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Appendix 1: PEG Referral and Assessment Form REFERRAL FOR P ERCUTANEOUS ENTERAL TUBE FEEDING // Surname Forename Height . m Weight kg Unit number DOB // Ward BMI . Referring Consultant Date admitted // Patient Information Date Reason for admission Indication for Enteral Tube Feeding Cerebrovascular disease / CVA Brain injury MND Multiple sclerosis Cerebral palsy Parkinson’s Dementia Other neurological disease Oro- pharyngeal malig.(pre Oro -pharyngeal malig.(post Oesophageal malignancy Other obstructive dysphagia Cystic fibrosis Crohns disease Short Bowel Syndrome Systemic sclerosis Nocturnal hypoglycaemia Other intestinal failure -treatment) - treatment) Details …………………………………………… .. Renal failure Other chronic disease Details ………………………………………………. Details ……………………………. Palliative (venting) Details ………………………………………………. Details ………………………………. Comorbidity Recent MI Date of MI // Cardiovascular disease Details ….…………………………………………… Respiratory disease Details .………………………………………………. O 2 sats on air % Diabetes Liver disease / portal hypertension Previousabdominal surgery Details ……………………………………………………………………………………………………………….. Renal haemodialysis Peritoneal dialysis Conscious level : Normal Confused Drowsy / Obtunded V-P shunt Stuporous Comatose Systemic infection Details ……………………… ……………….. …… Other Details ……………… ………………………………………… MRSA status Pos Neg Unknown Infection Medication Social Anticoagulants Clopidogrel Corticosteroids Antibiotics Anti- epileptics Immunosuppressants Likely discharge destination Home (self - caring) Unknown : Home (with carer) Other Carer training required? Residential home Nursing home Details …………………………………………………………………….. Yes No Assessment and Consent SALT assessment Dietetic assessment PreviousNutrition Team referral // // // Date of latest review Date of latest review Date: Current method of feeding: Are there ethical issues? Oral Yes No Capacity for consent? Family aware of referral Yes Yes IMCA service required? Interpreter required Yes Yes NG/NJ Parenteral Ethical committee review? Yes Case conference? No No No No Don’t know Language Yes No No Date: Date: // // ……………………………………………… Signed …………………………………. Print name ……………………………….. Designation …………………………………………… 1 Appendix 2: Pre-procedural check list Pre-procedural check list for Percutaneous Endoscopic Enteral Tube placement Must be signed and attached to case notes and sent to the Endoscopy Unit with the patient. Failure to complete will result in cancellation of the procedure Patient’s Name: Ward: Hospital Number: DOB: Consultant: Date of PEG/PEJ insertion: ……/……../…….. 1. Consent issues a) Does the patient have mental capacity for consent? Yes No b) Has a case conference/ethics review been held about this case? Yes No c) Does the patient have any family? Yes No d) Is the next of kin (if any) aware of the procedure? Yes No e) If the patient has no next of kin or family, has the IMCA service been involved in this case? Yes No f) Has the Nursing/Residential Home been contacted about the procedure? (if relevant) Yes No g) Is an interpreter organised? (if required) Yes No Type of Consent: Patient’s own consent completed Special consent completed 2. Comorbidity Please tick any relevant boxes On warfarin Ensure INR < 1.5 (See BSG Guidelines on Management of Anticoagulation) Diabetic On haemodialysis Date last dialysis: ……/….../….. Peritoneal dialysis Date last dialysis: ……/..…./….. (Dialysis should be stopped for 3 days and prophylactic antifungal therapy given) On clopidogrel (must be stopped at least one week pre-procedure) 2 3. Blood Results: INR must be less than 1.5 Platelets must be greater than 80 … or procedure cannot go ahead Date of blood results: ……/..…./….. Hb……….. Plat ……... Na ……….. K…………. INR …………. Alb ………. CRP ………….. 4. Has the patient been nil by mouth and nil by NG tube for 6 hours pre-procedure? Yes No 5. Has the patient had iv antibiotics 30 minutes pre procedure? Type of antibiotic: Yes No 1.2g co-amoxiclav i.v 400mg teicoplanin i.v (if penicillin allergy) 6. Does the patient have i.v. access? Yes No Type and site ………………………………………………………. ………………………………………………………. 7. Is the patient wearing an identification bracelet? Yes No 8. a) Is the medication prescription chart enclosed? Yes No b) How has the patient been hydrated pre-procedure? Oral Sub. Cutaneous Intravenous Print……………………………………………….. Signed……………………………………………. Designature……………………………………….. 3 Date ………./………../……….. Appendix 3 : Post-PEG Care Sheet DAY 1 BP / PULSE: hourly for 4 hours, then 4 hourly until stable. Inspect PEG insertion site for bleeding Opiate required once effects of local anaesthetic subsided. If patient develops prolonged pain, pyrexia, hypotension or bleeding, contact nutrition nurse or gastro SpR Expect some discomfort. Report immediately to the medical team any of the following symptoms: Severe Pain / guarding / rigidity / distension / no bowel sounds after 8 hours Report excessive bleeding. Do not touch site for 8-12 hours. Treat as a surgical wound NBM / PEG for minimum 4 hours Water to be administered via tube before feeding is commenced. See dietitian for feeding regimen. Renal patients must be reviewed by renal registrar before commencement. DAY 2 TEMPERATURE / PULSE/B/P: 6 hourly DAY 3 TEMP / PULSE/B/P: 6 hourly Offer moderate / mild analgesics This must be administered routinely / regularly to those patients having difficulty communicating Offer moderate / mild analgesics This must be administered routinely / regularly to those patients having difficulty communication Assess abdomen. Check it is soft, no distension and the patient is comfort Assess abdomen daily ASSESS TUBE Do not dismantle outer retainer device ASSESS COMFORT Administer frequent mouth care and clean the patients’ teeth if they have any. Allay patient anxiety, ensure they are positioned comfortably and are pain free Retainer device should be at a distance of 1cm from the skin because tightness will cause tissue necrosis, looseness will cause tube to migrate, allowing leaking gastric acid to aggravate the healing stoma Renal patients – Changes in body fluid will require adjustment of fixator at least daily. Refer to nutrition nurse if problems occur of for advice Administer frequent mouth care and clean teeth if appropriate Allay patient anxiety, ensure they are positioned comfortably and are pain free. RECORD BASE-LINE OBSERVATIONS ASSESS PAIN ASSESS ABDOMEN ASSESS WOUND PREPARE FEEDING Report immediately to the medical team any of the following symptoms: Severe Pain / guarding / rigidity / distension / no bowel sounds Expose to clean air, clean & dry at least once daily with normal saline and sterile gauze. Observe site at least 3 times during the day and clean as required. Feed (in absence of abdominal symptoms) as per dietitian’s regimen. Adopt safe position to prevent reflux and lung aspiration. Patient’s upper body must be elevated 30-40 degrees during feeding and at least 1 hour following a feed. Patient must not lie flat during this time. Flush with sterile water before and after every administration of feed and medicines (minimal amount of 5mls). Renal patients – see dietitian. 4 Report inflammation, excoriation or leakage. Consider drugs to suppress acid secretion while healing Feed as per regimen. Ensure patient is positioned appropriately. Begin daily tube rotation after 7 days. This will prevent adhesions and aid formation of a healthy stoma Administer frequent mouth care Provide information and education on benefits of nutrition and PEG care PEG CARE AND MANAGEMENT Your patient has had a Percutaneous Endoscopic Gastrostomy tube (PEG) placed. This is a feeding tube that enters directly into the stomach through the skin. It allows feed and medication to be given straight into the stomach, just like a naso-gastric tube, but with much more comfort and convenience for the patient. PEG tubes are of two basic types: those that can only be removed by endoscopy and those that can be removed by pulling hard on them (traction) without endoscopy. You should have received information on the type of tube that your patient has been fitted with. Generally, the type of external fixators (the disc at skin level) can tell a specialist which type of tube it is. Placing the PEG has required a small surgical incision and the initial care of the wound should follow usual surgical nursing principles. IMMEDIATE POST-PROCEDURE CARE OBSERVATIONS: Post-operative observations depend on your patient’s condition and should include pulse, temperature, blood pressure and inspection for bleeding around the site. At least hourly observations are recommended for the first 4 hours and then four hourly. ANALGESIA: Opiate is required, once the effects of local anaesthetic subside, for the first 24 hours post procedure. COMPLICATIONS: If patient develop any complication after the procedure such as prolonged pain, pyrexia, hypotension or bleeding, the Nutrition Nurse Specialist, Gastroenterology Registrar or Consultant should be informed at once. WOUND CARE: The site should not be touched for the first 8-12 hours after placement. Blood and clear or yellow fluid may be evident. This is normal. The stoma site should be treated as a surgical wound. Observe for signs of bleeding or infection. The use of dressings around the PEG site is discouraged. Discuss with Nutrition Nurses if concerned. FEEDING: After PEG insertion the patient should not be given anything by mouth or through the feeding tube for at least 4 hours. After this period, provided the patient has remained well, water should be first given via the PEG. IF THERE IS RESISTANCE OR THE PATIENT EXPERIENCES PAIN: DO NOT FORCE WATER DOWN THE TUBE POSTPONE FEEDING INFORM THE NUTRITION NURSE OR GASTROENTEROLOGIST. If the water bolus goes in without difficulty, it is safe to commence feeding straight away according to the dietitian’s instructions. It is preferable to begin the first feed during the day so that any problems can be attended to. 5 INFORMATION FOR PATIENTS/CARERS FEEDING GASTROSTOMY feeding is similar in principle to NASOGASTRIC feeding, the only difference being the entry site of the tube. Feeding may given slowly over a period of time by infusion pump or more quickly using a syringe (bolus feeding). The dietitian will advise about the most suitable feeding plan. 1. Ensure that you are in a sitting or semi-recumbent position (the upper body must be elevated 3040 degrees during and 1 hour post feeding). 2. Inspect the tube for slits or obvious blockage. 3. Close off the tube with the C-clamp. 4. Uncap the PEG connection port and connect a 50ml Enteral syringe filled with water (without the plunger). 5. Open the C-clamp and allow the 50mls of water to flow in via the PEG freely; do not use the plunger. If you experience pain, stop immediately and inform the nutrition nurse or doctor. 6. Close the C-clamp while connecting the feeding pump giving set to the Leur-lock port. 7. Set the pump flow rate and feeding time as per dietitian’s recommendation. 8. Open the C-clamp and commence feeding. 9. When the feed is complete, disconnect tubing and flush the PEG tube with at least 50mls water as above. 10. Replace cap and release the C-clamp. GENERAL POINTS Flush tube with water BEFORE and AFTER each feed. DO NOT leave C-clamp closed when the tube is not in use. This will damage the tube. Flush the PEG once a week with soda water to avoid fat build up in the tube. If feeding overnight, remember that you will need additional water during the day especially in hot weather (may not apply if you are on fluid restriction – check with your dietitian). Avoid excessive handling of the connector at the end of the tube. Discourage confused patients from playing with the connector or it may fall off. Replace feeding giving sets after 24 hours. The risk of regurgitation of feed (which may result in a chest infection) can be reduced by feeding in a sitting or semi-recumbent position. Most oral medication in liquid form can be administered via the PEG but should be diluted in an equal volume of water. Check with your pharmacist. Remember to flush the tube afterwards. 6 CARE OF THE STOMA SITE The area where the tube goes into the stomach is called the stoma site. The stoma site should not be touched for the first 8-12 hours after placement. After 24 hours clean around the PEG exit site. The stoma should be cleaned initially twice daily with cooled boiled water or saline and gauze, paying attention to meticulous hygiene. Serous discharge should stop within a few days. Two weeks following insertion, the stoma site can be cleaned daily using mild soap, warm water and gauze (saline will be used while in hospital). It is important that the area around the tube is dried gently but thoroughly. The tube should be turned in a full circle once weekly as part of the cleaning process. This helps to form a healthy stoma and makes cleaning easier. Observe for any leakage, swelling, irritation, redness, skin breakdown or soreness around the stoma. If the site becomes inflamed and tender to touch, seek medical advice. While the stoma site is healing (10-14 days) it is advised not to bathe or immerse the area in water. Showering is permitted provided the connector cap is fully closed and some effort is made to keep the stoma site dry. After 2 weeks you may bathe as normal. Always ensure the area is dried thoroughly afterwards to prevent infection. DAILY CLEANING ROUTINE Before cleaning the stoma site, wash hands thoroughly with soap and water. Rinse and dry well. Use non-sterile gloves if you wish. Make a note of the numbered position mark at the tube exit site. Remove the tube from the fixator device following the instructions (see dismantling instructions provided with the PEG). Clean stoma site with mild soap and warm water using a gauze swab – dry site thoroughly. Saline will be used while in hospital. Gently remove any crusting and debris around the stoma site and fixation device with warm water and gauze swab. Two weeks after PEG placement begin to rotate the tube on a weekly basis. The stoma site will not normally need a dressing but if there is excessive oozing or leakage a dry absorbent (e.g. Mepilex®) dressing may be required. After cleaning, the fixator device should be replaced back to its original position (judged from the numbered position marks). It is important that the fixator device is not too tight or skin damage may result. KEEPING YOUR MOUTH CLEAN You will need to keep your teeth and mouth clean. If you have had surgery to your face, neck or mouth the nurse or hygienist will advise you individually. Brush all the surfaces of the teeth, gums and tongue at least twice a day, using your regular toothpaste and toothbrush. Try not to lick your lips as it can make dryness and chapping worse. To moisten the lips you can use a moisturising cream or lip balm. Artificial saliva or a mouthwash may help if your mouth is dry. 7 COMMON QUESTIONS What is a percutaneous endoscopic gastrostomy (PEG)? Percutaneous endoscopic gastrostomy (PEG) is a technique used to pass a narrow plastic tube through the skin, directly into your stomach. Once in place, the tube can be used to give you liquid food and medication straight into your stomach. “Percutaneous” means that it passes through the skin, “Endoscopic” means that a flexible endoscope was used to place it, “Gastrostomy” means making an opening into the stomach. Your tube may have been placed in the X-ray department without the use of an endoscope, or even by a small surgical operation. In these circumstances it should strictly be called a percutaneous gastrostomy, but caring for it is exactly the same. . Why do I need PEG feeding? There are several reasons why you may not be able to eat normally at the moment. There may be a blockage at the back of your throat or in your gullet (oesophagus) that is stopping food going down normally. Or it may be that you have had a stroke or some other problem affecting your muscles or nerves, and this is stopping you from being able to swallow safely. The PEG tube will allow you to receive special liquid food to replace the meals you can no longer manage How is the tube inserted? The procedure is done under sedation, usually in the Endoscopy Unit. You will be lying flat on your back. A needle is inserted into a vein in your arm to give you the sedative. You will have a monitoring clip attached to your finger and will receive oxygen through a tube in your nose. While you are sedated, an area of your abdomen will be cleaned with cold antiseptic solution. A thin flexible telescope (endoscope) will be passed through your mouth to examine the inside of your stomach. An area of skin on your upper abdomen is then numbed with a local anaesthetic injection; this may sting for a short while. Next, the doctor makes a small hole through the skin and passes the feeding tube through it into your stomach. The whole procedure takes about 20 minutes. Are there any risks? Percutaneous endoscopic gastrostomy is a safe procedure. However, as with any medical treatment, there are some risks and complications that can occur. Occasionally the doctor is unable to get the tube into your stomach and the procedure has to be abandoned. If this happens, an alternative technique may be tried on another day. This might involve the X-ray department or perhaps even an operation. There is a small risk that the sedation used during the procedure might affect your breathing. Very rarely, damage can occur to other internal organs while passing the tube into the stomach. Leakage of stomach contents inside your abdomen can occasionally cause pain and infection. Internal bleeding is very rare, but is a possibility. If a serious complication occurs, an emergency operation might be needed to put things right. For the vast majority of people, the procedure goes smoothly. There is usually some pain immediately afterwards but you will be given painkillers for this. Minor problems can develop in the weeks and months following the procedure. Perhaps the most troublesome of these is leakage of feed (or stomach fluid) around the tube. This can cause the skin around the tube to become red and sore. The risk of infection around the tube can be minimised by keeping the skin in this area clean and dry. 8 How long will the gastrostomy tube last? This depends on the type of tube you have in place. Some PEG tubes last for up to 3 years. Tubes that are held in place by a balloon may last only 6 months but can be easily replaced. Your nurse will be able to advise you on your individual tube Will I be able to move around freely? Yes even when receiving a pump feed you can move about freely. Portable pumps are available as needed. If you are very active, you can ask your Nutrition Nurse about the possibility of having your gastrostomy tube replaced by a “button”. These are smaller and more discrete and are preferred by some people. What about bathing and showering During the first 2 weeks you may be allowed to shower but you should make an effort to keep the PEG site as dry as possible. After about 2 weeks, the site is fully healed and you can bath or shower as normal. Always ensure the tube end is closed and the clamp applied. Dry the area thoroughly afterwards Can I go swimming? Yes – after 2 weeks. It is advisable to cover the site with a waterproof dressing when swimming. Make sure the tube end is closed and the clamp applied. How do I look after the skin around my tube? The area where the tube enters your stomach is called the stoma site. You may experience a discharge at the stoma site for the first few days. This is quite normal and should dry up quickly. The stoma site is best left without any plasters or dressings on it if possible. It is important to keep your stoma site dry and to clean it daily, as advised by your Nutrition Nurse. Once the tube has been in place for 2 weeks and the stoma has healed, you should start to rotate it once a week to keep the stoma healthy. If you notice any redness, pain, odour or discharge around the tube, you should contact your nutrition nurse or district nurse. If you notice feed leakage around the stoma site you should stop feeding and contact your nutrition nurse or district nurse. If you experience nausea, vomiting or constipation you should contact your dietician for advice. How do I care for my gastrostomy tube? Your gastrostomy tube should be flushed with at least 50mls of water before and after every feed and after every dose of medicine (or as directed by your nutrition nurse). This will help prevent tube blockage. What food will I put down my tube? Specially prepared liquid feeds will be prescribed for you. The dietitian will decide which feed suits your individual needs. The liquid feed may be poured in from a syringe at meal times (bolus feeding) or pumped in gently over a longer period (pump feeding). Never change the type or amount of feed without first contacting your dietitian for advice. You should not generally put liquidised normal food down your tube or it may block. 9 How do I take my tablets and medicines now? All medicines should be given to you in liquid form to go down the tube. If a new medication is prescribed, your pharmacist can give you advice about a suitable liquid formulation. You will need to give each medicine with plenty of water to flush it through the tube. Remember, always flush your tube before and after using it. Will I receive anything else through my tube? Depending on your condition, you may require extra water through your tube. This will be explained in your feeding plan. It is a good idea to flush the tube with soda water once a week to dissolve any fatty deposits within it. Who will help me with feeding at home? Many people manage their own feeds at home without problems. However, help can be given by relatives, friends or district nurses. Some useful contact numbers are given on this sheet. Will I still be able to eat ordinary food with a gastrostomy in my stomach? Your doctor will decide if it is safe for you to eat or drink. For many people with a gastrostomy, taking anything by mouth is not allowed because there is a risk that the food or fluid will go down the wrong way, into the lungs. If you can eat, your dietician will monitor the amount you are taking and adjust your gastrostomy feeding plan accordingly. Eating and drinking will not affect the tube. If I can’t eat, what will happen to my mouth? Plaque can build up quickly so it is important to brush your teeth at least twice daily. A mouthwash or artificial saliva may help if your mouth is dry. What do I do if the tube becomes blocked? If you find you are unable to flush the tube you may try the following: 1. Ensure all clamps are open and the tube is not kinked 2. Connect the 50ml syringe to the end of the tube and try to flush with 50mls of soda water. Gently squeeze the tube between your fingers along its length (i.e. milking the tube). Leave the soda water in the tube for 30 minutes (to dissolve any fat globules). Re-flush with fresh water. 3. If the tube remains blocked contact your nutrition nurse or district nurse Never use excessive force with the syringe and never attempt to unblock the tube by pushing sharp instruments or wires into it. Can the tube be removed? Before the tube can be removed we must make sure that you are able to manage enough food and fluids by mouth to meet your body’s needs. The procedure will vary slightly depending on your condition, but generally is as follows: A speech therapist and dietitian will advise you about what foods to try and will check up on you from time to time. The dietitian will gradually reduce your tube feeds as the amount of food you can manage by mouth increases. Once you are managing enough by mouth you will be asked to flush the tube daily with water only for one complete month. This is to make sure you really can manage without the tube all the time. If your tube is to be removed, this may require another quick endoscopy procedure, depending on the type of tube you have. Some tubes can be removed without endoscopy. The procedure will be explained to you fully at the time. 10 Peg Tube Do’s and Don’ts – a Summary DO……… check the site every day. Tell your district nurse or doctor at once if you notice any swelling, leakage, redness, soreness or pain. DO……… clean and dry the area carefully each day, especially under the fixation device. DO……… flush the tube regularly as instructed. DO……… only put liquids down the tube. DO……… contact your district nurse if the feeding adapter is damaged in any way. DO……… start turning the tube weekly (after the first 2 weeks) and ensure that the tube moves in and out of the abdomen freely (unless you have been specifically instructed not to do this). DO NOT… put anything down the tube that the dietitian has not recommended. DO NOT… remove the fixator device from the tube except for cleaning. It stops the tube moving about. If it is uncomfortable, contact your district nurse. DO NOT… unscrew the feeding connector on the end of the tube. If it appears broken or damaged, contact your district nurse. DO NOT… clamp the tube except with the clamp provided. DO NOT… leave the clamp closed when not feeding as it can damage the tube. 11 Appendix 4: Trouble shooting guidelines for Enteral Feeding Devices Problem Stoma site is red and Nursing Intervention 1. The stoma should be cleaned initially twice daily with inflamed. (Non-qualified nurses/carers should follow steps 1-3. Contact the district nurse or nurse specialist for advice regarding steps 4-6) 2. 3. 4. 5. 6. Stoma site is leaking (Non-qualified nurses/carers should follow steps 1-4. Contact the district nurse or nurse specialist for advice regarding steps 5-7) cooled boiled water saline and gauze, paying attention to meticulous hygiene. It is advised that the patient should not bathe or immerse the area in water while the stoma is healing (10 – 14 days). After 2 weeks the patient may bath as normal. Showering is permitted provided the connector cap is fully closed and some effort is made to keep the stoma site dry. Always ensure the area is dried thoroughly afterwards to prevent infection. If the stoma site becomes red and inflamed, take a swab of the site for microbiological culture. Inform doctor, as antibiotics may be needed. If site is infected with MRSA, it is recommended to use an antimicrobial solution e.g. Octenisan® to wash the stoma and apply a dressing if appropriate. Further advice can be sought for the tissue viability nurse 3. 4. 5. 6. 7. Prevent infection occurring Reduce leakage of gastric contents the tube is secure (movement of the gastrostomy in and out and excoriation to of the stomach will cause leakage of gastric contents). Ensure the skin around the gastrostomy site is cleaned twice skin. a day with saline and gauze for first 2 weeks, and then mild soap and water from then on, dried thoroughly. Protect the surrounding skin with a skin barrier cream/spray e.g. Cavilon®. Note when patient last had their bowels opened. Leakage may be due to excessive pressure in the abdomen. Ensure patient is on an acid suppressing drug to reduce acidity of gastric contents. For balloon gastrostomy devices, check water volume in the balloon. Note volume of water in the balloon and compare with recommended volume. Replace with recommended volume of water. Leakage may stop if the balloon is inflated a further 2mls. Dressings can be applied to the PEG stoma when leakage is excessive. Recommend using an absorbent dressing to absorb moisture for example Mepilex dressings. (Contact nurse specialist for advice) 1. Ensure the external fixator (disc) is 1cm from the skin and 2. Rationale 12 Potential pain and discomfort following PEG insertion or change. 1. Each patient should receive a strong analgesia immediately 2. (Non-qualified nurses/carers should seek the advice of the district nurse/GP or pharmacist regarding pain control) 3. 4. 5. Over granulation around the stoma site (Non-qualified nurses/carers should seek the advice of the district nurse/GP/pharmacist regarding over granulation) Tube displacement Before 4 weeks After 4 weeks post procedure and for the following 24-48 hours depending on patient’s pain experienced. Pain assessment should be done regularly throughout the days following the PEG insertion. The use of moderate pain relieve is advisable for the first 48 hours post insertion. After 4-5 days the patient should only experience mild discomfort from the PEG tube. A patient who is experiencing severe pain needs urgent referral to the doctor or nurse specialist. Following PEG tube changes or gastrostomy changes, mild pain relief e.g. paracetamol may be helpful. 1. Observe the stoma site daily and ensure the site is cleaned as indicated, 2. If over granulation is noted, ensure the tube is secure and the fixator is snug to the skin. 3. Use a Lyofoam® dressing on the site 4. Refer to your specialist nurse regarding type of treatment, which may be helpful. Silver nitrate or 1% hydrocortisone cream may be appropriate which needs to be prescribed by the GP. Treatment should be continued for 7-10 days. If over granulation still persists then the nurse specialist should be contacted 1. Stop the feed immediately 2. Contact the nurse specialist or appropriate medical team. 3. If unavailable, attend your local A&E department. 1. Stop the feed immediately. 2. For patients in the community contact your district nurse urgently or attend the Accident and Emergency department at your local hospital. 3. Keep the stoma open by inserting a replacement tube through the stoma. If a replacement device is not available trying placing any tube you have available e.g. Foley catheter, the tube that fell out or a NG tube. Tape to the patient’s abdomen. 4. After inflating the replacement catheter, ensure the device rotates with ease and enters in and out of the stomach smoothly. 5. Check position of the replacement device by aspirating gastric contents and testing the pH with Universal Indicator paper. (pH less than 5 suggests correct placement). 6. If the replaced device is an appropriate feeding tube, this can be left in and used. For all other devices used, contact your specialist nurse or hospital for replacement of an appropriate device as soon as possible. 7. If in any doubt about the position of the catheter, DO NOT USE! Keep patient nil by tube/mouth and refer to nutrition nurse/Gastro Unit. A Foley catheter should only be used as a temporary device and not as a replacement gastrostomy. 13 To reduce patient discomfort and pick up on potential complications Ensuring the gastrostomy is secure will prevent tube movement and reduce the incidence of over granulation. Over granulation causes discomfort, infection and bleeding at the site. If the tube becomes displaced before the stoma is fully established there is the possibility of feed or gastric contents leaking into the peritoneal cavity. After 4 weeks the stoma tract is fully formed so there no danger of peritoneal leakage. The tract will close quickly (within 12 hours) so prompt action is required to keep it open. 8. Keep the patient hydrated with i.v. or sub-cutaneous fluid as required. For patients in the community, guidance regarding i.v. or subcutaneous fluid provision should be sort through GP, district nurse or hospital specialist. Damaged tube, connectors/extension set. (Non-qualified nurses/carers should seek the advice of the district nurse/GP or pharmacist) Potential oesophageal reflux/aspiration problems. (Non-qualified nurses/carers should follow steps 1-3 then seek advice from the district nurse/GP or pharmacist) 1. Spare connections/extension sets for patients can be obtained from the local dietetic department or nurse specialist. 2. Please ensure patients at home have spare connectors/extension sets for button gastrostomy tubes in stock or at least have direct access if required (e.g. via dietitian or district nurse). 3. Patient should be set up on a homecare delivery company by the local dietitian 4. Replacement connectors/extension sets are available from the company (see separate order sheet). 5. DO NOT rely on the hospital to provide spare connectors/extension sets for patients at home, as they may be unavailable. 6. If you are unable to repair the tube, contact your community nurse, the dietitian or endoscopy unit. 1. Check feeding position/technique. 2. Ensure the patient is nursed in the most appropriate position for the patient during feeding and at least 1 hour post feeding (patient’s upper body should be elevated 30-40 degrees). 3. Check when patient last had their bowels opened. 4. Check for other causes of vomiting, e.g. infection, antibiotic therapy, etc. 5. Suggest medication which increases gastric motility and prevents/reduces vomiting (discuss with the specialist nurse/dietitian or GP). 6. Contact dietitian for advice regarding the type and rate of feed. 7. If patient is at risk of aspiration they should be fed during the day when they can be closely monitored. Pump alarming 1. 2. 3. 4. 5. 6. Tube Blockage 1. Always ensure the tube is flushed with a minimum of 30ml (or as directed) cooled boiled water before and immediately after feeding, and before and after administering medication. 2. If the tube becomes blocked, try flushing with soda water using reasonably firm pressure with a small enteral syringe. 3. Gently squeeze/roll the tube between the fingers along its length. 4. Leave the carbonated water in the tubing for 30 minutes and then try flushing again. (Non-qualified nurses/carers should follow steps 1-5 then seek advice from the district nurse/GP or pharmacist) Check clamp is not on. Observe tube/giving set for kinks. Ensure drip chamber is not overfilled. Refer to trouble-shooting guide provided with your pump. Consider tube blockage (see below). If unable resolve contact company representative. 14 Prevent any delay in feeding the patient and unnecessary admission to hospital. Feed is delivered in a safe and effective manner without causing complications. Solving simple pump problems will reduce interruptions in feeding. Tube blockages must be resolved safely without damaging the tubing or harming the patient. Excessive force applied with small Problems with diarrhoea (Non-qualified staff/carers should contact the patient’s district nurse or GP or pharmacist). Constipation (Non-qualified staff/carers should contact the patients’ district nurse or GP). 5. Make sure the tube can be rotated and pushed in an out of the abdomen easily. If the tube cannot be pushed in – suspect a “buried bumper”: contact your nurse specialist for advice. 6. Discuss with the GP regarding the prescription of Pancrex V®. This contains pancreatic enzymes and helps to clear blocked tubes. Caution must be taken not to get this medication on the hands and skin. 7. Do not insert guidewires down the tube in attempt to unblock it as they may damage the tube or cause trauma to the patient. 8. If all recommended methods to unblock the tube have failed, contact your dietitian, community nurse or nurse specialist. volume syringes may damage the tubing. 1. Observe for any changes in bowel habits and note existing problems with bowel. 2. If patient has diarrhoea, a specimen should be sent for culture and sensitivity. 3. Check medication, which could be contributing to diarrhoea, e.g. antibiotics, antacids, elixirs. Contact your pharmacist. 4. If stool samples are negative, anti-diarrhoeals maybe appropriate. Consult GP/ pharmacist/hospital doctor/district nurse. 5. Always ensure good hygiene standards are maintained when handling the tube or delivering the feed. 6. Refer to dietitian – who may recommend a fibre feed. Diarrhoea may be a consequence of enteral feed formulation but is more commonly caused by antibiotics, other medication or unrelated illness. 1. Monitor bowel function regularly. 2. If patient is constipated, seek advice about whether extra fluids can be given. Contact the dietician/ nurse specialist/ GP. 3. Contact the dietitian who may be able to advise on types of feed required. 4. Consult the GP/ pharmacist if problem persists. 15 Inserting metal guide wires into the tube can result in perforation. Insufficient fluid may result in constipation. A change in the feeding plan or feed formulation may help.
