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Document Title and Code: Policy for Care and Management of Residents with Percutaneous Endoscopic Gastrostomy feeding tubes. NMA-PEG.

Version: 2Author: Prepared by Nursing Matters and Associates.Adapted for local use by:Issue Date: October 2012Review date: October 2014Authorised by:

1.0 Policy Statement:It is the policy of the Centre that the use and management of Percutaneous Endoscopic Gastrostomy (PEG) nutritional support for residents will be based on a person centred and evidence based approach with due regard to legal and ethical requirements.

2.0 Purpose of the Policy:The purpose of this policy is to outline the process and procedures for use and management of PEG nutritional support in the Centre.

3.0 Objectives:3.1 To ensure that nurses are knowledgeable in the indications for and decision

making about PEG feeding in the Centre. 3.2 To provide nurses with the knowledge for providing person centred and evidence

based care to residents who have PEG feeding tubes in place.3.3 To ensure that nurses have guidance on writing an evidence based care plan for

residents’ with a PEG tube,3.4 To provide guidance for nurses on care following accidental removal of a PEG

tube.

4.0 Scope:This policy applies to all nursing and healthcare staff in the Centre that are involved in the care and maintenance of a PEG tube.

5.0 Definitions:

Care and Management of PEG Tube Policy. October 2012

5.1 A Gastrostromy entails the establishment of a communication between the interior of the stomach and the skin surface for tube feeding in clients and is the most appropriate where feeding is for a period of greater than four weeks (Doughterty & Lister, 2004)

5.2 Gastrostomy Feeding Tubes : a feeding tube that has been directly inserted through the abdominal wall into the stomach. It is secured by a soft spongy balloon or bumper on the inside and a firm plastic/polyurethane fixation device on the outside. Most are inserted by the percutaneous endoscopic technique (PEG) (Clinical Resource Efficiency Support Team CREST, 2004).

5.3 Low profile button tube (LPBT)/ Mic-Key button tube: these are shorter tubes that sit flush with the skin on the abdomen and come in a variety of lengths. They have a flexible disk on the stomach end to hold the tube in place.

6.0 Responsibilities.

Responsible Person.This policy will be disseminated to and read by all nursing personnel involved in the care and management of gastrostomy feeding tubes and a record kept of all those who have signed the policy acknowledgement forms.

Person in Charge/Director of Nursing.

Where a new version of this policy is produced, the previous version will be removed and filed away.


An explanation of this policy will be given on induction to all nursing and care staff and any other health care professional involved in providing gastrostomy feeding tube care to residents.



Nurses will be provided with the opportunity to attend training /updates on management of gastrostomy feeding tubes every two years or where there is a significant change to practice in this area.


Every resident with a gastrostomy feeding tube will be assessed on admission for the presence of care needs. Admitting and/or designated nurse.Assessment and care planning to meet the nutritional and hydration and gastrostomy feeding tube needs of residents will be carried out as per this policy. All registered nurses.

Residents and/or residents representative(s) will be supported and provided information regarding the gastrostomy feeding tube. All nursing and care staff.

Nurses will maintain their competence in the care and management of gastrostomy feeding tubes and communicate any competency / knowledge deficits to their line manager/Person in Charge. All registered nurses

Food and fluids given via gastrostomy feeding tube to meet the nutrition and hydration needs of residents will be in accordance with the feeding plan developed by the resident’s dietician. All registered nurses.

Changes in a resident’s condition will be reported to the senior nurse in charge and changes to care will be communicated to all relevant healthcare professionals.

All nurses, care assistants and other healthcare professionals involved in the resident’s care.

7.0 Gastrostomy Tube Insertion and Decision Making. 7.1 Indications for a Enteral Tube Feeding. 7.1.1 As a general rule, PEG feeding should be considered if it is expected that the

patient’s oral nutritional intake is likely to be qualitatively or quantitatively inadequate for a period exceeding 2–3 weeks (ESPEN, 2005). Enteral tube feeding is indicated in the following:

Intact GI tract but unable to consume sufficient calories to meet nutritional needs;

Impaired swallowing related to neurological conditions e.g. stroke, Parkinson’s Disease; and

Obstruction related to neoplasm or surgery.

7.1.2 Table 1 lists the indications for enteral tube feeding from NICE (2006).

Indication for enteraltube feeding

Example

Unconscious patient Head injury, ventilated patient


Neuromuscular swallowing disorder

Post-CVA, multiple sclerosis, motor neurone, disease, Parkinson’s disease

Physiological anorexia Cancer, sepsis, liver disease, HIV

Upper GI obstruction Oro-pharyngeal or oesophageal stricture or tumour GI dysfunction or Malabsorption Dysmotility inflammatory bowel disease, reduced bowel

length (although PN may be needed)

Increased nutritional requirements

Cystic fibrosis, burns

Psychological problems Severe depression or anorexia nervosa

Specific treatment Inflammatory bowel disease, for short term enteral access during surgeryi.e. head and neck cancer

Mental health Residents with Dementia

7.2 It is recommended that Enteral tube feeding should not be given to people unless they are malnourished or at risk of malnutrition and have; inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract (NICE, 2006).

7.2.1 Careful consideration should be given to the insertion of a feeding tube. Tube placement is an invasive procedure and common risks of tube feeding include:

Pain at the tube site,

Discomfort from tube repositioning.

Local infection.

Aspiration pneumonia.

Tube occlusion.

Nausea, vomiting, constipation and diarrhoea.

Loss of pleasure from eating.


7.2.2 The use of enteral feeding for residents in the end stages of dementia is a controversial and an emotional issue, and it is a decision that requires individual and careful consideration by the resident’s representative and the health care team.

7.3 Decision Making Process.7.4 In many cases, the decision to commence PEG feeding for a resident is made

when the resident is in hospital. However, there are times when, while the resident is in the centre, that his/her condition requires consideration of PEG feeding as an appropriate means of providing nutritional support. In such instances, the process of decision making in the Centre involves the following:

7.4.1 Each resident will be assumed to have the capacity for decision making, unless the following conditions exist and then a formal assessment of capacity will be required:

■ The resident is unable to communicate a clear and consistent choice;■ The resident is obviously unable to understand the information and

choices provided; or■ The resident makes a choice that seems to be based on a misperception

of reality or one that doesn’t seem consistent with that person’s known beliefs and values insofar as they are known.

(HSE, 2012).

7.4.2 Where the resident is able to make the decision, he/she will be given all necessary information required so as to enable him/her make an informed decision. This includes:

■ Information being given in a language and format appropriate to the resident’s needs.

■ Information being given at an appropriate time and place when the resident is best able to understand and retain the information.

■ Explanation of the nature, purpose and expected benefits of the intervention.

■ Information about alternatives, their benefits and known adverse effects of each.

■ Explanation of any possible adverse effects/potential risks associated with the intervention.

(HSE, 2011).


7.4.3 The information will be given by the resident’s general practitioner or medical consultant.

7.4.4 Family members, significant others and other healthcare professionals will be involved in accordance with the resident’s wishes.

7.4.5 A record of discussions, information provided and outcome of discussions will be made by the medical practitioner involved in the resident’s medical record.

7.5 Where a resident lacks the capacity to make an informed decision about the procedure, decision making will involve the following:

7.5.1 The Person in Charge of the Centre or his/her deputy will arrange meetings of all relevant persons as outlined below in order to facilitate decision making.

7.5.2 Collaborative decision making involving the resident as far as he /she is able, particularly where the resident’s cognitive impairment fluctuates and there are times where there may be lucid periods.

7.5.3 Involvement of the resident’s family and / or representative with a view to ascertaining their views as well as the resident’s known or previously expressed preferences or advanced care planning.

7.5.4 Consideration of the purpose, benefit and expected outcomes of PEG feeding.

7.5.5 Consider of other options, including the option of not having nutritional support via PEG feeding.

7.5.6 Involvement of nurses and other healthcare professionals who may be involved in the resident’s care. This for example may include, a dietician and /or psychiatry of old age.

7.5.7 Deciding on which options for treatment would provide overall clinical benefit for the service user.

7.5.8 Discussions and their outcomes will be recorded and kept in the resident’s medical record.

7.6 Where the resident is a Ward of Court, the Office of Ward of Court will be contacted regarding advice.


8.0 Guidelines for care of residents with Percutaneous Endoscopic Gastrostomy (PEG)

8.1 Immediate post insertion care.8.1.1 A PEG feeding regimen from the hospital should accompany the resident from

the hospital

8.1.2 Nil via PEG for the first 6 hrs post operatively including administration of sterile water/medications.

8.1.3 Sterile Water /Medications only for next 6 h-12hrs.

8.1.4 Feeding Regimen to commence 12 hrs post insertion of PEG as per instructions accompanying the resident.

8.1.5 Nurses should comply with the feeding regime accompanying the resident from the hospital and liaise with the hospital team regarding any queries or problems encountered.


8.2 Site Care Up to 48 hours post-insertion.Following the initial tube insertion, a channel of scar tissue forms during wound healing

between the gastric wall and the abdominal wall. This process takes 10 -14 days. During

this time the resident should be monitored for signs of cellulitis and peritonitis and

referred to the general practitioner if any of these signs develop. Treat the entry site as a

surgical wound for the first 48 hours.

8.2.1 During this period, aseptic technique non touch technique must be used when cleaning/ dressing the site.

8.2.2 Nursing and care staff must not touch site and tube for 8 – 12 hours after placement.

8.2.3 After 12 hours, nursing staff should remove dressing, observe site for signs of swelling, bleeding or infection.

8.2.4 Nursing staff should cleanse site and fixation device with sterile 0.9% Sodium Chloride solution and gently dry.

8.2.5 A dry dressing only should be applied if required to absorb exudate.

8.2.6 The fixation device must not be released.

8.2.7 Staff should adhere to manufacturer’s guidance in relation to tube rotation. Some devices should not be rotated.

8.3 After 48 hours post insertion

8.3.1 A ‘clean’ non touch technique technique using sterile equipment e.g. dressing pack with nonwoven gauze should be used until the tract has healed. This may take up to 3 weeks post-insertion.

8.3.2 The site and fixation device must be kept meticulously clean and dry.

8.3.3 The fixation device must not be released.

8.3.4 Staff must adhere to manufacturer’s guidance in relation to tube rotation.

8.3.5 Residents with an abdominal stoma for gastrostomy feeding should maintain/be assisted in maintaining a high standard of personal hygiene.

8.3.6 NOTE: Residents may shower but should not have an immersion (tub) bath until tract has healed – approximately 3 weeks post–op.

NB: For resident’s who are immunocompromised, aseptic non touch technique should continue.


8.4 Tube Care.8.4.1 The position of the fixation device must be checked daily in relation to markings

on the tube and tightened to correct position if necessary. This position should be confirmed before feeding is commenced to ensure that tube has not been displaced.

8.4.2 The tube should be rotated to 360 degrees (according to manufacturer’s guidance) within stoma tract 24 hours after insertion, then daily.

8.4.3 The external fixation device should not be opened or removed for 10 – 14 days or until the tract has healed.

8.4.4 If the tube is dislodged within the first 3 weeks before the tract has formed, it can result in peritonitis and the situation must be treated as an emergency.

8.4.5 Tubes that are sutured should be rotated following removal of the suture.

8.4.6 Document care and any changes or problems in the resident’s care plan and refer as appropriate.

8.5 Identification of Infection Associated with Enteral Feeding and Appropriate Action

8.5.1 It is important for staff to be alert to the signs of infection associated with enteral feeding.

8.5.2 Early recognition is important to permit early treatment.

8.5.3 Local infection at the stoma site can occur indicated by redness, swelling, pain and ulceration of the skin.

8.5.4 Bowel infections may present with nausea, abdominal pain, vomiting and /or diarrhoea.

8.5.5 Systemic infection may present as fever, lethargy or altered consciousness.

8.5.6 All suspected infection should be reported to the doctor and documented in the care plan.

8.5.7 In addition to the treatment of infection it is important to try and identify why the infection occurred.

8.5.8 A review and change in procedures may be required to prevent a reoccurrence.


8.6 General Care of PEG Stoma Site, when Established and Healed8.6.1 Standard Precautions are applied when dealing with all stoma sites. Wash hands

before and after contact with a stoma site or tube. Wear gloves if in contact with body fluids, non-intact skin, or mucous membranes and/or if the resident presents a risk of infection.

8.6.2 Before cleaning observe the skin around the site for signs of leakage, swelling, redness, excoriation and/or infection and if present swab for culture and sensitivity. Document any signs of infection and liaise with the resident’s GP.

8.6.3 Wash the skin around the stoma with gentle soap and warm water paying attention to the area under the bolster / button and then dry carefully. Do not leave gauze in situ as this may attract bacteria.

8.6.4 Anti septic creams and talc should not be applied to stoma sites as they may damage the tube.

8.6.5 Wash tube in the direction away from the body daily and dry thoroughly.

8.6.6 Avoid covering the PEG device with dressings or gauze as this may irritate the skin and cause infection

8.6.7 Rotate the PEG tubes 360 degrees daily to prevent adhesion to stomach wall.

8.6.8 The balloon volume should be checked once a week using sterile gloves and a 10ml syringe to withdraw the water and a separate 10ml syringe to insert the correct amount of sterile water to re inflate the balloon. The procedure should be documented in the care plan each time it is performed.

8.6.9 The volume of the water withdrawn must be the same volume as originally inserted. Use sterile water each time.

8.6.10 Where the volume of water withdrawn is noted to be less than that originally inserted, it should be checked again on 3 consecutive days. If the volume is less on these three-recorded dates, the resident’s GP should be informed as the PEG tube may need to be changed.

8.6.11 Check for in and out plays of tube 0.5- 1 cm by gently pushing the tube in by 5mm and pull back again (this does not apply to button tubes).

8.6.12 If unable to move tube in or out, or rotate contact general practitioner/designated hospital/ endoscopy unit immediately as may have adhered to surrounding tissue and may need surgical intervention.

8.6.13 Gastric contents should be tested using a ph strip to ensure correct positioning of the tube after insertion and before administration of feed or medications.


8.7 Change of Tubes:8.7.1 PEG tubes usually have a lifespan of 18-24 months but this may vary according

to manufacturer and individual residents. The PEG tube should be monitored for signs of degeneration such as the tube becoming cracked or leaking. Where there are signs of degeneration, the tube should be replaced before feeding access becomes an emergency.

8.7.2 Mic-Key buttons need to be changed every three months or as per manufacturer’s instructions. Mic-key buttons can only be changed by a nurse or other health care professional who has completed the required training.

8.8 General Hygiene Needs.8.8.1 Bedbaths and showers are permitted, but plunge baths should be avoided until

the tract has healed, usually 3 weeks.

8.8.2 The resident should have a plan of care to address oral hygiene and mouth care needs in accordance with individual needs and wishes.

8.8.3 Particular attention to dental and oral hygiene needs are required for resident’s with natural teeth so as to prevent plaque, calculus and tartar build up in the stagnant oral environment.

8.9 Flushing of PEG Tubes8.9.1 PEG tubes should be flushed with sterile water/cooled boiled water or plain tap

water.

◙ Before and after bolus feeds◙ After administration of each medicine, using 5-10mls of sterile water/cooled

boiled water between each drug being administered.◙ Four hourly during continuous feeding.

8.10 Procedure for Flushing PEG tubes8.10.1 Gloves should be worn.

8.10.2 30ml syringe or larger should be used

8.10.3 50mls of sterile water should be used to flush each time unless the resident is on restricted fluid intake.

8.10.4 Flush through extension tube taking due care not to cause undue pressure.

8.10.5 Button tubes with right angled extension sets:

Disconnect the extension set daily from the PEG button and securely cap the feeding port cover.

Wash the extension set in warm water immediately after use. Flush through with water. Air-dry and/or push air through tube with syringe and store in airtight plastic

container If continuous feeding use two extension sets. Record that the procedure has been completed in the care plan.


8.11 Management of Feeding equipment.8.11.1 Devices designed for ‘single use’ must not be re used under any circumstances.8.11.2 Feeding pumps should be cleaned with a cloth moistened in mild detergent and

water solution.8.11.3 Spillages of feed onto the pump should be cleaned immediately.8.11.4 Single use giving sets should be discarded after each use8.11.5 Right angle giving sets and extension sets should be maintained according to the

manufacturer’s instructions.8.11.6 Frequent disconnection of the giving set from the feeding tube increases the risk

of infection.8.11.7 A clean non-touch technique should be used for disconnection.8.11.8 Reservoirs should not be topped up with feed. Single use reservoirs should be

clearly labeled with the time and date first used and if used for a full 24 hour feed, should be discarded.

8.11.9 Bottle openers / can openers/ scissors and other feeding utensils should be designated for feeding use and washed in a dish washer or in hot soapy water, rinsed and left to air dry.

Fig 1: Care of Enteral Feeding Equipment

Item MethodConnectors – single resident use Thoroughly wash in detergent and warm

water. Rinse and dry. Store in a clean container with lid.Follow manufacturer’s instructions

Extension sets that are single resident use Thoroughly wash in detergent and hot water.Rinse and dry. Store in a clean container with a lid. Follow manufacturer’s instructions

Extension sets that are single use Discard after single useGiving sets Use a new giving set every 24 hoursPumps Wipe over with a damp cloth to keep dust

free. Clean any spillages immediately.Syringes for flushing and medication Syringes, which are designated for single

use should be discarded after each use.


9.0 PEG Feeding Protocol.9.1 Feeding containers should be stored unopened at room temperature in the ward

kitchen. Any opened / out of date unused feed must be discarded.

9.2 Assembly of Feeds9.2.1 Effective hand hygiene must be carried out before starting to assemble a feed.

9.2.2 Check expiry date of feed and feeding system prior to opening.

9.2.3 Do not use equipment that has been damaged or opened.

9.3 Setting up of Enteral feed9.3.1 Nurses should wash and dry hands thoroughly and put on disposable gloves.

9.3.2 Check expiry date and visually inspect feed, before setting up the feed.

9.3.3 Do not touch giving set connections or the foil top of the feed container.

9.3.4 Only cut foil by attaching the administration set. Do not use anything else.

9.3.5 Enteral feeding administration sets should not contain ports that can be connected to intravenous syringes or that have end connectors that can be connected to intravenous or other parental lines.

9.3.6 Ready-to-use feeds should be used in preference to decanting or diluting feeds.

9.3.7 If decanting or diluting feeds is necessary a clean area should be used to prepare the feed.

9.3.8 Equipment dedicated for enteral feeding should be used.

9.3.9 Ensure the top of the container is clean and dry prior to decanting.

9.3.10 Cool boiled water or freshly opened sterile water should be used to dilute feeds using a no-touch technique.

9.3.11 Label giving sets with date and time feed is commenced and change every 24 hours.

9.3.12 A new water container should be used every 24 hours.

9.4 Hanging Time of feeds9.4.1 Pre-packaged sterile feeds can hang for a maximum of 24 hours, and then

discard.

9.4.2 Non-sterile feeds (decanted or reconstituted feed) should hang for a maximum of 4 hours.

9.5 Administration of feed.9.5.1 If patient is able and not nil by mouth, offer oral fluids before aspiration or if

unable to take oral fluids, perform oral care to stimulate gastric juices.

9.5.2 Position patient on their left side.

9.5.3 Aspirate gastric contents, using a 50-ml enteral (do not use intravenous syringes) syringe and test using pH paper.

9.5.4 A reading of < 5.5 suggests gastric aspirate. If reading is pH 5.5 or more, discuss with doctor

9.5.5 Use a 50-ml oral/enteral syringe or catheter tip syringe for water administration as directed by feeding regime.

9.6 Pump assisted feeding9.6.1 Position the patient upright at an angle of at least 30 degrees during

administration of the feed and for one-hour post feed

9.6.2 Ensure that the feeding container is situated higher than the residents head.

9.6.3 Ensure that the giving set is correctly inserted into the pump.

9.6.4 Ensure that the rate is set according to the prescription.

9.6.5 Monitor rate of delivery during feed.

9.7 Bolus Feeding.9.7.1 Administration of each feed bolus should take 10-15 minutes and should not be

rushed.

9.7.2 Equipment:

Feed, 50ml enteral syringe, Syringe adapter (for use compatible with enteral feeding systems) if necessary. Sterile water.

9.7.3 Wash and dry hands.

9.7.4 Open feed.

9.7.5 Open the feeding tube.

9.7.6 Fill the enteral syringe with approximately 50mls water and slowly syringe into the feeding tube.

9.7.7 Remove the plunger and pour feed into the enteral syringe, allowing it to run through. DO NOT use the plunger unless feed does not flow (may take several minutes for feed to flow).

9.7.8 After the feed, syringe 50 mls water with plunger to flush the tube.

9.8 Tube Blockage.9.8.1 Adherence to meticulous flushing regime before and after feeds/medication

reduces the risk of blockage.

9.8.2 Ensure correct method of medication administration to prevent build up of medication/feed within the lumen of the tube.

9.8.3 Do not use smaller than a 50ml. syringe to unblock the tube as this may cause the tube to burst.

9.8.4 Do not use pineapple juice, coca –cola or other sugary, fizzy drinks to unblock the tube.

9.8.5 Flush tube with 50mls lukewarm sterile water to maintain body temperature as cold water may cause gastric spasm.

9.8.6 Milk the tube using thumb and forefinger as this may dislodge the obstruction.

9.8.7 If a PEG tube is still blocked use manufacturer’s recommended declogging agent or ‘Clog Zapper’ following manufacturer’s instructions. This must prescribed by the GP in the resident’s medical chart.

9.8.8 If all of the measures above are unsuccessful contact medical officer/GP/nearest endoscopy Unit/A& E Department.

9.8.9 Document blockages and actions taken in the resident’s nursing notes.

9.8.10 Once blockage has been resolved, review flushing regime with GP and /or dietician.

9.9 Administration of medication via PEG feeding tubes9.9.1 Medicines to be given via a feeding tube must be measured using an oral /

enteral syringe (National Patient Safety Association, 2007).

9.9.2 Liquids or soluble tablets can be used for drug administration via feeding tubes only following guidance from the pharmacist and include consideration of the following:

That some liquid preparations are in fact suspensions of small granules and therefore not suitable for administering via an enteral tube, e.g. Lansoprazole suspension.

Liquid medications, which are mostly, designed for children under 8, can be low strength and may require larger volumes and can be quite viscous and cause difficulties with narrow tubes e.g. Paracetamol Suspension.

Liquid preparations can contain high levels of sorbitol which acts as a laxative, or have a high osmolality which unless diluted will pull water into the bowel to dilute the high osmotic load and cause osmotic diarrhoea.

9.9.3 Use soluble tablets where possible

9.9.4 Slow release tablets or capsules are specifically designed to release the drug over a long period of time. Crushing these will cause all of the drug to be released at once and may cause toxic side effects (BAPEN, 2004).

9.9.5 Sublingual/buccal tablets are formulated for absorption across the oral mucosa and are ineffective if administered through feeding tubes (CREST, 2004).

9.9.6 Medicines not to be given via the feeding tube are:

Sublingual/buccal tablets. ‘Melt’ tablets. Chewable tablets. Enteric coated tablets. Controlled, extended and sustained release products. Injections (unless specifically advised by a pharmacist) Cytotoxic preparations (unless specifically advised by a pharmacist)

(CREST, 2004).

9.10 Procedure for Administration of Medication via PEG tube.9.10.1 Wash hands and wear gloves prior to administering medication

9.10.2 Stop feed - check break not needed between feeding and drug administration*

9.10.3 Flush tube before drug administration with at least 30mls of water, using a 50ml syringe (do not use intravenous syringes – only use labeled oral/enteral syringes that cannot be connected to intravenous catheters or ports).

9.10.4 Give each drug separately and flush with at least 10mls of water between each drug.

9.10.5 Flush tube after administering all drugs with at least 30mls of water.

9.10.6 Check that a break is not needed before recommencing feed

9.10.7 Recommence feed

10.0 Accidental removal or dislodgement of PEG Tube10.1 If the tube becomes dislodged before the tract has formed (within the first 3

weeks), the situation should be treated as an emergency.10.2 If accidental removal or dislodgement occurs stop feeding or do not commence

feed.10.3 Observe stoma for signs of damage due to pulling of tube. The stoma site may

close if left for 20 minutes, therefore it is important to maintain the patency of the site outlined in the following points.

If stoma is intact, it should be replaced with a same size tube. Replacement of a tube can only be carried out by either a nurse/ GP/dietician with the required training and competency.

Replacement tubes for each resident should always be available on unit.

When inserting a suitable tube replacement, check viability of gastric balloon, and ensure that enteral-feeding tube has been secured in place as per manufacturer’s guidelines.

Use catheter tipped syringe to check that tube is in stomach, by withdrawing a small amount of fluid.

The fluid withdrawn from the stomach contains HCL (hydrochloric acid). This should be tested with P.H.strips and noted for PH level i.e. change of colour as outlined in the manufacturers instructions.

Where the PEG tube becomes dislodged, and there is no nurse available with the required training to replace the tube, a Foley catheter may be pushed through an established stoma tract and the balloon inflated while awaiting transfer to attending hospital or nearest A/E department).

The Foley catheter must be secured to the skin to prevent it slipping inward as there is no external fixator.

Nutrition and Hydration Policy. October 2012

11.0 References.

1. NHS Scotland Nursing and Midwifery Planning and Development Unit,(2002). Best Practice Statement: Nutrition assessment and referral in the care of adults in hospital. Nursing and Midwifery Planning and Development Unit. Edinburgh.

2. Clinical Resource Efficiency Support Team CREST (2004) Guidelines for the Management of Enteral Tube Feeding in Adults. CREST Secretariat, Stormont.

3. National Institute for Health and Clinical Excellence NICE, (2006). Nutrition Support in Adults: oral support, enteral tube feeding and parenteral nutrition. Accessed 11/02/2008 @ www.nice.org.uk

4. NHS Scotland (2008) Best Practice Statement Gastrostomy Tube Insertion and Aftercare: (for adults being cared for in hospital or in the community) www.nhshealthquality.org

5. Hartford Institute for Geriatric Nursing, (2008) Nursing Standard of Practice Protocol: Nutrition in Ageing. Accessed 11/02/2008 @ http://www.consultgerirn.org/topics/nutrition_in_the_elderly/want_to_know_more Hartford Institute for Geriatric Nursing, (2008) Nursing Standard of Practice Protocol: Hydration Management accessed 12/02/2008 @ http://www.consultgerirn.org/topics/hydration_management/want_to_know_more

6. T Finucane, C Christmas, K Travis, Tube feeding in residents with advanced dementia: a review of the evidence. JAMA, 1999. 282(14): p. 1365-1370.

7. I Li, Feeding tubes in residents with severe dementia. American Family Physician, 2002. April.

8. Aged and Community Care Division Commonwealth Department of Health and Aged Care, Standards and Guidelines for Residential Aged Care Services Manual. 2nd ed. 2001, Canberra: Australian Government Department of Health and Ageing.

9. M Opilla, (2003) Aspiration risk and enteral feeding: A clinical approach. Practical Gastroenterology, April: p. 89-96.

10. P Guenter, Mechanical complications in long-term feeding tubes, in http://nsweb.nursingspectrum.com/ce/ce201.htm (accessed April 2004), University of Chicago Hospitals. 2004

Nutrition and Hydration Policy. October 2012

http://nsweb.nursingspectrum.com/ce/ce201.htm

http://www.consultgerirn.org/topics/hydration_management/want_to_know_more

http://www.consultgerirn.org/topics/hydration_management/want_to_know_more

http://www.consultgerirn.org/topics/nutrition_in_the_elderly/want_to_know_more

http://www.consultgerirn.org/topics/nutrition_in_the_elderly/want_to_know_more

http://www.nhshealthquality.org/

http://www.nice.org.uk/

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