gastrostomy feeding...> frequently asked questions 9 > accessory items 10 enteral nutrition...
TRANSCRIPT
Gastrostomy FeedingCARE GUIDELINESFor Patients & Carers
GP
Address
Tel. / Fax / Email
Hospital Dietitian
Address
Tel. / Fax / Email
Community Dietitian
Address
Tel. / Fax / Email
Nutrition Nurse
Address
Tel. / Fax / Email
District Nurse
Address
Tel. / Fax / Email
Nutrition Feed Company/Nurse Advisor
Address
Tel. / Fax / Email
Hospital Consultant Address
Tel. / Fax / Email
Fresenius Kabi: 01928 533 533
Useful Contacts
Contents
> Introduction 1
> Whatisgastrostomyfeeding? 1
> Howisthegastrostomytubeinserted? 1
> WhydoIneedagastrostomyfeedingtube? 2
> Howlongwillthetubelast? 2
> HowsoonaftertubeinsertioncanIbeginfeeding? 2
> Postgastrostomytubeplacementcare 2-3
> WhatfeedwillIreceive? 3
> Feedingregimen 3
> Tubecare 4
> Administrationofmedicines 4
> Methodsofflushingthetube 4
> Tubeblockage 5
> AttachinganewFreka®PEGENFit®connector 5
> Skincare 7
> RotatingandadvancingFreka®PEG 7-8
> Frequentlyaskedquestions 9
> Accessoryitems 10
Enteral Nutrition
IntroductionThisbookletaimstoprovideyouwithinformationaboutyourgastrostomyfeedingtubeandtoansweranyquestions.IfyouhaveadditionalquestionsorwouldlikefurtherexplanationpleasecontactyourNurseorDietitianwhowillbeabletohelpyou.Pleaseputthisbookletinasafeplaceasyoumaywishtorefertoitinfuture.Foradditionalinformationregardingyourtubepleaserefertothespecificaftercaresheet.
PleasenoteifyourNurseorDietitianhasprovidedyouwithotherspecificguidancepleasedofollowtheirinstructionsinplaceofthisbooklet.
What is gastrostomy feeding?Agastrostomyfeedingtube(orPEGasyoumayhearitreferredto)isasmallfeedingtubewhichisinserteddirectlyintothestomachsothatyoucanreceivefeed,fluidandmedicationwithoutswallowing.Itwillprovideyouwithasafeandlong-termmethodofobtainingnutrition.
How is the gastrostomy tube inserted?Theprocedureisperformedwithsedationunderlocalanaesthetic.Itiscarriedoutusingagastroscope(aflexibleinstrumentusedtoexaminetheinsideofyourstomach).
Enteral Nutrition
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StomachAbdomen
ExternalfixationplatekeepingPEGinposition
Internalretentiondisc,tokeepPEGinplace
02
Why do I need a gastrostomy feeding tube?Youarecurrentlyunabletotakeenoughfoodandfluidbymouthtomeetallyournutritionalneeds.Thegastrostomyfeedingtubewillprovideaccessforfeedtobeadministeredintoyourstomach.
How long will the tube last?Thetubeismadefrompolyurethane,whichiscompatiblewiththehumanbody.Ifthetubeiswellcaredforitmaylastupto5years1.
How soon after tube insertion can I begin feeding?ThiswillbedecidedbyyourDoctor,DietitianorNurse,butyourfeedusuallycommencesabout6-12hoursafteryourtubehasbeenplaced.Thefeedisintroducedslowlytobeginwith,sothatyourbodycanadjusttothefeed.
Post gastrostomy tube placement care (first 72 hours following placement)ThefollowingadviceshouldbetakenfollowingPEGplacement.*
Ifyou,thepatient,experienceanyofthesymptomsbelow,immediatemedicaladviceshouldbesought.
• Complaintsofsevereabdominal pain/distresswithpossible abdominalbloating.• Raisedtemperature.• Breathlessnessorincreased respiratorydistress.• Bleeding/leakageofgastric contentsatstomasite.• Painwhenfeedingorwhen flushing.• Unabletoobtainanygastric aspirateorpHtestisabove5.5.
DO NOT USEyourtube,immediatelycontacttherelevantmedicalteamorattendyourlocalAccidentandEmergencydepartmenttakingthisbookletwithyou,containingyourtubedetails.
Tube make and size:
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Enteral Nutrition
*NationalPatientSafetyAgency(2010)RapidResponse
ReportNPSA/2010/RRR010-Earlydetectionof
complicationsaftergastrostomy
http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.ax
d?AssetID=73458&type=full&servicetype=Attachment
1.SlauK,TrothT,GibsonE,etal.Howlongdopercutaneousendoscopicgastrostomyfeedingtubeslast?Aretrospectiveanalysis.PostgraduateMedicalJournal2018,94:469-474
03
What feed will I receive?Youwillreceiveaprescribed,commerciallyproducedliquidfeedwhichcontainsalltheessentialnutrientsyouwillneedonadailybasis.
Youmayreceivepartorallofyourdailyfoodviayourgastrostomyfeedingtube,dependingonyourspecificmedicalconditionandneeds.
Youmayalsoneedextrafluidsthroughyourgastrostomyfeedingtube.Watercanbeadministeredusingasyringeoradministrationset.
Feeding regimenYourDietitianwillprescribethevolumeandrateofyourfeedtosuityourneeds.Youmaybefedintermittentlyorcontinuouslyduringthedayorovernight,dependingonwhichisbestforyou.
Alwaysfollowtherecommendedregimen.IfyouhaveanyproblemswiththefeedyoushouldinformyourDietitian.
Topreventheartburnandfeedrefluxing,youshouldfeedinanuprightposition.Forovernightfeedingyoushouldusesupportingpillowsorabackrest.Ifyoufindthisuncomfortableyoucanraisethemattressattheheadofthebedinstead.
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Tube CareThegastrostomyfeedingtubeshouldbeflushedwithatleast30mlofcooled,boiledwaterbeforeandafterfeed,ormedicineadministration,orasdirectedbyyourHealthcareProfessionaltopreventtubeblockage.Youshouldonlyusethetubetoadministerfeed,waterandliquidmedicines.
Administration of medicinesAllmedicinesshouldbeadministeredinaliquidform.Thesameappliestoselfmedication(e.g.forheadache)andyourpharmacistwillrecommendaliquidformofpainrelief.
Donotcrushsustained-releasetablets/capsules.Theyareunsuitableforcrushingbecausethewholedoseisreleasedatonce.
Medicineswithentericcoatingsshouldnotbecrushedandgivenviayourgastrostomytubeastheyaredesignedtobereleasedinthesmallintestine.
Donotaddmedicinestoyourenteralfeedasitmaycausephysical/chemicalinstabilityofthefeedandcauseablockage.Flushyourtubebeforeandafteradministrationofeachmedicine.Medicationshouldbegivenseparatelytopreventpossibleinteraction.Forfurtheradvice,pleasecontactyourPharmacistandNutritionNurse.
Methods of flushing the tubeUsingENFitsyringeforflushing.
Enteral Nutrition
1.ConnecttheENFitsyringetothemedicationportofthegivingset.Turnthemedicationportto90ºinordertoadministerwaterormedication.
2.ConnecttheENFitsyringedirectlytothetube.
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Tube blockageIfyouareunabletoflushthetubeoryoucanseeablockage,youmaytrythefollowingsteps.Ifunsuccessfulonthefirststep,trythenext:
1. Ensurealltheclampsareopen andthetubeisnotkinked.
2. ConnectanENFitsyringetothe endofthetubeandtrytodraw back(aspirate)toremove anyexcessfluid.
3. Massagethetubearound theareaofblockageif obviouslyvisible.
4. Flushwith50mlofwarm water(sterileorcooledboiled). Leaveinthetube(clamp)for 30minutesthenreflush.
5. Flushwith50mlcarbonated water.Leaveinthetube(clamp) for30minutesthenreflush.
Whentryingtoflush,useapumpingactionwiththeplungeronthesyringe.Neveruseexcessiveforceandneverattempttounblockthetubebyinsertingsharpinstruments.IfthesestepsdonotworkcontactyourDietitian,GPorNurse.
Attaching a new Freka PEG ENFit connector CH/FR 9/15/201.Washanddryhands
2.Closeclampontube(A)
Removing old ENFit end:
3.Detachtheouterwhitering(B)fromthenewENFitend.
(A)
(B)
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4.Attachtheouterwhiteringtothecolouredhexagonalfixingscrew(inthepicturethisisbluefortheCH/FR15FrekaPEG)ofthepreviousENFitconnector.
8.Pushthepinwithadaptorintothetube(F).
9.Ifconnectionislooseorthetubeisstretched,trim1cmoffthetubelength.
10.SlidethefixingscrewtowardstheENFitadaptorandscrewtogetherusingtheouterwhitering.
11.Removetheouterwhitering(G)topreventaccidentalremovaloftheadaptorend.
5.Unscrewtheprevioushexagonalfixingscrewfromtheadaptor(C).
6.Pulloffthepin(D)andremovethepreviousadaptorfromthetube.(Itisusuallyfirmlyattached,useafingernailtoeaseoffthepin).
Attaching the new ENFit end:
7.ReplacetheouterwhiteringbackontothehexagonalfixingscrewonthenewENFitendandslideontothetube(E).
(D)
(F)
(G)
(E)
(C)
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SkincareTheareawherethetubeentersyourstomachiscalledthestomasite.Youmayexperienceadischargeatthestomasiteforthefirstfewdays.Aloose,thin,absorbentdressingmaybeusedtocoverthesiteuntilthestomahashealed.Donotplacebulkydressingsundertheexternalplate.24hoursafterPEGplacementthedressingshouldberemoved.Oncethestomasitehashealed(usually7-10daysafterplacement)itisimportanttocleanyourstomasitedaily,asadvisedbyyourHealthcareProfessionalandkeepitdry.Afterthetubehasbeeninplacefor10daysandthestomasitehashealed,youshouldstarttorotateitafteryouhavecleanedit(seenextsection).
However,ifrotationcausesexcesspainand/orthetubewillnotturn,stopandtryagainthenextday.Ifatthistimeitisstillpainfulandwillnotturn,donotattempttocarryouttherotation.ContactyourHealthcareProfessionalforfurtheradvice.
Ifyounoticeanyredness,pain,odourordischarge,youshouldcontactyourNurseorGPwhowilltakeawoundswabtoidentifywhatiscausingtheproblem.Yourdoctormayprescribeantibioticswhichyoucanadministerinthesamewaythatyouadminister
yourregularmedicines(seeunderAdministrationofMedicines).IfyounoticefeedleakagearoundthestomasiteyoushouldstopfeedingandcontactyourHealthcareProfessional.Ifyouexperiencenausea,vomitingorconstipationyoushouldcontactyouHealthcareProfessionalimmediatelyforadvice.
Rotating and Advancing the Freka PEG1,2
Itisknownthatsomepeoplemaybepronetowhatiscalled‘BuriedBumperSyndrome’(wheretheinternaldiscofthePEGtubebecomesburiedandthestomachlininggrowsaroundit).Tohelppreventthisdeveloping,thePEGshouldberotatedandadvanced.Rotationandadvancementshouldbecarriedoutonceaday.
Thismeansholdingtheendofthetubeandrotatingit360°(acompletecircle)andpushingthetubeapproximately3-4cmintothestomachandpullingitbacktotheoriginalposition.
References
1.Löser,C.etal.ESPENGuidelinesonartificialenteral
nutrition,PercutaneousEndoscopicGastrostomy
(PEG).ClinNutr2005;24(5):848-861
2.NNNGGoodPracticeConsensusGuideline-ExitSite
ManagementforGastrostomyTubesinAdultsand
Children(2013)www.nnng.org.uk
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Donotrotatethetubeifthesiteisdischargingorhasnothealed.
AlwayscheckwithyourHealthcareProfessionalaboutwhentostartrotation.
Suggested rotation process:
1. Washhandsthoroughlywithsoap andwater.
2.Cleantheexternalplateasadvised byyourHealthcareProfessional.
3.Openthefixationcatch(seeFig1).
4.Detachtubefromgroove infixationplate(seeFig2).
5.Moveplateawayfromskin (seeFig3).
6.Cleantubeandstomaareaand theundersideoftheplateanddry. Push3-4cmofthetubeintothe stomachandrotate,gentlypull backthetubetofeelresistance.
7. Placethefixationplatebackto itsoriginalposition(approx1cm awayfromtheskin).Re-inserttube inthegroove(seeFig4)andclose thefixationcatch(seeFig5).
8.Yourfixationplateshouldnot betootightortooloose.Ifyou feelthatitis,yourHealthcare Professionalwillbeableto adviseyou.
Fig 1
Fig 2
Fig 3
Fig 4
Fig 5
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Frequently asked questionsCan I swim, bath or shower?
Afterthesiteisfullyhealed,youcanswim,batheorshowerasnormal.Ensuretheclampisclosed.Thoroughlydrytheareaafterwards.AwaterproofdressingshouldbeplacedoverthePEGsitebeforebathingorshoweringforthefirst4weeks.
How long will the tube last?
Thiswilldependuponthetypeoftubeyouhaveplaced.YourHealthcareProfessionalcanprovidethisinformation.Followingtheaftercareinformationwillhelptoprolongthelifeofthetube.
Who do I contact if the tube gets damaged or I get a problem with the site?
ContactyourlocalHealthcareProfessional.
Can I go on holiday?
Enteralfeedingdoesnotstopyougoingonholidaybutitisagoodideatohavealetterfromyourdoctorandmakesureyouhavethenecessaryinsurance.
ContactyourlocalHealthcareProfessionalforadviceaboutreplacementtubesandinformationregardingthesupplyofyourfeed.
If I cannot eat what will happen to my mouth?
Plaquecanbuildupveryquicklysoitisimportanttobrushyourteethatleasttwiceaday.Amouthwashorartificialsaliva,suchasGlandosane®mayhelpifyourmouthisdry.
How do I clean the site?
RefertotheinformationgivenbyyourlocalHealthcareProfessional.
Are there any patient support groups available?
PINNT-PatientsonIntravenousandNasogastricNutritionTherapy
PINNTsupportspeopleonenteralandparenteralnutrition,providingadviceandlocalsupportgroups.
PINNTcontactinformation:-Tel: 020 3004 6193www.pinnt.com
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Accessory Items
FrekaPEGConnectorCH/FR9ENFit
FrekaPEGConnectorCH/FR20ENFit
FrekaPEGConnectorCH/FR15ENFit
RepairSetCH/FR9/15/20
FixationPlateCH9
FixationPlateCH20
FixationPlateCH15
Code:7981385
Code:7981387
Code:7981386
Codes
9: 7981382
15: 7981383
20: 7981384
Code:7903002
Code:7751541
Code:7904002
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Enteral Nutrition
Notes
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Notes
® The signs/names marked with ® are registered trademarks of the Fresenius Group in selected countries.® Freka is a registered trademark of Fresenius Kabi AG. Fresenius Kabi Ltd is an authorised user.® ENFit is a registered trademark of GEDSA, Inc.© Fresenius Kabi Ltd. January 2020
Fresenius Kabi Limited,Cestrian Court, Eastgate Way,Manor Park, Runcorn,Cheshire WA7 1NTtel: 01928 533516 fax: 01928 533520email: scientific.affairsUK@fresenius-kabi.comwww.fresenius-kabi.co.ukDate of preparation: January 2020 EN00322