. Flush the feeding tube at
the beginning and end of feeding and before and after
medication; refer to feeding regime for flushing instructions.
To prevent any leakage from the tube
9.

input and output. Prior to commencement to feeding ensure

state.
10.
Check bowel movements daily by observation, or by asking

the patient about the frequency and nature of stools. If
abnormal, commence a stool chart and inform the Dietitian
and/or medical team.
To monitor bowel function.
11.

equipment etc.
record
12.

governance
49
Best Practice
FLUSHING THE TUBE
To flush the tube using low pressure technique:

Draw up the required volume of freshly drawn drinking tap water (sterile water is often used as routine
in hospitals if there is concern about tap water, please check local guidelines. Always use sterile water
for immunosuppressed patients). Open the port or cap on the gastrostomy tube. Attach the 50ml
purple enteral syringe and gently and slowly depress the plunger to flush the tube.
To flush the tube using free-flow technique:
Remove the plunger from a 50ml purple enteral syringe. Open the port or cap on the feeding tube,
attach the syringe barrel and fill with the required amount of water, open the clamp and allow the
water to go through the tube.
Best Practice
SYRINGES
Only use 50ml purple enteral syringes with enteral feeding tubes, smaller syringes may produce too
much pressure and split the tube (BAPEN, 2003). Do not use syringes intended for intravenous use
due to the risk of accidental parenteral administration.(BAPEN 2003) (NPSA 2007)
Best Practice
WEEKLY WEIGHING
As a general rule, all patients having gastrostomy feeds should be weighed at least weekly to monitor
nutritional status and signs of over/under hydration. Weighing more frequently may be advised. Ask
medical staff, Nutrition Support team or dietitian. When weighing, the same set of scales should be
used to main consistency
CARE OF THE STOMA
Table 12: Care of the stoma

Principle
Rationale
1.
Remove dressing, if present, after 24 hours and

observe for any signs of infection.
To reduce infection.
Some tubes may have Brown Mullert-clips. These

clips are inserted during the procedure to hold the
stomach in position before placing the gastrostomy
tube.
As above remove the dressing after 24-48 hours and
only if needed cover the gastrostomy with sterile dry
dressing.
The t-clips, if they have been place, should be
removed according to the post procedure instructions.
To maintain tube position.
Tubes placed surgically will usually have a dressing

in place. Care for the dressing as above or according
to the postoperative sheet. If there are any sutures
holding the tube in place, these must not be removed.
50
2.
For the first 7-14 days use an aseptic technique to

clean the stoma site and external fixation device daily
with sterile normal saline, and dry well.
Ensures the stoma site is cleaned all

around, this will help with the formation
of a healthy stoma.
After 7 14 days tubes with internal bumpers should

be rotated 360o and retracted (ie moved in and out by
6cm when cleaning. Tubes should be neither rotated
nor retracted in the first 7 days after placement
Tubes with internal pigtail fixators should neither
be rotated nor retracted at all.
3.
Assess daily and observe for signs of

swelling, inflammation, leakage, soreness, irritation,
and skin breakdown. Observe to see if the external
tube fixation device is too tight or loose.
To monitor and maintain patient safety
If any infection is suspected, swab the site and send

for culture and sensitivity and seek advice from the
patients doctor for treatment if necessary.
4.
If a dressing is required Redress daily if applicable

with sterile gauze until stoma site is healed (7 14
days).
To avoid infection
If an alternate dressing is required please seek advice.

5.
Dressings should be removed as soon as possible.
To prevent maceration of skin by

trapped moisture (Faller et al 1993).
6.
Once the stoma site has healed

(7-14 days) wash the stoma site, fixation device and
tube daily with soap and water and dry skin well.
To maintain hygiene.
7.
The external fixation device must remain in original

position for at least 48 hours.
8.
If required, the fixation device can be loosened

slightly (0.5cm approx) after 48 hours by a member of
the nutrition support team or appropriate staff only.
If in doubt seek advice. After 14 days the external
fixation device can be moved for cleaning the tube
and stoma site. After cleaning it should be
repositioned next to the skin with approximately 1cm
or little finger space between the skin and fixation
device.
To reduce risk of peritonitis as the

fixation device sandwiches the layers of
the abdominal wall and stomach
together whilst the stoma forms (Grant,
1993).
To prevent necrosis.
9.
Do not immerse the stoma site in water until full

healing has taken place (approximately 14days).
Showers should be used instead of a bath and site
covered with water proof dressing during shower.
To promote optimum healing.
10.
The clamp on the tube should be in the locked

position when syringes or giving sets are being
attached and then opened to allow flow of feed or
flush. It is best to move the clamp to a new position
To prevent reflux of gastric contents

onto the patient and carer
To prevent degradation of the tube
51
on the tube regularly, at least once a day

11.
Document all interventions and variances in the

patients record

governance
Table 13: Care of the gastrostomy tube

Principle
Rationale
1.
Note and record length of tube at skin level in the

nursing documentation by using the graduations that
are printed on the side of the tube. This should be
checked every shift and each time the tube is used. If
in any doubt about the position, aspirate some gastric
contents and check the pH. If the pH is 5.5 or below
the tube is safe to use.
If in any doubt, do not use and seek advice from your
nutrition nurse or the patients doctor.
To ensure the tube is in the correct

position and not migrated into the
oesophagus or through the pyloric
sphincter.
2.
If the tube has migrated inwards return to the correct

position, open the external fixation device and gently
pull the tube until some resistance can be felt.
Ensures the internal fixation device is

up against the stomach wall.
Reposition the external fixation device next to the skin

with approx 1 cm (or little finger space) between the
To maintain the correct position of the
skin and fixation device.
tube and reduce the risk of infection.
3.
Always ensure the external fixation device is locked

in position with the clip firmly closed.
To minimise the possibility of tube

migration.
4.
On a weekly basis open the external fixation device,

rotate the tube 360o and retract back and forth
ensuring the tube can move in and out of the stoma
tract freely.
To prevent the internal fixation

embedding itself on the stomach lining
(buried bumper syndrome).
5.

patients record

governance
REMOVING AND REPLACING GASTROSTOMY TUBES

Removal and replacement of gastrostomy tubes should only be undertaken by a health care
practitioner or carer who has undertaken the required training and been verified as competent in
accordance with the framework outlined in Working in New Ways Policy and Guidelines
(Nottingham Acute Trusts, 2003 or equivalent). Different tubes require different removal and
replacement techniques. Some can be removed by deflating the internal balloon, some by traction and
some need to be retrieved endoscopically. Rarely tubes are cut and allowed to pass in the faecal
stream. It is therefore vital that the nurse or doctor removing the tube is competent in the correct
procedure to do so.
ACCIDENTAL REMOVAL OF A GASTROSTOMY TUBE

If, a gastrostomy tube has been removed accidentally it is important to try to maintain the stoma open
so that the patient will not have to have another invasive procedure to site a new gastrostomy should
the stoma close. Therefore if a doctor or nurse competent in reinsertion is not available, best practice is
52
to use a sterile Foley catheter of the same size as a temporary replacement. It should be inserted by a
doctor or registered nurse competent in the procedure. This should not be used until the device is
changed to a feeding tube and the position is confirmed. www.mhra.gov.uk
Replacement of the gastrostomy tube or temporary insertion of a Foley catheter should take place no
longer than 4 hours following accidental removal and the Nutrition Support team informed as soon as
possible. After approximately 8 - 12 hours, the stoma will have started to close, and the patient may
require a further invasive procedure to replace the tube.
NB: When the gastrostomy tube is removed within three weeks of placement the stoma tract
may not have formed and there is a risk of free gastric perforation and peritonitis. Medical
advice should be sought immediately should this occur. RE-INSERTION OF A TEMPORARY
TUBE MUST NOT BE ATTEMPTED.
MEDICINES THROUGH GASTROSTOMIES

Table 14: Medicines through gastrostomies
Medicines (Refer To Separate Guideline On Use of syringes to administer flushes, feeds and
medication via the oral and enteral route in adults)
Principle
Rationale
1.
Tubes should be flushed with at least 15ml of freshly

drawn drinking tap water (Adams, 1994, BAPEN
2003) before and after each individual medication.
2.
Medication should ideally be in liquid form.
If more than one drug is to be

administered they should be
administered separately and the tube
should be flushed with water between
each one (Colagiovanni, 2000) to
prevent the tube blocking.
Inadequate tube flushing is the most
common cause of tube blockage
(BAPEN 2003)
Some thick liquid medications may require diluting in

an equal amount of water before administration.
All medications should be given separately.
Some liquids are viscous and this may

block the tube.
3.
If medicines are only available as a tablet, check with

the pharmacist that they can be crushed. Do not
administer crushed tablets that have not been
completely dispersed in water.
Liquids or soluble tablets are preferred formulations to
be administered via a feeding tube.
Tablets that have not been completely

crushed can block feeding tubes, as
can preparations that are incompatible
when mixed with enteral feeds
(Marcuard and Perkins, 1988)
4.
Some medicines react with feed, affecting the efficacy

of the drug. Always check with the pharmacist before
administering any medication down an enteral feeding
tube. Where possible give dose during the feed rest
period.
To maximise drug efficacy.
5.

patients record

governance
Best Practice
MEDICATION
53
there are many occasions when it is the only option. It is vital, however, to first seek the advice of a
for gastrostomy administration. (Refer To Separate Guideline On Drug Administration via Tubes
and Stomas)
Best Practice
MEDICINES
Medications which must not be crushed include:

Enteric Coated (EC). The coating is designed to resist gastric acid to protect the drug and/ or reduce
gastric side effects. Modified/slow Release (MR, SR,LA,XL). These are tablets or capsules that are
specifically designed to release the drug over a long period of time. Crushing these will cause all the
drug to be released at once and may cause toxic side effects. Cytotoxics and hormones. These should
not be crushed due to the risk of exposure from the powdered drug.
Some Problem Drugs Phenytoin,Digoxin and Carbamazepine Blood levels may be affected by feeds;
these should be checked regularly. It may be necessary to increase the dose. Antacids The metal iron
in the antacid binds to the protein in the feed and can block the tube. Consideration of an alternative
may be necessary. Penicillins Feed may reduce the absorption, a higher dose may be needed. If
possible stop the feed 1-hour before and 2 hours after administration. Other antibiotics
Levels of antibiotics such as Ciprofloxacin tetracyclines and rifampacin can be significantly reduced
by feed.
REFERENCES
BAPEN (2003) Administering drugs via enteral feeding tubes - a practical guide London: Bapen
Colagiovanni L (2000) Preventing and clearing blocked feeding tubes Nursing Times Vol. 96 No 17
Faller N. A, Lawrence K. G, Ferraro C.B. (1993) Gastrostomy, replacement, feeding tubes: the long
and the short of it Ostomy & Wound Management Jan/Feb. pp 26 33
Grant J. P. (1993) Percutaneous endoscopic gastrostomy Ann of surgery Vol 217 No 2 pp 168 174
Grant M (2000) Delivery of enteral nutrition Advanced Practice in Acute Clinical Care Vol. 1 No. 4
Larson D.E., Burton D.D., Schroeder K.W., Di Magno E.P (1987) Percutaneous endoscopic
gastrostomy. Indications, successes, complications and mortality in 314 consecutive patients Journals
of Gastroenterology Vol. 93 No. 1 pp. 48-52
Marcuard and Perkins (1988) Clogging of feeding tubes Journal of Parenteral and Enteral Nutrition
Vol. 12 No.4 pp. 403 - 405
Nottingham Acute Trusts (2003) Working in New Ways Policy and Guidelines Nottingham: NAT
Scanlan & Frisch (1992) Nasoduodenal feeding tubes: prevention of occlusion Journal of
Neurosurgical Nursing Vol. 24 No. 5 pp. 256-259
So J.B. & Ackroyd F.W. (1998) Experience of percutaneous endoscopic gastrostomy at
Massachusetts General Hospital. Indicators and complications. Sinapore Medical Journal Vol. 39
No. 12 pp. 560-563
54
JEJUNAL FEEDING
Once the jejunal feeding tube has been inserted the principles of caring for a patient receiving jejunal
feeding, either NJ or jejunostomy are very similar to NG and gastrostomy care respectively. The
dietitians will normally have prescribed a starter regimen (see appendix 3 for emergency starter
regimen if required). Ensure that this is available and used.
It is not possible to aspirate jejunal contents to confirm position so it is essential that the length of the
tube at the nose or skin is recorded and checked. If these tubes migrate so that the level of the tube has
changed at the nose/skin, the tubes should not be used for feeding and the tubes should not be
removed, unless the patient is in distress, until an expert opinion is sought.
Table 15: Care of patients with jejunal feeding
Principle
1.
Tube Type
When a tube is placed record:
a)
b)
c)
d)
e)
f)
Rationale
the batch number

the type of tube
the manufacturers name
who placed the tube
how the tube is fixed, internally and externally
Identification of different lumens.
For easy identification of the tube,

how it is secured and therefore how it
can be removed.
If there is any concern about the position of the tube in the

gut a tubogram in radiology is the usual method to check
position
2.
a)
Tube Position
Immediately after the tube has been placed, record the
length of tube that is visible at the nose or skin by using
the markers on the tube, or by measuring and marking the
tube using a permanent marker.
Document this length in patient record.
b)
Continue to monitor the distance the tube is at the nose or

skin.
If the tube has moved significantly do not feed until an
expert opinion has been sought.
3.
a)
Fixation
Nasojejunal
Renew tape fixing a nasojejunal tube to the cheek and
neck daily (Burns et al 1995 cited in Bengmark, 1998).
Do not secure at nose as this could cause the tube to loop
in patients mouth.
b)
Jejunostomy
Sutures that secure jejunostomy tubes should not be
removed unless indicated by the surgeon who placed the
tube. Sutures which grow out may need replacing.
To identify initial position of tube.
To identify inadvertent misplacement

of the tube.
To reduce risk of feeding into the

stomach or peritoneal cavity.
Nasojejunal tubes are only secured by
tape at the cheek and neck, therefore
it is vital that the tape works
effectively, to reduce risk of
accidental removal or displacement of
the tube.
External skin sutures are sometimes
the only method of securing the tube.
55
c)
Jejunostomy/PEGJ
The position of external fixation plates on jejunostomy
and gastro-jejunostomy tubes should be maintained close
the skin but not tight. It should be positioned next to the
skin with approximately 1cm or little finger space
between the skin and fixation device.
4
a)
Feeding
Only commence feeding via the tube when the doctor has
specified in the patients medical notes that the tube is in
the correct position.
Always refer to feeding regime.
b)
Once feeding has commenced, observe the patient for

abdominal distension, abdominal cramps, fever, vomiting
or for the presence of feed in gastric aspirate (from a
multi-lumen nasojejunal tube) or vomit (Eisenberg, 1994).
.
May indicate that a nasojejunal tube

has migrated from the bowel back
into the stomach or a jejunostomy
tube has migrated into the abdominal
cavity (Eisenberg, 1994).
c)
If any of the above signs or symptoms are observed stop

feeding, flush tube with sterile water, inform medical staff
and seek expert advice.

stomach or abdominal cavity.
Do not remove the tube (unless the patients condition

dictates).
To maintain the tubes position and to

minimise damage to the skin
(Arrowsmith, 1996).
To reduce the risk of feeding into the

Some tubes may migrate (or can be

repositioned) back into the bowel.
Flush tube according to feeding regime.

d)
Use only commercially prepared sterile feed, which is

attached to the giving sets using an aseptic technique.
Change the giving sets every 24 hours.
If a powdered feed is reconstituted at ward level sterile
water must be used. The reconstituted feed cannot be
regarded as sterile and any remaining feed should be
discarded after 4 hours (Anderton, 1995).
e)
Regulate flow for feed using an enteral feeding pump.
Best Practice
To reduce the risk of infection

(Anderton, 1995).

By using a pump a regular and
accurate flow can be ensured.
To minimise the risk of Dumping
Syndrome.
DUMPING SYNDROME
Unlike enteral feeding into the stomach, intermittent feeding into the jejunum may cause Dumping
Syndrome (rapid dilution of hypertonic intestinal fluid which may cause hypovolaemia and
sympathetic vasomotor responses) sweating, tachycardia, electrocardiograph changes, weakness and
abdominal pain (Holmes, 1996).
Principle
5.
a)
Flushing the Tube

Use only 50ml purple enteral syringes and discard after
single use. Do not re-use.
Rationale
To reduce risk of rupturing the tube
(Shaw, 1994) and risk of crossinfection (Rollins, 1995).
56
b)
c)
Flush the tube with 50ml sterile water according to

feeding regime.
i)
at maximum intervals of 4 hours, unless contraindicated, e.g. patients on restricted fluids
To prevent tube blockages.
ii)
and immediately before and after feed
iii)
Before and after all medications (Brennan Krupp

and Heximer, 1998).
iv)
discard any unused sterile water after flushing the

tube.
Flush the tube with at least 30ml sterile water before

administering medication, 10ml between different
medications and at least 30ml following administration of
the last drug (BAPEN 2003).
Best Practice
FLUSHING THE TUBE
In the published evidence (Bengmark, 1998; Brennan Krupp and Heximer, 1998), tubes which are not
flushed immediately before and after feeds and/or medication have a much higher risk of blocking.
Sterile water is used because the acid barrier in the stomach is being bypassed.
Refer to local guidelines. Use most cost effective method.
Best Practice
SYRINGES
50 ml syringes should be used. A smaller syringe may produce too much pressure and split the tube
(BAPEN 2003). Shaw (1994) found that small syringes are more likely to cause tubes to rupture.
Greater pressure can be exerted using a small syringe therefore only syringes of 30ml or greater should
be used. Do not use syringes intended for intravenous use due to the risk of accidental parenteral
administration.(BAPEN 2003) (NPSA 2007)
Best Practice
SINGLE EQUIPMENT USE ONLY
Re-use of single use only items contravenes the Medical Devices Agency Regulations (1995). Rollins
(1995) demonstrated that single use items reduced the risk of infection; this is backed up by advice
from the Public Health Laboratory Service (Ward et al, 1997).
Principle
Rationale
6.
a)
Care of Tube and Skin

All external sections of the tubes including the luer ends
should be washed daily with soap and hot water and dried
with a paper towel.
To reduce the risk of cross-infection.
b)
Jejunostomy/PEG
A new stoma should be treated as a surgical wound using
an aseptic technique.
Observe the patient for signs of complications e.g.
peritonitis, ileus.
For early detection of complications.
Soap and water is sufficient to clean established stomas.

The skin should be completely dried afterwards.
To prevent excoriation of skin

(Arrowsmith, 1996).
If signs of infections are present, e.g. inflammation, pus,

and if present to take a swab for microbiological
examination.
Stoma infections often require

antibiotic treatment.
To identify micro-organisms.
57
7.
Medication
Principle
Rationale
a)
Discuss with pharmacist and doctor to see if an alternative

route of administration for medication can be used.
To ensure the most appropriate and

suitable route is used.
b)
If alternative routes cannot be used discuss prescription

with pharmacist to find the best possible preparation of
each drug.
Prescribed medication should be administered separately,
dispersed in sterile water (Adams, 1994) or if this is not
possible, in liquid form (Brennan Krupp and Heximer,
1998).
Do not administer crushed tablets that have not
completely dispersed in water. If necessary ask
pharmacist if a solution or suspension can be prepared.
c)
When administering medication to patients with multi

lumen tubes ensure that the correct lumen is used.
d)
See section number 5 flushing the tube.
Tablets dispersed in water have a

lower osmolality then elixirs,
therefore the risk of osmotic diarrhoea
is reduced (Adams, 1994).
Sediment increases the risk of

blocking the tube (Naysmith and
Nicholson, 1998).
To prevent error in route of
administration.
Best Practice
MEDICATION
there are many occasions when it the only option. It is vital, however, to first seek the advice of a
for jejunal administration. (Refer To Separate Guideline On Use of syringes to administer flushes,
feeds and medication via the oral and enteral route in adults)
Best Practice
MEDICINES
Medications which must not be crushed include: Enteric Coated (EC). The coating is designed to
resist gastric acid to protect the drug and/ or reduce gastric side effects. Modified/slow Release (MR,
SR,LA,XL). These are tablets or capsules that are specifically designed to release the drug over a long
period of time. Crushing these will cause all the drug to be released at once and may cause toxic side
effects. Cytotoxics and hormones. These should not be crushed due to the risk of exposure from the
powdered drug.
Some Problem Drugs: Phenytoin,Digoxin and Carbamazepine Blood levels may be affected by
feeds; these should be checked regularly. It may be necessary to increase the dose. Antacids The metal
iron in the antacid binds to the protein in the feed and can block the tube. Consideration of an
alternative may be necessary. Penicillins Feed may reduce the absorption, a higher dose may be
needed. If possible stop the feed 1-hour before and 2 hours after administration. Other antibiotics
Levels of antibiotics such as Ciprofloxacin tetracyclines and rifampacin can be significantly reduced
by feed. Consider other alternatives. Always check with the pharmacist.
58
8.
Jejunostomy or PEGJ tube fallen out or inadvertently removed
Principle
a)
Rationale
The stoma made for a jejunostomy or gastrojejunostomy will close within hours of tube removal.
To save the stoma a new tube must be placed
IMMEDIATELY.
A suitable replacement feeding tube or Foley catheter
may be used in the short term to keep the stoma open.
This must be inserted by a competent practitioner and
the balloon filled with 5ml of sterile water only. This
should take place no longer than 2 hours following
accidental removal.
Foley catheters and replacement tubes

must not exceed 12fr as inflation of a
balloon greater than 5ml would cause
an obstruction in the bowel.
The replacement feeding tube should not be used for

feeding until its position has been confirmed in X
Ray.
The tube may not extend to the

jejunum Gastric feeding may be
contra-indicated.
Foley catheters should not be used for feeding and

should be replaced in X Ray.
Foley Catheters do not have an

external fixation device and there is a
risk of migration or displacement. See
patient Safety Alert One Liners
2005 www.nhra.gov.uk
The Nutrition Support team, Nutrition Nurse

Specialist or dietitian should be informed as soon as
possible to arrange for a replacement tube
b)
If the stoma was formed less than 6 weeks previously

or if trauma was caused when the tube was removed,
observe the patient for signs of peritonitis.
Bowel contents may leak into the

peritoneal cavity.
c)
The position of any newly placed tube must be

checked endoscopically or radiologically.

Although the tube appears similar to a
gastrostomy tube externally, internal
positioning cannot be determined
without one of these investigations.
9.
a)
b)
Removal of Tube
Nasojejunal
Flush tube with sterile water and remove in the same
way as a nasogastric tube.
Discard any unused water.
Jejunostomy/PEGJ
Ask for expert advice prior to removal of tube.
After tube removal the stoma will close within a few
hours.
There are many different ways of

securing these tubes internally and
externally.
In the interim cover with a sterile dressing.
59
REFERENCES
Adams D (1994) Administration of drugs through a jejunostomy tube. British Journal of Intensive
Care. January, pp 10 17.
Anderton A (1995) Reducing bacterial contamination in enteral tube feeds. British Journal of Nursing.
Volume 4, Number 7, pp 368 376.
Arrowsmith H (1996) Nursing management of patients receiving gastrostomy feeding. British Journal
of Nursing. Volume 4, Number 5, pp 268 273.
Bengmark S (1998) Progress in perioperative enteral tube feeding. Clinical Nutrition. Volume 17 pp
145 152.
Brennan Krupp K, Heximer B (1998) Going with the flow. Nursing. Volume 28, Number 4, pp 54
55.
Eisenberg P G (1994) Gastrostomy and jejunostomy tubes. Registered Nurse. November, pp 54 59.
Holmes S (1996) Percutaneous endoscopic gastrostomy: a review. Nursing Times. Volume 92,
Number 17, pp 34 35.
Jeppsson B, Tranberg K G, Bengmark S (1992) Technical developments. A new self propelling
nasoenteric feeding tube. Clinical Nutrition. Volume 11, pp 373 375.
Medical Devices Agency (1995) The Reuse of Medical Devices Supplied for Single use only (MDA
DB 9501).
Naysmith M R, Nicholson J (1998) Nasogastric drug administration. Professional Nurse. Volume 13,
Number 7, pp 424 427.
Rollins H (1995) The re-use of flushing syringes in Enteral Feeding. Unpublished.
Shaw J (1994) A worrying gap in knowledge. Nurses knowledge of enteral feeding practice.
Professional Nurse. July, pp 656 661.
Ward V, Wilson J, Taylor L, Cookson B, Glyns A (1997) Preventing Hospital acquired infection.
Public Health Laboratory Service, London.
Carr C S, Ling K D E, Boulos P, Singer M (1996) Randomised trial on safety and efficacy of
immediate postoperative enteral feeding patients undergoing gastrointestinal resection. British
Medical Journal. Volume 312, pp 869 871.
McKinlay J, Anderton A, Wood W, Gould I M (1995) Endogenous bacterial contamination of enteral
tube feeding systems during administration of feeds to hospital patients. Journal for Human Nutrition
and Dietetics. Volume 8, pp 3 8.
60
COMPLICATIONS OF ENTERAL FEEDING

Complications can happen at any time while receiving tube feeding and it is important that the patient
is monitored closely throughout.
Complications can be split into 3 areas
Insertion related
Tube related
Feeding related
Insertion related complications
Tube misplacement, eg into lungs
Tube removal, accidental or otherwise
Oesophageal or gastric perforation
Haemorrhage
Peritonitis
Management of tube placement is dealt with in detail elsewhere in this guideline. Other problems need
dealing with promptly along standard medical and surgical management pathways. The nutrition team
can always advise.
Tube related
Pulmonary aspiration and chest infection
Peristomal infection
Tube obstruction
Buried bumper syndrome, where the internal fixation device buries itself within the abdominal
wall. This can occur when the gastrostomy tube has not been rotated and retracted weekly (see
care of tubes). This is a complication that happens late, ie at least several months after
insertion
Adherence to the guidelines above should minimise these problems. Should they occur, contact the
nutrition team.
Feeding related
Diarrhoea
Constipation
Nausea and vomiting
Regurgitation
Metabolic disturbances (rare) and usually occur in the early phase of feeding in a patient who
has been fasted for a prolonged period of time or in diabetic patients, eg refeeding syndrome
(see separate guideline)
a) Management of enteral tube feeding diarrhoea

Bowel frequency and stool form in patients being enterally fed may be different from when they were
having oral diet, and patients, carers and staff need to be aware of this. Diarrhoea can be defined as
loose stools sufficient to inconvenience patients and/or staff, or at least 3 loose stools /day for at
least 2 days or a volume of >500ml of stool for at least 2 days.
Enteral tube feeding related diarrhoea occurs in up to 30% of enterally fed patients on medical and
surgical wards and 60% of patients on intensive care units.
New or pre-existing disease-related pathology e.g. colitis/enteritis, malabsorption, gut motility
disorders, should be excluded as potential causes in the first instance. A low albumin level can also
cause gut oedema, therefore the cause of this e.g. sepsis should be addressed. Overflow due to
constipation should also be excluded as a cause, or treated (see constipation section below).
61
Best Practice
All patients with new onset diarrhoea must
Be barrier nursed and have
Stool sent for culture and sensitivity and Clostridium Difficile Toxin
Simultaneous use of other drugs, particularly antibiotics, is usually the cause of apparent enteral tube
feeding related diarrhoea. Other medications which can cause diarrhoea include: laxatives, H2
blockers, proton pump inhibitors, antiarrhythmics, antihypertensives and non-steroidal antiinflammatory drugs. Medications containing magnesium, such as antacids, and drugs containing active
fillers, such as sorbitol, can also contribute to the development of diarrhoea. Therefore, medications
should always be reviewed and adjusted if possible.
Other causes of enteral tube feeding related diarrhoea include infection, with Clostridium Difficile
being found in 20-50% of patients with antibiotic related diarrhoea. Stool cultures should be sent for
culture and sensitivity to rule out an infective cause. Bacterial feed contamination can also cause
gastrointestinal related problems and so it is vital to prevent microbial contamination when setting up
enteral feeds, by using closed enteral feeding systems whenever possible and following guidance when
setting up enteral feeds (Guideline for the care of patients receiving NG/PEG/Jejunal feeding).
The enteral feed per se is rarely the cause of enteral feeding related diarrhoea. In some situations a too
rapid feed rate may contribute to the development of diarrhoea, particularly in patients receiving
jejunal feeding. In patients receiving long term enteral feeding there may be some benefit in reviewing
the type of feed as fibre containing formulae can sometimes improve stool form. If other causes, as
described above, have been excluded then the dietitian should be contacted at the earliest opportunity
to consider changes to the enteral feeding regimen.
In all situations it is vital to monitor the amount, frequency and type of diarrhoea using a Bristol Stool
Chart. Fluid balance should be monitored very carefully to prevent dehydration, particularly in those
patients producing large volumes of watery stools. Additional IV fluids may be required. Electrolytes
should also be monitored and correction considered. Anti-diarrhoeal agents could be considered once
it is known that the cause of diarrhoea is non-infective.
In a patient with enteral tube feeding diarrhoea,
Standard management should include monitoring stool type, frequency and volume on a stool
chart and overall fluid balance, hydration status and electrolyte levels.
IV fluid replacement should be given if required.
Stool samples should be sent off for MC&S and C.Difficile toxin
Table 16: Management of enteral feeding related diarrhoea
If stool sample +ve
If stool sample -ve
Treat according to Guideline for infection
Review medications consider altering or
stopping:
Laxatives
Drugs with side-effect of diarrhoea including
o Antibiotics, H2 blockers, PPIs,
antiarrhythmics, antihypertensives
and NSAIDs
o Drugs containing active fillers e.g.
sorbitol
Consider specific gastrointestinal causes and seek
help from the NST
If no cause can be identified use anti-diarrhoeals
But NEVER use antidiarrhoeal agents in patients
with infective or bloody diarrhoea
Review tube or stoma management to ensure that

there is no cross contamination of tubes or stomas
62
b) Management of constipation in enterally-fed patients

Bowel frequency and stool form in patients being enterally fed may be different from when they were
having oral diet, and patients, carers and staff need to be aware of this. Constipation is defined as
difficulty in passing stools or incomplete or infrequent passage of hard stools.
As with all patients, constipation is usually due to a combination of inadequate fluid intake,
dehydration, reduced mobility and drug side-effects. Clinical condition should be reviewed to ensure
no other explanation such as colonic pathology or motility disorder.
Ensuring adequate fluid intake is of utmost importance in preventing and treating constipation. Fibrecontaining feeds can be beneficial and will usually be prescribed by dietitians for long-term enteral
feeding unless contra-indicated, but it is even more important that sufficient fluid is provided if fibre is
being used. The dietitian should be contacted to review the fluid and fibre content of the feeding
regimen.
Medication should be reviewed to identify and if appropriate stop any anti-diarrhoeal drugs being
prescribed. Consideration should also be given to stopping / altering drugs where constipation is a
side-effect, e.g. opiates.
Constipation should be treated in the usual way with laxatives and suppositories.
c) Management of enterally-fed patients with regurgitation, nausea, vomiting or aspiration
Regurgitation is defined as the return to the mouth of food already present in the oesophagus or
stomach. A patient with an enteral tube feed may report regurgitation or staff may see feed in a
patients mouth or when they cough, or hear gurgling sounds.
Regurgitation and vomiting can both lead to secondary aspiration, particularly in patients with an
unsafe swallow. Both nasogastric and gastrostomy feeding can be associated with the risk of
secondary aspiration as can jejunal feedings if the tubes become displaced. Wide bore nasogastric
tubes especially increase the risk of aspiration because they interfere with oesophageal sphincter
function.
The most important measure to avoid regurgitation and vomiting in an enterally fed patient is to ensure
they are positioned correctly, where possible at 30-45 during feeding and for thirty minutes
afterwards.
Other common causes of vomiting and nausea are infections, side-effects of medication and
constipation. Constipation should be treated and medications should be reviewed and altered or
stopped if possible where nausea and vomiting are known side-effects.
As with all other patients who are vomiting, hydration, electrolyte levels and nutritional status should
be monitored. Additional IV fluids and electrolytes may be necessary in severe cases. In patients with
a nasogastric or nasojejunal tube there is also a risk of tube displacement with vomiting and tube
position should be checked after each episode (see Guideline for the care of patients receiving NG / NJ
feeding). Standard anti-emetics and pro-kinetic drugs can be used under medical supervision.
Bacterial feed contamination can also cause gastrointestinal related problems and so it is vital to
prevent microbial contamination when setting up enteral feeds, by using closed enteral feeding
systems whenever possible and following guidance when setting up enteral feeds (Guideline for the
care of patients receiving NG/PEG/Jejunal feeding). The enteral feed per se is rarely the cause of
vomiting, but once the causes above have been considered, the dietitian should be contacted at the
earliest opportunity to review the feeding regimen. They will consider reducing the size of boluses or
the rate of a pump feed and/or using higher energy, lower volume feeds if these measures are
appropriate for the individual patient. If there are persistent problems with regurgitation, nausea or
vomiting then alternative feeding routes may be considered.
63
Table 17: Management of enterally-fed patients with regurgitation, nausea, vomiting or

aspiration
Nausea, vomiting or regurgitation of feed
Check administration of feeding regimen:
Feed system being set up correctly (closed system, feed hanging time, use-by date of feed,
temperature)
Correct feed type and rate or bolus size
Tube position checked also re-check NG or NJ position after any episode of vomiting
Patient position at 30-45 during feeding and for thirty minutes afterwards
Review medications
Consider stopping / altering those with nausea or vomiting as side-effect
Consider trialling pro-kinetics and / or anti-emetics
Consider clinical cause including gastrointestinal condition, infection, constipation, treat as
necessary
Monitor hydration status, fluid balance and electrolyte levels.
Consider IV fluids and electrolytes
Contact dietitian and/or Nutrition Support Team and / or Gastro Team for further advice
REFERENCES
Bowling T. Nutritional Support for Adults and Children A handbook for hospital practice 2004.
The Burdett Institute of Gastrointestinal Nursing Enteral Tube Feeding Guidelines
National Collaborating Centre for Acute Care, February 2006. Nutrition support in adults: Oral
nutrition support, enteral tube feeding and parenteral nutrition
Stroud M, Duncan H, Nightingale J. Guidelines for enteral feeding in adult hospital patients. Gut
2003; 52 (suppl. VII); vii1 vii12
64
MANAGEMENT OF UNEXPECTED DISCONTINUATION OF ENTERAL FEEDING

Unexpected discontinuation of enteral feeding by tube or stoma may occur and for some patients this
can have serious metabolic and or nutritional consequences. If unexpected discontinuation occurs the
following steps should be taken:
1. Check that the patients environment is safe
2. Displaced tubes removed and disposed of
3. Partially displaced tubes may be left in situ until review by someone competent in replacement
unless the patient is in distress when the tube should be removed
4. Running pumps switched off
5. Hanging feeds disposed of
6. Can the feed be re-established within the next 2 hours? This may be the case if the cause of
discontinuation was
a. Tube blockage
b. Pump failure. Check feed and pump have been set up correctly following the
instructions. If necessary a new pump can be obtained from the Medical Equipment
Library
c. Lack of correct feed supply / ancillaries on ward when a new supply can be obtained
from
i. QMC Campus during normal working hours phone dietetic office on 67318.
Outside of normal working hours, call Diet Bay store in the main kitchen on
63221 to organise delivery or collection. If ordering giving sets please quote
the relevant 5 digit reference number
ii. City Campus phone main kitchen for supply on next meal trolley (ext
55970, bleep 7551) or arrange collection from Diet Bay store in main kitchen
(For non-urgent stocks phone diet bay answerphone ext 57184)
d. Displacement of nasogastric feeding tube when competent staff are available to
replace it
If feed cannot be restarted in 2 hours continue to steps 3 and onward
1. Is the patient on insulin or oral hypoglycaemic agents? If so please monitor BMs hourly until
review by the medical team and request review within 2 hours. If feeding cannot be reestablished the medical team will decide whether the patient needs to be converted onto
sliding scale insulin or if it is sufficient to stop or reduce their diabetic medication
2. Is the patient dependent on the tube or stoma for their medication? If so request a review by
medical team before next drugs are due to determine which if any drugs need to be given by
another route until enteral access is re-established
3. Is the patient dependent on the tube or stoma for hydration? If so request a review by the
medical team within 4 hours so that parenteral or subcutaneous fluids can be prescribed until
enteral access is re-established
4. Is this a gastrostomy which has been displaced? If so request a competent clinician (usually
the gastroenterology on call service) to review the patient within 4 hours so that a replacement
balloon gastrostomy (available in the Enteral feeding emergency supply box on Hogarth ward
at City Campus and on the Nutrition Unit at QMC campus ) can be re-sited or the stoma can
be kept patent with a cathether. Please know that such stomas must not be used for feeding
until it is confirmed that the replacement tube is in the stomach either by aspirating acid or
radiologically by tubogram.
5. Is this route of enteral feeding access being lost recurrently (eg NG tubes being pulled out)? If
it is discuss the most appropriate route of feeding access with the patients medical team.
Assess and document the reason for discontinuation of the feed and the actions you have taken
in the patients record
65
PROCEDURE FOR DISCHARGING PATIENTS ON HOME ENTERAL FEEDING

INTRODUCTION
When discharging patients on enteral feeding it is important to ensure that their feeding regimen is
stable and that they or their carers know
a. how to care for and manage the stoma, infusion devices and the feeding tube
b. how to manage common problems
c. how to get assistance in the case of emergencies or problems which they cannot deal with
d. what to expect in terms of by whom and when follow up and monitoring will be provided.
THE STEPS IN DISCHARGE PLANNING

1. Discharge planning should begin as early as possible but at least 3 working days before
discharge of new patients.
2. The discharging dietitian will assess patients home circumstances, identify what training
support will be needed and what feeding regimen would be best to suit the patients clinical
and social needs
3. The discharging dietitian will alter the feeding regimen as appropriate.
4. Teaching and training will be provided as follows
a. If the patient is being discharged on enteral feeding the discharging dietitian will
contact the Homecare nursing team at least 3 working days prior to discharge to
arrange teaching and training for the patient and carers. When patients are being
discharged to competent nursing homes this will not be necessary.
b. If the patient is being discharged with a feeding stoma which is not currently in use
for feeding the nutrition support nurse will contact the Homecare team to organise
teaching and training in the patients home and will give the patient an information
booklet as in 6c below
5. Rarely, in exceptional circumstances, this training function can be provided by the Nutrition
Support team nurses
6. The nursing home and community nurses will be contacted to inform them about the discharge
and this will be done at the same time as the Home care team are contacted and by the same
staff member
7. The discharging dietitian will :
a. Send a letter confirming that the patient will be tube fed, including details of the
prescription if required
b. Create HETF notes medical office (if the patient is to be supervised by the HEFT)
c. Give the patient/carer a completed information booklet for home
d. Give 7 days supply of feed and equipment will be given at discharge
e. Ensure that the patient is registered with the Homeward service using the e or Fax
registration form
f. A separate BANS form will be completed if the Homeward service is not being used.
The patient will be registered with BANS if they have consented to this. BANS and/or
Homeward forms will be stored according to local policy
g. Update the Clinical Manager (dietetic) records
h. Ensure a telephone check by the discharging dietitian within 5 working days of
discharge
i. Ensure copy letters to GP
Discharge for patients outside local catchment area
Patients being discharged out of Nottinghamshire: Local health care professionals will be
contacted about arrangements for future care unless alternative arrangements have been
agreed.
If the patients GP is in Nottingham City or Nottinghamshire County PCT or GPs from the
former Rushcliffe, Broxtowe and Hucknall and Gedling PCTs no prescription is required for
feed.
66
If there is agreement to follow up an out of area patient, the GP should be contacted to request
a prescription for feed.
The managing dietitian, if different, will retain the dietetic records, including brief discharge
summary.
67
APPENDIX 1
CLINICAL GUIDELINES
Title of Guideline: ADULT CRITICAL CARE ENTERAL FEEDING
GUIDELINES
Date First Issued: September 2009
Latest Re-Issue Date:
Version: 1
Review Date: September 2011
Main Author and Job Title:

Anne How (Senior Dietitian)
Anne Illsley (Sister, Adult Critical Care)
Tracy Lovejoy (Senior Dietitian)
Astrid Heyer (Pharmacist)
Local Contact including job title and

Ext. No.
Sr Illsley
Critical Care Group

Ratified by:
Distribution:

guideline:
This guideline has not yet been fully ratified and registered with the Trust. However,
clinical guidelines are guidelines only. The interpretation and application of clinical
guidelines will remain the responsibility of the individual clinician. If in doubt contact
a senior colleague or expert. Caution is advised when using the guidelines after the
review date.
68
ADULT CRITICAL CARE FEEDING GUIDELINES

WHY FEED?
Critically ill patients undergo depletion of lean tissue especially skeletal muscle. This wasting
is not preventable even if the patient is fed adequately1,2. These losses can however be
reduced or minimised with nutrition.
Malnutrition in critically ill patients is associated with increased morbidity, mortality and length
of critical care stay due to increased ventilator dependency, higher rates of infection and
impaired wound healing3.
WHOS RESPONSIBILITY
The decision of whether to commence nutrition, and by which route, is predominately that of
the individual patients parent medical or surgical team. The role of providing critical care
patients with appropriate and adequate nutrition is shared between the intensivists, medical
and surgical staff, the nursing staff, the dietitian and the pharmacist.
The Nutrition Team on both campuses are able to provide advice and support about the
feeding of any patients. To contact the Nutrition Team on the City campus please make a
referral via the HISS system, to contact the Nutrition Team on the QMC campus please
contact CNU (ext 62119) or acute GI SpR (bleep 84 1170). To contact the Nutrition Nurses
please use Bleep 80 6993 or Ext 56754 for the City campus and Bleep 80 6417 or Ext 61036
for the QMC campus.
NUTRITIONAL PLAN
The Malnutrition Universal Screening Tool (MUST) is not currently being used by Critical
Care within the Mid Trent Network. This will be looked at in the future.
Once the decision of when and by which route(s) to feed the patient has been made by the
surgical team, the medical team or the intensivists, this information must be documented in
the patients medical notes. If a patient is not to be fed this must also be clearly documented
in the medical and nursing notes. All patients should have a nutritional plan documented in
the patients notes whether they are receiving artificial nutrition or not.
When patients are transferred to a ward from critical care, the nutritional plan should be
handed over to the ward. For patients who are receiving artificial nutrition, the details of the
nutrition plan should be documented in the medical notes by the dietitian. If this is not the
case and artificial nutrition is continuing on the ward please contact the ward dietitian at the
earliest convenience. For patients who are not receiving artificial nutrition, the receiving ward
should carry out nutritional screening.
BENEFITS OF EARLY FEEDING
Initiating nutritional support in critically ill patients within 48-72hours of critical care admission
results in better clinical outcomes than if nutritional support is delayed4-6.
BENEFITS OF ENTERAL NUTRITION COMPARED TO PARENTERAL
Enteral nutrition is more physiologic, it helps to maintain gut integrity, it supports the immune
function of the gut, it is associated with less infectious complications, it is less likely to be
associated with hepatobiliary dysfunction and metabolic derangements and it is cheaper than
parenteral nutrition7-11.
FEEDING ROUTE
The enteral route should be used whenever possible. To initiate enteral feeding, the patient must have
a functioning gut and suitable access.
Our aim is to electively commence feeding via a nasogastric (NG) tube as soon as possible
but within 12 hours of admission to Critical Care unless specifically contra-indicated (see
below).
69
Nasojejunal tubes (NJTs) are an alternative feeding route. These can be inserted by the
gastroenterology team on the unit under sedation. At the QMC Campus a consultant may
pass an NJT at the bedside. Endoscopic placement of an NJT is usually feasible. The
Nutrition Team at either campus will be able to facilitate such a request. For some GI and
hepatobiliary surgical patients, a feeding jejunostomy may be placed in theatre. PEG tubes
are not commonly used in Critical Care but may be inserted in those requiring long term
gastric tube feeding.
Patients for whom the enteral route is not suitable or successful, parenteral nutrition should
be considered. There will be some occasions when nutrition needs to be delivered by more
than one route.
POSSIBLE CONTRA-INDICATIONS TO COMMENCING FEEDING
Various factors should be considered when the making the decision about when and by
which route(s) to start feeding. These include the following:
Has the patient got a functioning gut?
What is the patients nutritional status?
Is the patient surgical or medical? If they are a surgical patient it is worth noting that
small bowel motility usually returns within 12 hours after an operation.
Did the surgery involve the gastro-intestinal tract?
Was the surgery an elective or an emergency procedure? An elective patient will be
metabolically different to an emergency patient. Generally an elective post-op patient
will be more stable than an emergency post-op patient.
What are the possible routes for commencing nutrition e.g. was a feeding
jejunostomy tube inserted in theatre?
Absolute contra-indications to enteral feeding
There are some absolute contra-indications to enteral feeding these include:
Obstructed bowel
Ileus
Proximal gut fistulae
Relative contra-indications to enteral feeding
There are also relative contra-indications to feeding these include:
When the patient has been assessed and felt able to resume adequate oral feeding,
eg after extubation
Upper GI surgery (proximal to the DJ flexure) NG feeding may be contra-indicated,
consider jejunal feeding.
Upper GI anastomotic leak/ perforation (proximal to the mid-jejunum)
Distal small bowel and colon fistulae may occasionally require parenteral support liaise with surgeons and Nutrition Team for advice
Insufficient working bowel / small bowel disease with possible failure to absorb/ short
bowel liaise with Nutrition Team for advice.
Caution is required for patients receiving non-invasive BiPAP/ CPAP via a full face
mask. If this method of respiratory support is needed only for a short period of time
(e.g. a few days it is considered safest not to NG feed as there could be an
increased risk of aspiration with gastric distension). If this type of respiratory support
is needed for more than a few days in a malnourished patient or for more than 7-10
days in a well nourished patient, an alternative to NG feeding should be considered
e.g. NJ feeding or TPN if NJT placement is not possible.
70
REFEEDING SYNDROME
This is defined as the severe fluid and electrolyte shifts and related metabolic implications in
malnourished patients undergoing refeeding, either by the oral, enteral or parenteral route.
Patients at particular risk include those with cancer, anorexia nervosa and alcohol
dependency. If the patient is identified as being at risk of refeeding, seek medical advice
before commencing feed. Please the Trust guidelines on Refeeding for further details.
STARTING THE FEEDING
If the decision has been made to commence NG feeding, use protocols for Level 2 and Level
3 patients on pages 72 & 73. Please use these guides in association with the Trust
guidelines on Enteral Feeding
The giving sets should only be changed every 24 hours. Label the giving set with the date
and time when they are due to be changed.
Enteral feeding has now been standardised to feed patients continuously over 24 hours.
This is to allow tight glycaemic control. Intermittent feeding regimens can lead to hyper- and
hypo-glycaemic episodes12,13. For the same reason it is advised to avoid prolonged feeding
breaks during drug administration via feeding tubes. However, enteral feed may interact with
certain drugs when these are administered via feeding tubes. For further guidance discuss
this with a pharmacist.
NG feeding for level 2 patients
A fine bore Flocare NG tube should be used to provide the access for the feed unless
advised otherwise by the patients parent team. If a fine bore NG tube is inserted the patient
cannot have their gastric residual volumes checked.
The enteral feeding regimen is individualised for each patient by the critical care dietitian.
Outside of the dietitians working hours nasogastric feeding can be built up as shown in
Figure 1:
NG feeding for level 3 patients
A 14Fr Salem Sump NG tube should be used to provide the access for the feed. Level 3
patients will have their gastric residual volumes (GRVs) checked six hourly. Increasing the
designated GRV from 200ml to 400ml has been shown not to increase the risk of aspiration14
and also accounts for the stomachs intrinsic secretions.
The enteral feeding regimen is individualised for each patient by the critical care dietitian.
Outside of the dietitians working hours NG feeding can be built up as shown in Figure 2.
71
Figure 1: NG feeding in level 2 patients

Commence Nutrison Standard (=Nutrison 1.0kcal/ml) feed at 25ml/hr for 24
hours and monitor if the patient tolerates the feed (see pages 74 below).
Is the patient tolerating the feed?
Yes
Increase feed by 25ml/hr to a rate
of 50ml/hr* for 24 hours

(see pages 74 below).
Yes
Increase feed by 25ml/hr to a rate
of 75ml/hr* for 24 hours or the
final feeding rate as stated in the
Dietitians regimen.
No
Consider possible reasons for
intolerance and liaise with
medical staff/ dietitian

(see pages 74 below).
Yes
Continue at final feeding rate.
*NB If the patients weight is less than 60kg keep the feed rate at 50ml/h until the patient is
assessed by the dietitian. If the patients weight is less than 40kg keep the feed rate at
25ml/h until the patient is assessed by the dietitian.
72
Figure 2: NG feeding in level 3 patients

Commence Nutrison Standard (=Nutrison 1.0kcal/ml) feed at 25ml/hr. Aspirate NG Tube after 6
hours. Is the gastric residual volume greater than 400ml?
Yes
No
Return any gastric residual volume and increase rate by 25ml/hr every 6
hours until a rate of 75ml/h* or the final feeding rate as stated in the
dietitians regimen is reached.
Replace 400ml
and continue
feed at 25ml/hr
NB If the gastric residual volumes are greater than or equal to

400 ml on more than 2 consecutive occasions or vomiting
(and bowel obstruction excluded) administer Erythromycin IV
250 mg BD and Metoclopramide IV 10mg tds# for up to 7 days
Repeat aspirate after 6 hours. Is the gastric residual volume greater than 400ml?
Yes
No
When full rate is established, Aspirate NGT 6 hourly
Replace 400ml and reduce rate to 10ml/ hr

and transfer to the Guidelines on Prokinetics and Tolerance to feed on page 74.
Yes
If gastric residual volumes are greater
than 400ml on two consecutive occasions
reduce feed rate to 10ml/h and transfer to
the Guidelines for the Use of Prokinetics
on page 74
Is the gastric residual volume greater than 400ml?

No
Continue feed. If the patient has tolerated the
feed at full rate for 48 hours and needs to
continue being NG fed consider changing the
sump NG tube to a Flocare fine bore feeding
NG tube.
*NB If the patients weight is less than 60kg keep the feed rate at 50ml/h until the patient is
assessed by the dietitian. If the patients weight is less than 40kg keep the feed rate at
25ml/h until the patient is assessed by the dietitian.
Erythromycin cautions:
Care if patient pro-arrhythmogenic or receiving Amiodarone. IV Erythromycin is contra-indicated in patient receiving
IV or oral amiodarone. Oral erythromycin may be administered alternatively but may not be effective due to poor
absorption.
Risk of QT-prolongation when co-administered with Imidazole anti-fungal agents e.g. Fluconazole.
Risk of myopathy or rhabdomyolysis if Erythromycin co-administered with statins: withhold Atorvastatin and
Simvastatin while patient receives Erythromycin.
15
Erythromycin also may increase benzodiazepine levels monitor sedation closely .
#
Metoclopramide cautions:
Dopamine antagonist - Metoclopramide will be ineffective if patient is on dopamine or dopexamine.
Avoid in young patients under the age of 20 years and in patients with Parkinsons Disease.
73
GUIDELINES FOR THE USE OF PROKINETICS (GI MOTILITY)16-18

Continue feed at the same rate. Continue prokinetics if these have been commenced.
Consider starting these if they have not yet been prescribed see details in bold on
page 73
Is the gastric residual volume still greater than 400ml after a further 6 hours?
No
Return to the start of the level 3
flowchart on page 73. Stop prokinetics if the patient has
tolerated the feed at full rate for
24 hrs
Yes
Consider possible reasons (see
tolerance to feed information below)
and re-assess after another 24 hrs
Is the gastric residual volume still greater

than 400ml after 24 hrs?
No
Return to the start of the level 3 flowchart on
page 73. Stop prokinetics if the patient has
tolerated the feed at full rate for 24 hrs
Yes
Continue prokinetics, stop the feed
and contact the Nutrition Team to
consider nasojejunal tube or other
alternative feeding routes
TOLERANCE TO FEED
Several parameters should be monitored to assess tolerance to feed.
Large or increasing gastric residual volumes/ regurgitation of feed / nausea/
vomiting
- Has anything changed? Recheck the contra-indications for NG feeding
- Is the patient receiving sedatives, opioids or inotropes/vasopressors (e.g.
noradrenaline, adrenaline, dopamine)? These will decrease gut motility could these
infusions be reduced or stopped?
- Is the rest of the gut working? Consider if bowels have opened or if the
stoma is functioning? Could the patient have an ileus or a bowel obstruction?
- Is the patient supine? Could the patient be repositioned into the semirecumbent position at 30- 45?
- Recheck the position of the feeding tube.
- If a fine bore NG tube is in situ consider changing this to a wide bore.
- Consider starting prokinetics if this has not already been done.
- NB nausea and vomiting can be related to a range of factors not just GI function.
Abdominal distension
- Consider possible ileus
- Is the patient constipated? Treat if possible see Guidelines for the
use of Laxatives
- If a fine bore NGT is insitu consider changing this to a wide bore.
Diarrhoea
- This may be caused by medications (especially antibiotics), an infection or
be disease related.
- Review medications (especially antibiotics) and send a stool sample.
- If stools are watery consider the possibility of overflow diarrhoea.
74
USE OF LAXATIVES
Enteral nutrition commenced at prescribed rate
Patients with good hepatic function
Patients with hepatic encephalopathy
Commence Senna liquid 10mL BD

+
add Docusate liquid 200mg BD
if severe constipation likely
Commence Lactulose 30 mL TDS
Docusate liquid 200mg BD

if severe constipation likely
No bowel movements after

48 hours refer to medical
staff.
Consider review of
abdominal findings, need
for abdominal radiography
and indication of
phosphate
enemas/Movicol sachets.
Bowels
open > twice
a day or
very loose
refer to
doctor or
pharmacist
No bowel movements after 24

hours - refer to medical staff.
Consider review of abdominal
findings, need for abdominal
radiography and indication of
phosphate enemas/Movicol
sachets.
Bowels
open > three
times a day
or very
loose refer
to doctor or
pharmacist
MANAGEMENT OF ENTERAL FEEDS

There may be additional reasons why an NG feed needs to be stopped, for example before a
procedure such as a tracheostomy insertion, a bronchoscopy, extubation or because the
patient needs to leave the Unit e.g. for transfer to CT scan or theatre.
If a feed needs to be stopped, follow the medical guidance about the timing of this. If no
specific guidance has been documented, check with the doctors about when to stop the feed
prior to the procedure and when to restart.
If a feed needs to be stopped prior to a procedure being carried out or a transfer:
1.
Stop the feed, aspirate the salem sump NGT and discard the contents. NB: If the
patient has a fine bore NGT in situ the feed may need to be stopped earlier as it is
difficult to effectively aspirate gastric residual volumes. When the feed has been
stopped, flush the NGT with water to keep the tube patent.
2.
If the patient is receiving sliding scale insulin, monitor BM levels hourly and adjust
or stop the insulin infusion according to the Units protocol.
3.
Consider if a fluid replacement is required whilst the feed is off.
After the procedure has taken place, recommence feed immediately unless medical
guidance differs.
75
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1. Green, CJ et al (1995). Energy and nitrogen balance and changes in mid-upper arm
circumferences with multiple organ failure. Nutrition 11(6);739-746.
2. Streat et al (l987). Aggressive nutritional support does not prevent protein loss despite fat
gain in septic intensive care patients. Journal of Trauma 27(3);262-266.
3. Mault 2000, Dempsey et al (1988). Shukla et al (1985), Chandra (1983), Robinson et al
(1987) cited in Barr et al (2004) Outcomes in Critically ill patients before and after the
implementation of an evidence based nutritional management protocol. Chest 125;14461457.
4. Marik, PE, Zaloga, GP. (2001) Early enteral nutrition in acutely ill patients: a systematic
review. Crit Care Med 29;2264-2270
5. Lewis, SJ, Egger, M, Sylvester, PA et al (2001) Early enteral feeding versus nil by mouth
after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ
323;1-5
6. Neumayer, LA, Smout, RJ, Horn, HG, et al (2001). Early and sufficient feeding reduces
length of stay and charges in surgical patients J Surg Res 95;73-77
7. Gramlich, L et al. (2004) Does enteral nutrition compared to parenteral nutrition result in
better outcomes in critically ill adult patients? A systematic review of the literature. Nutrition
20(10):843-848.
8. Moore, FA, Feliciano, DV, Andrassy, RJ (1992) Early enteral feeding, compared with
parenteral, reduces postoperative septic complications. Annuals of Surgery 216:172-83.
9. Frost, P and Bihari, D (1997) The route of nutritional support in the critically ill:
physiological and economical considerations. Nutrition 13(9 suppl):S58-63.
10. Braga, M, Gianotti, L, Gentilini, O, Parisi, V, Salis, C, Di Carlo, V. (2001). Early
postoperative enteral nutrition improves gut oxygenation and reduces costs compared with
total parenteral nutrition. Critical Care Medicine 29:242-248
11. Braunschweig, CL et al (2001). Enteral compared with parenteral nutrition: a metaanalysis. American Journal of Clinical Nutrition 74:534-42.
12. Van den Berghe, G, Wouters, P, Bouillon, R et al (2003) Outcome benefit of intensive
insulin therapy in the critically ill: Insulin dose versus glycaemic control. Crit Care Med
31(2);359-366
13. Turner, P, Harper, J, Breen, A, Shenkin, A. (2004) The importance of 24hour enteral
feeding in achieving tight glycaemic control in critically patients. BAPEN Abstract
14. McClave, SA, Lukan, JK, Stefater JA, Lowen CC, Looney, SW, Matheson, PJ, Gleeson,
K, Spain, DA (2005). Poor validity of residual volumes as a marker of aspiration in critically ill
patients. Critical Care Medicine 33:324-330
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Medicines Complete at www.medicinescomplete.com April 2009
16. Nguyen NQ, Chapman M, Fraser RJ, Bryant LK, Burgstad C, Holloway RH; Prokinetic
therapy for feed intolerance in critical illness: one drug or two? Crit Care Med 2007 (35):
2561-2567
17. Booth CM, Heyland DK, Paterson WG; Gastrointestinal promotility drugs in the critical
care setting: A systematic review of the evidence; Crit Care Med 2002 (30): 1429-1435.
18. Grant K, Thomas R; Prokinetic drugs in the intensive care unit: reviewing the evidence;
JICS 2009 (10): 34-37
76
APPENDIX 2

CLINICAL GUIDELINES
Title of Guideline: GUIDELINES FOR WIDE-BORE NASOGASTRIC TUBES

Date First Issued:
Version:
NUH (1)
Author and Job Title:
Dr T E Bowling
Tracey Buchanan, Nutrition Nurse
Specialist
Vicky Baldwin, Sister, Critical Care
Rebecca Dykes, Sister, Critical Care
Anne Illsley, Sister, Critical Care
Latest Re-Issue Date:

September 2009
Review Date:
September 2012
Local Contact including job title and
Ext. No.
Dr T E Bowling
Ext 63862
See main references
Nutrition Steering Committee, Critical

Care Team, Ward Managers, PDMs,
Clinical Leads, Matrons
Ratified by:
Distribution:
Nursing Practice Guidelines Ratification

Group
Ward Managers, PDMs, Clinical Leads,

Matrons, Nursing Practice Guidelines
Ratification Group

guideline:
In local areas as required
Will be audited in individual speciality as

appropriate
This guideline has been registered with the Trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will remain
the responsibility of the individual clinician. If in doubt contact a senior colleague or
expert. Caution is advised when using the guidelines after the review date.
77
GUIDELINES FOR PASSING AND CHECKING THE POSITION

OF
A WIDE BORE NASOGASTRIC TUBE
Nasogastric tubes are flexible tubes passed through the nose into the stomach.
Wide bore tubes are generally used to relieve gastric distension by removing gas,
gastric secretions or food (George-Gay and Chernecky, 2001), or in a specialist ENT
environment to maintain the patency of a tracheo-oesophageal puncture for voice
rehabilitation.
For nutritional support best practice indicates that fine bore tubes should be used
wherever possible. However, in critical care, wide bore tubes are routinely used for
administering feed as well as for aspiration purposes.
Best practice
Nasogastric feeding via a wide-bore tube
This is possible, e.g. with a Ryles tube, but in general is not recommended as:
It can be very uncomfortable for the patients
Has increased risk of complications
Can cause oesophageal erosions
For guidance on feeding via a nasogastric tube please refer to the Trusts Enteral Feeding
Guidelines.
If a patient is being fed by wide-bore tube in a critical care area, on discharge to the
general ward if nasogastric feeding needs to be continued without need for gastric
aspiration, this should be exchanged for a fine-bore tube on arrival to the ward.
Types of wide-bore tube

Argyle Salem Sump Tube A double lumen, vented 14FR tube. The smaller lumen
has a sump port that allows air into the stomach when suction is applied (e.g. when
the larger lumen is aspirated). This port should always be open when suction is
applied to the tube, this prevents the tube sticking to or damaging the gastric mucosa
(George-Gay and Chernecky, 2001). The larger lumen is the tube of choice for
gastric emptying / decompression. Salem sump tubes are radio-opaque tubes with
markings to enable accurate measurement, identification and documentation of their
position.
Ryles Tube A single lumen unvented tube used for gastric aspiration, temporary
feeding in critical care and administration of medicines. (For guidelines on the
recommended method for nasogastric feeding please refer to (Clinical Nutrition
Network Guidelines, 2009) and (The use of syringes to administer flushes, feeds and
medication via the oral and enteral routes, policy and procedures, 2007)
78
Argyle Salem Sump Tube
Contra-indications for wide-bore tubes

Wide bore nasogastric tubes can be difficult to pass or dangerous in patients with physical
injuries or deformities, for example:
Confirmed or suspected basal skull fracture (in such cases, an orogastric feeding
tube should be passed by an anaesthetist);
Laryngectomy;
Obstruction or partial obstruction, e.g. oropharyngeal / oesophageal tumours.
Bleeding oesophageal varices
Oesophagectomies
Trainee Doctors should not insert or attempt to insert wide bore NG/OG tubes that may be
difficult and /or dangerous to pass, or when there is a high risk of complications resulting
from the insertion.
Tube Placement + Verification

Concerns regarding tube placement have been raised by The National Patient Safety
Agency (NPSA), who issued an alert in 2005, entitled Reducing the harm caused by
misplaced nasogastric feeding tubes, and more recently in 2009.
The critically ill patient may have a decreased ability to report symptoms of misplacement
such as diminished gag reflex and a reduced conscious level that could suppress cough
reflexes. (Methany et al, 1998). Recommendations have been drawn up by the Intensive
Care Society (ICS) regarding tube placement and verification of position. These are included
in this guideline.
Passing a wide-bore nasogastric tube
Equipment needed
Wide Bore Nasogastric (NG) tube
Lubricating gel
Disposable non-sterile gloves
Disposable apron
50ml purple enteral catheter tip syringe
Drinking straw and glass of water (if patient can swallow safely)
Hypo-allergenic tape or commercial attacher
pH paper (with expiry date checked)
Bile bag (if continuous gastric drainage is needed)
79
Table 1: Passing a Wide-bore nasogastric tube

Principle
Rationale
To ensure understanding and valid consent

(NMC 2006)
Explain procedure with the patient
Check patients notes and enquire if the patient has a

known nasal obstruction e.g. old fracture / polyp / Passage of the tube may be more difficult.
previous operation.
If an obstruction is present or suspected, do not
proceed and discuss options with medical staff.
2
Arrange a signal by which the patient can To give the patient a sense of control, gain
communicate if she/he wants to stop the procedure, their co-operation and to ensure the safe
for example, by raising their hand.
passing of the tube.
Ask the patient to sniff with one nostril and then the To check if the nostrils are clear and to
other or to blow their nose. If needed, clean the identify any obstruction, which may hamper
nostrils before commencing the procedure.
the procedure.
Sit the patient in an upright position, with head well The patients natural inclination is to move
supported and with the chin 90 to the neck, unless backwards away from the tube.
contra-indicated.
A 90 angle helps to close the glottis,
protecting the airway (McConnell, 1997).
5.
Prepare tape or commercial attacher.
To facilitate procedure.
Wash hands and put on apron and gloves.
To prevent cross infection and protect

clothing. NUH (2008)
Measure the length of tube required by placing the To ensure the appropriate length of tube is
end of the tube at the patients xiphisternum and passed into the stomach.
measure the distance from here to the bridge of the
nose and then from the nose to the earlobe. Note the
mark on the tube.
Dip the distal end of the tube into the water or thinly
coat up to 15-20cm of the distal end of the tube water
soluble jelly Give mouthcare or offer the patient a
drink if able to swallow.
Carefully insert the distal end of the tube into the To facilitate passage of the tube by following
clearest nostril and slide slowly along the floor of the the natural anatomy of the nose.
nasopharynx.
To lubricate the tube and oesophagus, and

reduce any friction between mucous
membranes and the tube, making insertion
easier.(Marsden 2008)
Further attempts can be made if an obstruction is felt.

10
As the tube passes down into the nasopharynx, ask A swallowing action closes the glottis,
the patient to start sipping water and swallowing (if enabling the tube to pass into the oesophagus
able).
and reduces the risk of it entering the
trachea.(Groher 1997)
80
11
12
Advance the tube, as the patient swallows, at a speed

acceptable to the patient, until the pre-determined
mark is reached.
If the patient coughs and gags violently, becomes
cyanosed, or shows other signs of distress Stop the
procedure and remove the tube.
To gain patients co-operation.

To ensure correct length of tube is inserted.
The tube can stimulate a strong cough and gag
reflex as it enters the pharynx but violent
coughing / gagging may indicate that the tube
is in the trachea (George-Gay and Chernecky,
2001)
NB If the patient does not show any signs of
distress, do not assume that the tube is in the
correct position. (NPSA 2005)
13
14
Anchor the tube securely in position. If possible, a To secure the tube and determine tube
commercial attacher should be used.
position.
Document the exact position (cm length) at the nostril
of the tube in the appropriate record.
Verify tube position see Table 2
Verifying wide-bore tube position

Checking the position of the tube is a shared responsibility between Nursing and Medical
staff. There are two methods of determining tube placement
Aspiration
Radiography
The method of choice for verifying tube position for patient with wide-bore tubes is the same
as for fine-bore, ie pH testing of the aspirates. However, pH testing in the critically ill may be
unreliable because of enteral feed contamination (Metheny and Titler, 2001), aspiration of
gastric contents (Goodwin, 1996), reflux of duodenal secretions (Fuchs and Demeester,
1990), the effect of acid-inhibiting medications (Metheny et al, 1993), effect of peptic ulcer
prophylaxis medications (Metheny et al, 1993).
Therefore the method of choice of tube verification is:
Critical care:
Chest xray
General ward:
pH testing and chest
possible/unsuccessful
xray
only
if
this
is
not
Methods NOT to be used in verifying tube position

The Whoosh test injecting air through the tube and auscultating over the stomach.
This may dislodge the exit part of the NG feeding tube from the gastric mucosa. The
pressure can also split the tube. (NPSA Alert, 2005)
Do not monitor bubbles at the end of the tube - the stomach also contains air and
could falsely indicate respiratory placement (Metheny et al 1990)
Do not observe the feeding tube aspirate. This is unreliable, as gastric aspirate can
look very similar to respiratory secretions (Theodore et al 1994)
Do not interpret an absence of respiratory distress as an indicator of correct
positioning. This has been shown to be an ineffective method in detecting a displaced
tube (Metheny et al 1990)
81
Table 2: Verifying Tube Position

Principle
1
For patients on general wards
Using a 50ml syringe (BAPEN, 2003) aspirate a small
amount of aspirate from the tube and test it on pH paper
(MHRA, 2004). Ensure that the patient has not eaten or had
any oral medication for at least one hour.
Flushing the tube with 20ml of air will help to clear any
residual substances (Metheny et al 1993)
Only indicator strips that range from 0-6 or 1-11 should
be used to obtain an accurate pH reading via aspiration
NPSA (2005)
Rationale
To establish the position of the tube.
A pH value of 5.5 or below. There are
no known reports of pulmonary
aspirates at or below this figure. NPSA
Safety Alert 2005)
The safest syringe size for flushing or
aspirating is a 50ml syringe as a smaller
syringe may produce too much pressure
and split the tube (BAPEN, 2003).
If aspirate is not obtained - see flow chart on below for

instruction
If a pH of above 6, or a pH in the range of 5-6 raises
concerns as to the position of the tube then seek medical
advice, as the tube may either need to be repositioned or To ensure tube position can be verified
confirmed with x-ray (see below)
For patients on critical care and those without adequate
or appropriate aspirates
A chest xray is performed and is checked by a doctor who
is deemed competent in interpreting x-rays, who will decide
whether the tube is in the correct position.
If the tube is NOT in the correct position on xray, it will
need either to be repositioned or replaced and then a repeat
chest x-ray performed.
If the position cannot be verified or the tube is not visible,
abdominal x-ray and NG contrast must be ordered by the
Doctor to ensure verification
2
Once position verified, tube is secured to the cheek, and a

marker attached to the tube as close to the nostril as To prevent the tube moving and
possible (or mouth for orogastric tubes). If possible, a displacing
commercial attacher should be used.
Record in the patients notes:

Date and time tube passed
Number of attempts made to pass the tube
Any difficulties in passing the tube
The type of tube used
The nostril used
The cm length at the nostril
Method used to check the position, recording the
pH aspirate obtained if applicable
Where an xray has been checked, the certifying
doctor needs to document this in the hospital notes
+ signature + grade + date
Nurses to document the same in daily care plan
To ensure there is adequate

documentation of verification of
position of tube and adequate
communication to the nursing staff
82
Nursing staff to commence feeding if instructed to do so. If To ensure prompt use of the tube.
being used for drainage, to connect the bile bag
Nursing staff to observe NG/OG tube for signs of

displacement and movement
To identify tube displacement quickly

and to reduce the risk of harm to the
patient
Nursing staff will review medical notes on commencement

of each shift to locate documentation on tube verification
and safety to use
Nursing staff will perform NG/OG safety check on the 24
hour observation chart on commencing their shift.
To ensure patient safety.
What to do if aspirate is not obtained

Advance or withdraw tube
10-20 cm and retry
Change patients
position and retry
Put the indicator and

syringe below the
level of patients
stomach to obtain
syphon effect.
If no aspirate obtained, wait 30-60 minutes and retry
If still no aspirate obtained, consider chest xray
Syringes
Note that syringes used in hospital are single use only. Only 50ml purple enteral
syringes are to be used for aspirating all nasogastric tubes. Please see (The use of
syringes to administer flushes, feeds and medication via the oral and enteral routes,
policy and procedures, 2007)
A tube position should be verified
Insertion of all new tubes
Tubes which have been re-inserted, repositioned or there is a suspicion of
displacement
All new admissions who have a nasogastric or orogastric tube insitu.
83
Correct placement of a wide bore nasogastric tube, visible on x-ray
84
REFERENCES
British Association for Parental and Enteral Nutrition (2003) Administering drugs via enteral
feeding tubes - a practical guide London: BAPEN
Dougherty, L. Lister, S. (2008) The Royal Marsden Hospital Manual of Nursing Procedures
7th Ed. Wiley Blackwell, Oxford
Colagiovanni L (1999) Taking the tube Nursing Times Vol. 95, No. 21 pp. 63-71
Ellett MLC (2004) What is known about the method of correctly placing gastric tubes in adults
and children Gastroenterology Nursing 27(6):pp253-259
Fuchs, K and DeMeester, T (1990) Intragastric pH Pattern analysis in patients with
duodenogastric reflux Digestive Diseases 8(1):pp54-59
George-Gay, B and Chernecky, C (2001) Clinical Medical-Surgical Nursing: a DecisionMaking Reference Philadelphia: WB Saunders
Goodwin, RS (1996) Prevention of Aspiration Pneumonia: a Research Based Protocol
Critical Care Nursing 15(2):pp58-71
McConnell (1997) How to determine gastric pH Nursing Times Vol. 27 No. 8 pp. 126
Medicines and Healthcare Products Regulatory Agency (2004) Medical Device Alert Ref:
MDA/2004/026 London: MHRA
Metheny N, Reed L, Worseck M, Clark J (1993) How to aspirate fluid for small bore feeding
tubes American Journal of Nursing 93(5):pp86-88
Metheny, NA and Titler, MG (2001) Assessing placement of feeding tubes American Journal
of Nursing 103(3): pp36-45
Metheny NA, Wehrle MA, Wiersema L, Clark J (1998) Testing Feeding Tube Placement:
Auscultation vs pH Method American Journal of Nursing 98(5):pp37-42
Metheny N, Dettenmeier P, Hampton K, Wietsema L, Williams P (1990) Detection of
Inadvertent Respiratory Placement of Small Bore Feeding Tubes: a Report of 10 Cases
Heart and Lung Journal of Acute Critical Care 19(6):pp631-638
Neumann M, Meyer C, Dutton J, Smith R (1995) Hold that x-ray: Aspirate pH and
auscultation prove enteral tube placement Journal of Clinical Gastroenterology Vol. 20 No.
4 pp. 293-295
NPSA (2005) Reducing the harm caused by misplaced nasogastric feeding tubes.
www.npssa.nhs.uk/alerts-and-directives/alerts/nasogastric-feeding-tubes.
National Patient Safety Agency (2007) Nasogastric Tube Incidents: Summary Update. NPSA
London
Nottingham University Hospitals NHS Trust (2008) Hand Hygiene Policy
Theodore AC, Frank JA, Ende J, Snider GL, Beer DJ (1984) Errant Placement of
Nasoenteric Tubes. A Hazard in Obtunded Patients Chest 86(6):pp931-933
85
APPENDIX 3
STARTER REGIMENS FOR ADULT PATIENTS WHEN DIETETIC SUPPORT IS

NOT IMMEDIATELY AVAILABLE
MONITORING the severely at risk Restore circulatory volume and monitor fluid balance and
overall clinical status closely. Monitor cardiac rhythm continually in these patients and any
other who develop cardiac arrhythmias (NICE 2006)
When the starter regimen is used please:
Document the regimens use in medical / nursing notes stating regimen A,B or C
Use fluid balance charts to record the enteral feed input
Consider additional IV fluids which may be required as feeding regimens below unlikely to meet fluid
requirements
Use a new giving set every 24 hours
Use a new enteral syringe after every administration episode
Monitor blood sugar if the patient has diabetes. If blood sugars are greater than 11mmol/l or less than
4mmol/l on 3 separate occasions over 3 days please refer to diabetes nurse via HISS
Refer to Step 1 on next page to determine correct feeding regimen for your patient
_______________________________________________________________________________________
Regimen A-Severe risk
Water flushesgastric tubes =50ml before & after FEEDING, MEDICATION AND STOPPAGES
Jejunal tubes =50ml every 4 hours & before & after FEEDING, MEDICATION AND STOPPAGES
Day 1: Nutrison Standard 200ml over 20hours at 10 ml/hour
Do NOT proceed to day 2 until STEP 4 in flowchart overleaf followed
Day 2: Nutrison Standard 500mls over 20 hours at 25mls/hr
_______________________________________________________________________________________
Regimen B-Moderate/high risk
Water flushesgastric tubes =50ml before and after FEEDING, MEDICATION AND STOPPAGES
Jejunal tubes =50ml every 4 hours & before & after FEEDING, MEDICATION AND STOPPAGES
Do NOT proceed to day 2 until STEP 4 in flowchart overleaf followed
Day 2: Nutrison Standard 1000ml over 20hours at 50ml/hour
_______________________________________________________________________________________
Regimen C-Low risk
Water flushesgastric tubes =50ml before and after FEEDING, MEDICATION AND STOPPAGES
Jejunal tubes =50ml every 4 hours & before and after FEEDING, MEDICATION AND STOPPAGES
Day 2: Nutrison Standard 1000ml over 20hours at 50ml/hour
86
Starter regimen for adult enteral feeding

Instructions for use: Only to be used when dietitians are unavailable (e.g. weekends and public holidays)
Please contact the dietitian to assess the patient at the earliest opportunity
Not for use on critical care and the renal unit
STEP 1: Prior to feeding assess patient for risk of re-feeding syndrome
Severe risk:
See Step 2
Patient has both of the following

BMI less than 14 kg/m2
Negligible intake for greater than 15 days
Moderate / high Risk: Patient has one or more of the following:

BMI less than 18.5kg/m2
Unintentional weight loss greater than 10% within the previous
3-6 months
Very little intake for greater than 5 days
See Step 2
Start feeding
using:Regimen C
All other patients
Low risk:
STEP 2:Patient identified Moderate/high or Severe risk of refeeding syndrome

a) Give Pabrinex High Potency Ampoules 1 & 2 daily for first 3 days of feeding
b) Check K, Mg and PO4 (plus Ca for later reference) before beginning feed
Are K ? 3.0mmol/L and Mg ? 0.5mmol/L and PO4 ? 0.5mmol/L?
No
STEP 3a: If K < 3.0 and/or Mg <0.5 and/or PO4 <0.5
i) Commence correction of electrolytes. Once the
infusion(s) is/are complete, repeat K, PO4 and Mg levels
ii) Proceed to Step 3b
iii) Prescribe additional supplementation of electrolytes
that remains low
>=More than or equal to
<= Less than
Yes
STEP 3b: Start enteral feeding
Follow appropriate feeding regimen overleaf
Start feeding
using:Regimen A
Severe risk
Start feeding
using:Regimen B
Moderate/high risk
STEP 4: After 12 hours of feeding repeat K, Mg and PO4
Is K?3.0 and
Mg?0.5 and
PO4?0.5
Yes
At appropriate time increase to Day 2
Is K <3.0 and/or
Mg <0.5 and/or
PO4 <0.5
Yes
Keep the feed at the current rate.
Consider correcting the low electrolyte(s)
MONITORING the severely at risk Restore circulatory volume and monitor fluid balance and
overall clinical status closely. Monitor cardiac rhythm continually in these patients and any other
who develop cardiac arrhythmias (NICE 2006)
87
APPENDIX 4
CLINICAL NUTRITION NURSE SPECIALIST GASTROSTOMY CARE PATHWAY
PRE- PROCEDURE ASSESSMENT
Name
Hospital Number
Age
DOB
Admission Date
Ward
Date of Referral
Consultant
Date Seen
Is feeding appropriate? (If you answer yes to any of the questions in the next table you must
identify an acceptable clinical reason for going ahead with a feeding stoma as justification for
deviating from standard practice. Alternatively, the patient should be discussed with a clinical
nutrition consultant)
Patient is / has
Yes
No
If you answer yes justify reason for variance or
outcome of discussion with medical team
.. able to maintain their own nutrition?
.. a prognosis assessed to be<4 weeks?
.. a persistent vegetative state?
..inability to eat due only to advanced
dementing illness?
.. dysphagia due to debilitating,
progressive systemic illness?
Additional appropriateness comments
Signed
Date
Medical History (from past medical history):
Current Diagnosis:
Does the patient have significant respiratory disease? (on continuous O2 or shortness of breath at rest)
No
Yes
(If yes discuss with CNC before booking procedure)
Does the patient have significant cardiac disease ? (uncontrolled heart failure or recent , < 6 weeks,
myocardial infarct)
No
Yes
(If yes discuss with CNC before booking procedure)
Is the patient diabetic ?

No
Yes
(If yes document whether this is diet, drug or insulin
controlled and identify the relevant care guideline for the patient pre and post procedure)
88
Reason for referral (underlying diagnosis leading to loss of swallow)
Medication history: (If you answer Yes to any of the questions in this section, discuss with medical team to
plan anticoagulation / anti platelet management peri-procedure)
Is the patient taking anticoagulants/ antiplatelets?
Warfarin
No
Yes
Enoxaparin
No
Yes
Heparin
No
Yes
Aspirin
No
Yes
Is the patient taking chemotherapy drugs ?

No
Yes
(discuss with medical team, gastrostomy should be
planned when clotting, platelets & white cell count are normal & predicted to remain so for 10 days)
Are there any obstructive neck, pharyngeal, laryngeal or oesophageal problems?
No
Yes
method for placement of gastrostomy)
(if you answer yes discuss with CNC to determine best
Can the patient open their mouth fully ?

No
Yes
placement of gastrostomy
(if No discuss with CNC to determine best method for
What is the Condition of the mouth?

Good
Poor
Very poor
(if poor give advice and continue with plan for stoma placement/assessment, if very poor advise on the use
of the mouth care policy and review patient until condition of mouth is satisfactory for placement)
Are there any abnormalities on abdominal examination?

Subcutaneous fluids (advise that there must be no anterior abdominal fluids for 48 hours pre procedure)
If there is ascites, abdominal mass or previous abdominal surgery discuss with Clinical Nutrition consultant,
and document outcome of discussion (problem, risk for gastrostomy and recommended nutrition plan in the
patient record)
Has the patient had a S&LT assessment?

Yes
Document
Date seen
Seen by whom
S&LT recommendation
No
(Is S&LT required for this patient, if yes then suggest that a referral is made)
Consent
Can the patient consent for themselves
YES (explain procedure, leave the relevant consent form and
89
information pack with the patient and return 24 hours pre procedure
to pre-sign the form)
NO (if no identify reason here and
a) Leave Form 4 for responsible consultant to sign
b) Arrange to see relatives to give them the relevant information
pack
If NO has the appropriate consent been completed by the consultant
The procedure will not be carried out without the responsible consultants signature.
Consent Form 4 left / Instructions written in the medical notes
YES / NO
YES / NO
Is the patient at risk from re-feeding syndrome?

NO
YES (if yes discuss with dietitians and identify relevant guideline
for the ward staff post procedure)
Gastrostomy assessment outcome?
Pre gastrostomy assessment has identified clinical issues as detailed above. I will discuss these with the
patients medical team or the CNC and return to complete the assessment on
Date____________________
Pre gastrostomy assessment has identified no contra-indications or extra ordinary risks and the patients
procedure has been booked for
Date____________________ Please ensure care is in line with the following guidelines pre procedure
a) Therapeutic endoscopy
b) Procedure consent
c) Diabetes
d) Anticoagulation/antiplatelets
e) Mouthcare
f) No anterior abdominal wall SC fluids
48 hours pre procedure
Yes
No
Not relevant
90
APPENDIX 5
GUIDELINE & CARE-PATHWAY FOR SCREENING OF SWALLOWING IN
PATIENTS WITH SUSPECTED / CONFIRMED STROKE
Introduction
The term dysphagia is used here to describe difficulties, which may occur in the oral and/or
pharyngeal stages of swallowing.
Studies have shown that between 30% - 40% of conscious stroke patients have significant impairment
of their swallow on the day of the stroke and 15% - 20% at one week post stroke (Wade et al 1987[1],
Barer 1989[2], Ellul et al 1993[3]). Patients with impaired swallow function are at risk of serious
complications such as aspiration and malnutrition (Davies with Barer 2001[4].) Hinchey, et al ( 2005)
[5]
reported that using a formal dysphagia screen resulted in a greater compliance with dysphagia
screening and significantly reduced the risk of pneumonia and concluded that a formal swallow
screening programme should be offered to all stroke patients, regardless of stroke severity. In addition,
Perry (2001)[6] noted that when a validated screening tool is used, significant benefits can be achieved
although Perry also noted that full training and education were required to achieve competency in
administering the screening tool and that this training was reflected in how accurate the tool was in
identifying dysphagia. There can be no doubt, then that early detection of dysphagia positively affects
the outcome of stroke (Smithard, at al, 1997)[7].
There are a number of guidelines recommending the use of screening for dysphagia in the first 24
hours as a quality marker for good care for stroke patients. These include; The National Service Framework for Older People[8], Standard 5: Stroke, states that
multidisciplinary assessment and rehabilitation must start within 24 hours and that this process
should include a formal swallowing assessment and a plan for safe hydration, feeding and
medication.
The Royal College of Physicians, National Clinical Guidelines for Stroke 3rd Edition, (based on
NICE Guidelines for stroke 2006), [9] supported by the National Stroke Strategy (QM8, 2007)
4.16.1 Recommendations
A* On admission, people with acute stroke should have their swallowing screened by an
appropriately trained healthcare professional before being given any oral foods, fluid or medication.
B* People with acute stroke for whom the admission screen indicates problems with swallowing
should have a specialist assessment of swallowing early after stroke. [The NICE group defined early
as within 24 hours if possible and no later than 72 hours after admission]
C* People with suspected aspiration on specialist assessment or who require tube feeding or dietary
modification for three days should then be reassessed and be considered for instrumental
examination.
D* People with acute stroke who are unable to take adequate nutrition and fluids orally should
receive early tube feeding with a nasogastric tube. [The NICE group defined early as within 24
hours of admission]
The care pathway for the assessment of swallowing following stroke therefore comprises a three-tier
approach (Farrell and ONeill 1999) [10]. The first tier consists of the Nurse Stroke Swallow Screen
that should be routinely carried out by trained staff on all patients suspected of having a stroke. The
second tier is an in-depth assessment by a specialist, usually a speech and language therapist, followed
by objective testing such as videofluoroscopy (VF)/ videopharyngography (VPG), if the first two tiers
do not provide enough information.
The standardised swallow screening tool in place in Nottingham, on which the Nurse Stroke Swallow
Screen was originally based was developed for non-specialists to detect dysphagia after stroke by
doctors and speech and language therapists in Manchester and Liverpool (Keeney and Hibberd 1997)
[11]
. It has since been adapted to include the 3-oz water sip test (De Pippo et al, 1992) [12]to improve
its sensitivity in detecting patients at risk of aspiration (Suiter and Leder, 2007) [13].
91
A working in new ways package has been developed. This package is designed to provide nurses
working within the inpatient Stroke Service with a competency framework to acquire the knowledge
and skills necessary for the safe and effective administration of a swallow screen for patients with a
confirmed/ suspected diagnosis of stroke. The development of this skill is underpinned by a
comprehensive training programme including the attendance at a study session, observed clinical
practice sessions, which will be supported by a portfolio of evidence, including reflective accounts and
witness statements.
The Nurse Stroke Swallow Screen is designed for staff to identify dysphagia using the validated
screening tool and therefore staff who undertake this training programme are fulfilling the role of a
Foundation Dysphagia Practitioner as specified by the Interprofessional Dysphagia Framework.[14]
This level of practitioner is directly linked to the Skills for Health Competence DYS 1: Undertake a
protocol-guided swallowing assessment, as well NHS Knowledge and Skills Framework (October
2004) [15] Dimension: Health and well-being HWB6 & 7 - Interventions and treatments Level 2
Indications and contraindications

All fully conscious patients admitted with suspected or confirmed stroke should start the swallow
screening process within 24 hours of admission.
Patients who are drowsy should not be screened until they are fully conscious.
Care pathway and method

On admission, if appropriate i.e. alert and able to sit upright, the patient will be screened by an
appropriately trained professional using the Stroke Swallow Screen tool. Those patients who do not
pass after 3 swallow screens over a 48 hour period will be referred on for in-depth assessment
usually by a speech and language therapist.
The nursing/medical team will regularly review those patients not deemed sufficiently alert to
undergo a swallow screen at least every 6 hours and document findings in the MDT notes as unable
to screen. This is not a failed screen. The screening can commence as soon as consciousness
levels improve. The medical team should consider referral to the dietician as appropriate, in line
with the departmental referral procedure.
If it is not possible to start the screening process within the first 48 hours due to reduced
consciousness levels then the multidisciplinary team would need to agree how many screens to
carry out before onward referral for specialist in-depth assessment.
Until a patient has passed the nurse stroke swallow screen or has been seen by a speech and
language therapist and/or dietitian, they should be kept nil by mouth and hydrated using
intravenous/subcutaneous fluids. If patients are not appropriate to be screened within the first 48
hours please refer to nutrition guidelines for stroke.
Equipment
Mouth care kit
Glass of water
Teaspoon
Tongue depressor if available
Pen torch
Screening proforma
Principle
Rationale
1.
High incidence of oropharyngeal dysphagia in

patients who have had a stroke. Early detection
can reduce secondary complications such as
aspiration, dehydration and malnutrition
All conscious patients admitted with a

confirmed or suspected diagnosis of stroke will
be screened for dysphagia.
92
2.
Check the medical notes for any previous

symptoms of dysphagia, current status
regarding chest and consciousness levels.
If patient is already on a modified diet it would be

inappropriate to screen them on consistencies that
they are known to have difficult with - discuss with
MDT in these situations.
If patient has a chest infection then proceed with
caution and consider whether coughing is related to
a poor swallow or not.
If the patient is not fully alert then the screen
cannot be carried out, this should be documented.
3.
If the patient is fully alert, gather equipment

needed for the assessment. Wash hands and be
aware of food handling requirements. Wear
gloves and apron. Consider placing an apron
on the patient.
To reduce the risks of infection. Protect clothing

from spills.
4.
Sit the patient upright at 90 degrees.
A reclined position increases risk of aspiration in

patients with reduced oral control and a delayed
swallow reflex.
5.
Carry out preliminary observations. Check

mouth condition and administer mouth care if
required. Check voice quality and cough.
Complete the proforma
Increased levels of bacteria in the mouth is

associated with an increased risk of aspiration
pneumonia. If there are lots of dried secretions in
the mouth these will form a barrier to both
sensation and movement of the bolus. Voice
quality and cough will give a general indication of
the airway protection mechanism and also
information about how patient is managing
secretions, e.g. wet voice or not. If any of these
areas are abnormal then you should proceed with
caution.
6.
Stage 1 administer first tsp of water, feel for

the swallow. Score whether it felt normal,
delayed or absent. Mark whether the patient
coughed, choked, there was voice change or
significant drooling.
Only water to be used, if it is aspirated it is less

likely to cause a pneumonia and cannot occlude the
airway. The screen should start with small
amounts, i.e. teaspoons as some patients may have
a completely absent swallow reflex. Feeling for
laryngeal elevation helps determine if the swallow
has been triggered and therefore will give some
information on the timing of the swallow. If it is
present, then it is safe to proceed further with more
water. Noting any signs of aspiration or dysphagia
7.
If you tick a shaded box the screen has been

failed and the screening stops. On the first tsp
patients can have a delayed swallow.
Stop when there are signs of difficulty. There

might be a short delay on the first tsp due to a dry
mouth or prolonged period of patient being nil by
mouth. If it is a long delay then you should use
your clinical judgement to fail the screen.
8.
If the patient manages the first tsp then

continue with the next tsp. Stop if a shaded
box is ticked
9.
If the patient passes the tsp test, then ask the

patient to try drink a continuous sip of half a
glass of water.
Some patients will manage small boluses but will

be at risk of aspiration on a larger bolus. The
continuous swallow is a stress test and is more
likely to pick up patients with subtle problems or
93
Continue to record results on the screening

proforma
10.
If patients pass stage 1 continue to stage 2,

observe the patient as soon as possible eating
their first meal. This should be a SOFT DIET.
Look for signs of difficulty chewing, pouching
of food or any signs of difficulty such as
coughing. Document findings on screening
proforma
who are at risk of silent aspiration, i.e. you are

more likely to trigger a cough if a larger volume of
fluid is aspirated.
Choose soft diet to start with as it will be easier for
the patient to manage if they have been nil by
mouth for a while and have a dry mouth or poor
dentition.
11.
If stage 2 is passed and there are no concerns

regarding the state of the patients dentition or
the fit of their dentures, then as soon as
possible observe them eating a normal diet.
Record the results on the screening proforma
To ensure that patients that can manage a normal

diet start having a normal diet as soon as possible
and do not remain on a soft diet unnecessarily.
12.
If the patient fails at any stage of the screen it

must be stopped immediately and repeated a
total of 3 times over a 48 hour period as
appropriate.
A number of patients swallowing problems

resolve in the first 48 hours. Repeating the screen
regularly during this time allows patients to return
to normal diet and fluids as soon as they can.
13.
If the patient passes, it is the nurses

responsibility to ensure that all stages are
completed and documented before the patient
can eat and drink
To ensure that the patient receives the correct fluid

and food consistencies.
14.
All completed swallow screen forms should be

signed, dated, timed and placed in the patients
MDT notes.
Comply with trust policy regarding documentation

and future audit of swallow screen.
15.
If the patient was screened within the first 48

hours, there must be 3 completed forms before
referral to the Speech and Language Therapy
Department.
To ensure that only patients who have swallowing

problems are referred.
16.
It is the responsibility of the nurse carrying out

the screens that all onward referrals are made.
Referrals to speech and language therapy are
made via orders on NoTIS.
To ensure continuity of care for the patient and

ensure a record of referral and acceptance of
referral is available.
17.
If the nurse carrying out the first screen is

unable to carry out the subsequent screens she
is responsible for handing over to / identifying
an appropriately trained nurse to carry on the
screening process.
To ensure that, patients are not left waiting to be

screened, inappropriate fluids/ foods are not
accidentally given to the patient and patients
overall nutritional needs are continuously
monitored and managed.
References
1. Wade DT, Langton-Hewer R. Motor loss and swallowing difficulty after stroke: frequency,
recovery, and prognosis. Acta Neurol Scand. 1987;76:50-54.
94
2. Barer D,H. The natural history and functional consequences of dysphagia after hemispheric
stroke. J Neurol Neurosurg Psychiatry. 1989 Feb;52(2):236-41.
3. Ellul J., Barer D. & the North West Dysphagia Study Group. Detection and management of
dysphagia in patients with acute stroke. Age and Ageing 1993 22(Suppl. 2), 1
4. Davies, S, Taylor, H., MacDonald, A., Barer, D. An interdisciplinary approach to swallowing
problems in acute stroke. International Journal of Language and Communication Disorders
2001 36: (suppl 1), 357-362.
5. Hinchey, J.A.; Shephard, T.; Furie, K.; Smith, D.; Wang, D. and Tonn, S. Formal Dysphagia
Screening Protocols Prevent Pneumonia. Stroke, 2005; 36:1972-1976.
6. Perry L. Screening swallowing function of patients with acute stroke. Part two: Detailed
evaluation of the tool used by nurses. J Clin Nurs. 2001 Jul;10(4):474-81.
7. Smithard DG, O'Neill PA, England RE, Park CL, Wyatt R, Martin DF, et al. The natural
history of dysphagia following a stroke. Dysphagia. 1997 Fall;12(4):188-93.
8. National Service Framework for Older People, Department of Health publication 2001
9. RCP National Clinical Guidelines for Stroke, 3rd Edition 2008
10. Farrell Z, O'Neill D. Towards better screening and assessment of oropharyngeal swallow
disorders in the general hospital. Lancet. 1999 Jul 31;354(9176):355-6
11. Keeney A and Hibberd. Training in undertaking swallowing screening. Eating Matters. Bond
S (Ed). Centre for Health Service Research. University of Newcastle upon Tyne. 1997
12. DePippo KL, Holas MA, Reding MJ. Validation of the 3-oz water swallow test for aspiration
following stroke. Arch Neurol, 1992; 49:1259-1261.
13. Suiter DM, Leder SB. Clinical utility of the 3-ounce water swallow test. Dysphagia. 2008
Sep;23(3):244-50.
14. Boaden E, Davis S Inter Professional Dysphagia Framework. Uclan 2006
15. NHS Knowledge and Skills Framework, Department of Health 2004
95
APPENDIX 6
PROCEDURE FOR REPLACING A BALLOON GASTROSTOMY TUBE

This procedure must only be carried out by a doctor or a registered nurse, who can demonstrate
relevant theoretical knowledge and who has been assessed as competent in the procedure.
This procedure is for the replacement of a balloon type replacement tube including a Foley catheter
and button.
Please refer to General Principles for All Procedures
EQUIPMENT
Replacement tube of appropriate size
Water soluble lubricant
Sterile gloves
Gauze
10 - 20ml compatible syringe (depending on balloon size) x 2
Sterile water or saline 10 - 20ml (as per manufacturers instructions for the inflation of the
balloon)
pH paper
Sterile jug and freshly drawn water
Basic dressing pack
ACTION
RATIONALE
1.
Explain the procedure to the patient.
To alleviate any fears.
Ask / assist the patient to lie in a supine position. Make stoma

site accessible.
Facilitate the procedure.
3.
Check expiry date on all packaging and size of tube is correct.
To ensure the correct tube size and

that the tube is within expiry date.
4.
Wash hands.
To reduce the risk of infection.
5.
Clean dressing trolley according to procedure. Wash hands or

alcohol rub.
Empty dressing pack onto trolley, open out dressing pack and
empty all equipment onto the opened dressing pack.
6.
Wash hands or alcohol rub and apply gloves.
7.
Draw up the appropriate volume of water or saline as per

manufacturers instructions (if applicable).
8.
The corflo replacement tube has a pre filled syringe within its
pack, with the appropriate volume of water.
Attach the compatible syringe to the balloon port and inflate
the balloon.
The balloon should be symmetrical. Check for any leaks.
To check the tube is in good working

order and it is not faulty.
Deflate the balloon.

To prepare for insertion.
Move the external fixation device to the top of the tube (away
from the balloon).
96
9.
Clean around stoma site if required with normal saline and dry.
Attach the other compatible syringe to the patients balloon
valve and deflate the balloon.
To remove the used tube.
Check the length of the tube at skin level prior to removal.
10.
11.
12.
Ensure all the water or saline is removed. Discard the syringe.

Gently remove the tube from the patients stomach and discard.
Clean around stoma site if required with normal saline and dry.
Lubricate the tip of the new tube with a water-soluble
To aid with the insertion.
lubricant.
Gently guide the tube into the stoma site approximately 2 - 4
cms more than the level the tube was at skin level on removal.
With buttons insert until they lie flat against the skin. See
stoma measuring procedure.
13.
Hold the tube in place, attach pre-filled syringe and inflate the
balloon.
Never use air to inflate the balloon.
14.
Gently pull the tube so a small amount of resistance is felt and

the balloon is up against the stomach wall.
15.
Wipe away the excess lubricant and adjust the external fixation
device to approx. 2mm away from the skin (excludes buttons
see above)
16.
Check the tube for correct placement, by aspirating the

stomach contents.
Balloon may over inflate.
Attach a 50ml purple enteral syringe to the feeding port or

Insert a secur-lok extension to the buttons feeding port
17.
18.
19.
20.
Aspirate some gastric contents and check the pH. If the pH is

5.5 or below the tube is safe to use.
Aspirate with a pH of less than 5.5 in a newly inserted tube is
predictive of gastric placement (Grant et al 2000).
If in any doubt, do not use and seek advice.
Flush the tube if in correct place with freshly drawn water.
Draw up approx. 30 ml of freshly drawn drinking water in a
50-ml purple enteral syringe and flush the tube (only if in the
correct position).
Note and record length of tube at skin level in the nursing
documentation by using the graduations that are printed on the
side of the tube Or With buttons, the shaft size.
Record the date, balloon volume, type of tube, size and batch
number.
With buttons check for any wetness immediately following
insertion. Follow the manufacturers guidelines for increasing
the volume of water in the balloon.
97
APPENDIX 7
PROCEDURE FOR MEASURING A PRE-FORMED STOMA FOR THE INSERTION
OF A LOW PROFILE DEVICE (BUTTON)
This procedure must only be carried out by a doctor or a registered nurse, who can demonstrate
relevant theoretical knowledge and who has been assessed as competent in the procedure, in
accordance with a competency based training package.
Please refer to General Principles for All Procedures
EQUIPMENT
Stoma measuring device
Water soluble jelly
Sterile gloves
Gauze
5ml compatible syringe
Sterile water or saline 5ml (as per manufactures instructions)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
ACTION
Explain the procedure to the patient.
Ask / assist the patient to lie in a supine position. Make
stoma site accessible.
Check expiry date of the stoma device.
Wash hands.
Clean dressing trolley according to procedure. Wash hands
or alcohol rub.
Empty dressing pack onto trolley, open out dressing pack
and empty all equipment onto the opened dressing pack.
Wash hands or alcohol rub and apply gloves.
RATIONALE
To alleviate any fears.
Facilitate the procedure.
To ensure that the tube is in date.

manufactures instructions (if applicable).
Moisten the tip of the measuring device with water-soluble
lubricant.
Insert the device through the stoma.
manufacturers instructions.
The corflo replacement tube has a pre filled syringe with
appropriate volume of water.
98

Enteral Feeding Adults2

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NOTTINGHAM UNIVERSITY HOSPITAL NHS TRUST

Latest Re-Issue Date: September

Main Author and Job Title:

Local Contact including job title

Nutrition Steering Committee

All Clinical Directorates

Plans for training on/implementing

Plans for audit of guideline:

Members of Writing Group

SECTION 1: POLICIES, STANDARDS & AUDIT PROPOSALS

Enteral feeding policy for adults

SECTION 2: GUIDELINES, PROCEDURES AND CARE PATHWAYS

When and how to refer to the Nutrition Support Team

Commercially-prepared feed using a pump

By pump and reconstituted powdered feed

Care of stoma and tube

Complications of enteral feeding

Management of unexpected discontinuation of enteral feeding

Procedure for discharging patients on home enteral feeding

Adult critical care enteral feeding

Wide bore nasogastric tubes

Starter regimes when dietitians unavailable

Nutrition team assessment of potential gastrostomy patients

Care pathway for patients with suspected/confirmed stroke

Procedure for replacing balloon gastrostomy

Procedure for fitting button gastrostomy

Clinical Nutrition Consultant

Clinical Lead Dietitian

Clinical Nutrition Nurse Specialist

Clinical Lead Dietitian

Clinical Lead Dietitian

Gastroenterology & Nutrition clinical pharmacist

Principal Speech & Language Therapist

Clinical Nutrition Consultant

ENTERAL FEEDING POLICY FOR ADULTS

A multidisciplinary Nutrition Support Team will be available in working hours to

Diabetes, Unexpected discontinuation of feeding, Constipation, Diarrhoea, Vomiting

The MUST, or a clinically appropriate adaptation approved by the Nutrition Steering

Patients requiring nutritional intervention are identified early and referred

Guidelines for Nutrition Support in the elderly. Public Health

WHEN TO REFER TO THE NUTRITION SUPPORT TEAM (NST)

Which patients to consider for referral

Helping the NST to provide an efficient sustainable service

WHEN YOU NEED HELP: WHO TO CONTACT & HOW

To refer for gastrostomy

DIABETES- Patients who

Ward based referral

Nutrition support team nurse

NotIS referral or if urgent bleep

Nutrition support team nurse

NotIS referral or if urgent bleep

Your ward pharmacist

Ward based referral

Ward based referral

NotIS referral (code = PEG)

Notis referral DIAB

(Acute gastro & choose Dr Teahon

REQUESTS FOR TEACHING & TRAINING

Figure 1: Algorithm for nutritional support

Feeding is in line with

Persistent vegetative state

patients known wishes

Ethics in Feeding guideline

functional & can be