leicestershire partnership nhs trust · the eatwell plate for patients in community hospitals fruit...

LEICESTERSHIRE PARTNERSHIP

NHS TRUST

LEICESTER NUTRITION

AND DIETETIC SERVICE

http://www.lnds.nhs.uk/xform.asp

ACKNOWLEDGEMENTS

Leicestershire Nutrition and Dietetic Service are grateful to

Nutricia Ltd for the production and printing of this

Community Hospital Nutrition Resource Folder.

Leicestershire Nutrition and Dietetic Service are also grateful to

Leicestershire Partnership NHS Trust for supporting this resource.

Revised: December 2014


INTRODUCTION

This folder contains comprehensive, up to date information and advice about nutritional

issues in Leicester, Leicestershire and Rutland Community Hospitals.

It provides guidance to ward staff and interested patients and relatives, about the

provision of food for specific dietary needs.

The information contained in this folder replaces the following out of date documents,

which should now be disposed of:

– Manual of Therapeutic Diets for Community Hospitals (undated A4 booklet)

– Enteral Feeding Handbook for Nursing Staff (October 1998)

– Enteral Feeding Procedures for Community Hospitals (undated A5 booklet)

– Leicestershire & Rutland Community Hospitals Nutrition Resource Folder (2010)


CONTENTS

Contact List

Training Available

Healthy Eating

Diabetes

Vegan Diet

Gluten Free Diet

Low Residue Diet

How to Identify and Treat Malnutrition

Nutritional Supplements Available

in Community Hospitals

Policies and Procedures

Websites

Appendix 1: Patient Suitability Charts

Enteral Feeding:

– Equipment

– Setting up Feed

– Starter Regimen

– Use of Flocare 800 Pump

– Gravity Feeding

– Bolus Feeding

– Medication & Enteral Feeding

– Problem Solving


CONTACT LIST

HOSPITAL CONTACT NUMBERS

Department Name Contact No

Dietitian

Hotel Service

Kitchen

Pharmacy

NUTRICIA HELPLINES

Nutricia Resource Centre 01225 751098

Nutricia Homeward Customer Management Team 01225 711982

Account Manager Tracy-Lee Nel 07718 384519 [email protected]

Websites www.nutricia.co.uk www.nutriciaONS.co.uk www.nutriciaflocare.co.uk


TRAINING AVAILABLE

Please liaise with your ward dietitian regarding training needs in regard to nutrition.

Dietitian’s can arrange training on a range of topics, for example, identifying nutritional

risk and it’s management, diabetes, enteral nutrition and dementia.

A food and nutrition self-directed learning is also available from the ward dietitian on

request. This can be handed in to your ward dietitian on completion to receive feedback

and a certificate on request.

Other health professionals may be able to offer additional training on issues relevant to

nutrition, e.g. the ward SALT may be able to offer training on dysphagia on request.


HEALTHY EATING

In August 1994, the Department of Health

published the first National Food Guide “The

Balance of Good Health”, which aims to help

people understand and enjoy healthy eating. In

September 2007 the Food Standards Agency

updated this model with the “eatwell plate”. Some

of the food groups have been renamed, the design

has been made more contemporary and the types

of food pictured reflect current eating patterns. The

eatwell plate provides us with a practical

interpretation of the scientific guidelines in the

(1991) COMA Report.

The eatwell plate applies to most people, including

vegetarians, black and minority ethnic groups,

people who are a healthy weight for height, as well

as those who are overweight* – it does not apply to

young children and some older people.

* Weight management of obese patients

whilst in hospital should be discussed

with the dietitian – weight loss may not

be appropriate during a hospital stay.


http://www.food.gov.uk/images/pagefurniture/eatwellplatelarge.jpg

THE EATWELL PLATE FOR PATIENTS

IN COMMUNITY HOSPITALS

FRUIT & VEGETABLES

Aim: 5 portions per day

Fruit juice is a source of vitamin C

and one glass should be offered with

at least 2 meals per day.

BREAD, RICE, POTATOES, PASTA

& OTHER STARCHY FOODS

1 or more helping should be provided

at each meal.

Encourage wholemeal varieties to

improve bowel function.

Portion size will vary according to

appetite.

MILK & DAIRY FOODS

1 pint milk per day should be offered

to each patient.

Full fat varieties should be offered to

undernourished patients or those with

a poor appetite / intake. FLUIDS

Aim to provide at least 8 cups of fluid

per day. Fluid helps to prevent

dehydration and constipation.

FOODS & DRINKS HIGH

IN FAT AND/OR SUGAR

Unless overweight or diabetic, fatty and

sugary food need not be restricted in the

elderly.

Sugar can provide useful calories, however

care must be taken that sugary foods do

not replace more nutritious foods.

MEAT, FISH, EGGS, BEANS AND

OTHER NON-DAIRY SOURCES OF

PROTEIN

2-3 portions should be offered daily.

Standard portion sizes of these

foods must be given and only

reduced if authorised by the dietitian.


http://www.food.gov.uk/images/pagefurniture/eatwellplatelarge.jpg

DIABETES

Dietary Guidelines for People with Diabetes

Eat regularly. Between meal and bedtime snacks** may be required if on insulin and certain medications** or if underweight.

Include a starchy food at each main meal, e.g. bread, cereal, potatoes, rice, pasta.

Limit fried and fatty foods unless undernourished / underweight.

Aim to eat five portions of fruit and vegetables each day.

Choose a low sugar diet. There is no need to completely exclude sugar from the diet, in practice this means avoiding very sugary foods, such as sugary drinks, cakes, sweets, chocolate, sweet biscuits.

Choosing Food Whilst in Hospital

Menu choices are no longer coded as “suitable for diabetes” as it is the

overall balance of foods that is important. This includes puddings with a

low sugar content, as well as diet yogurts and fruit.

Diet / low sugar yogurts are available if required, as a pudding or snack.

Snacks are available in between meals**.

A bedtime snack may be required if on insulin and certain medication.

Patients may order additional starchy carbohydrate at main meal time,

e.g. additional bread or larger portion of potatoes.

For patients with Type 1 diabetes on a basal bolus regimen who wish to

know the carbohydrate content of meals, please contact your ward

dietitian.

Patients who are Underweight

Nutritional requirements should be discussed with your community

hospital dietitian.

Dietary recommendations for people with diabetes are in line with recommendations for

healthy eating for the general population. The “eatwell” plate model (see Healthy Eating

sections) therefore applies to the majority of people with diabetes.

**Check with your dietitian if unsure about snacks


VEGAN DIET

Individuals who are vegan avoid foods that contain any animal products, including eggs,

milk and other dairy products (butter, cheese and cream). The diet normally consists of

vegetables, cereals, pulses, nuts and fruit.

Foods containing pure vegetable oil margarine can be included and soya products can be

used as a substitute for dairy products, e.g. soya milk, soya yogurt-style desserts and

soya cheese. These products should be fortified with calcium where possible.

The standard vegetarian menu is often unsuitable for patients who are vegan but Tillery

Valley Foods (TVF) do provide vegan meals, which can be ordered from the Hotel

Services Kitchen.

Guidance on suitable choices can be obtained from TVF Talking Technical Allergen and

TVF.

Please also refer to the Catering Resource Guideline for a list of vegan meals available

form TVF.


VEGAN DIET

If vegan dishes are not available from the menu, order vegan meal from TVF.

Alternative choices while awaiting order are:

– Jacket Potato and Baked Beans

– Toast and Baked Beans

– Fresh Fruit

– Tinned Fruit in natural juice

Due to the limited amount of vegan choice, it may be necessary to discuss choice with the kitchen and Hotel Services to source additional items.


GLUTEN FREE DIET

Patients with Coeliac Disease or Dermatitis Herpetiformis will need to be on a gluten free

(GF) diet. This means avoiding wheat, rye, barley, and oats, and any dish containing

these foods. This includes foods such as ordinary bread, pasta, cakes and pastry.

Gluten can also be hidden in manufactured and processed foods where flour or cereal

may be used as a processing aid.

It is also important to ensure gluten free food is not contaminated by gluten containing

foods. This can be prevented in the community hospital by remembering the following:

– Use a separate toaster or toastabag when toasting bread

– Use individual portion packs of butter/margarine and preserves or separate jars

– Removing gluten containing foods, such as butter or pastry does NOT make food safe to eat as it

will already have been contaminated with gluten

– Use separate utensils to serve.


GLUTEN FREE DIET

TVF do provide non-gluten containing ingredient (NGCI) meals, which will need to be

ordered in by Hotel Services.

NGCI means the food has been made with ingredients that do not contain gluten and

controls are in place to minimise cross-contamination with gluten-containing ingredients.

A list of NGCI meals is available from Catering Resource Guidelines or by the ward

dietitian.

Some community hospitals may keep a small selection of gluten free meals in stock.


GLUTEN FREE DIET

Alternatively, or while waiting for NGCI meals to be delivered, the following options are

suitable:

Breakfast

Gluten-free cereal (e.g. suitable brands of Corn Flakes, Rice Krispies, Coco Pops), Fruit/fruit

juice, gluten free bread*, butter/margarine, jam, marmalade – these can be ordered

through local “hub”

Dinner and Supper

Jacket potato/other suitable potatoes (refer to TVF information list of gluten free foods) or

gluten-free bread* with cheese, ham, tuna, salad

Suitable Puddings

Jelly, fresh fruit, fresh fruit salad, tinned fruit, suitable brands of yoghurt, rice pudding,

mousse (check with ward dietitian)

Between Meals/Snacks

Gluten-free biscuits*, fruit, NGCI items from the snack list provided by Hotel Services


GLUTEN FREE DIET

*Gluten free bread/biscuits may be supplied by the patient/relatives or ordered by the

ward via pharmacy. If the patient does wish to have bread and biscuits provided by

pharmacy, it is important that this is ordered in by the ward as soon as possible as

emergency supplies are not held on the ward.

NOTE: Several loaves will be delivered from pharmacy and the additional loaves will

need to be kept frozen until required.


LOW RESIDUE DIET

Patients may be advised to follow a low residue diet prior to endoscopy investigations.

The dietary information below has been provided by LRI / LGH Endoscopy Units.

The following foods only should be offered:

Meat: Lean meats, chicken, turkey, bacon, liver, kidney

Fish: Any kind, fresh or frozen, or tinned in brine

Cheese: Any type

Milk: 284ml per day (any kind)

Fats: 14g per day butter or margarine, or 28g reduced fat spread

Bread: White only – no more than 4 slices per day

Potatoes: Boiled or mashed – up to 4 egg-sized per day

OR

Rice: White – up to 4 tablespoons per day

Crackers: Plain, e.g. cream crackers (but not high fibre crackers)

Biscuits: Rich Tea or Morning Coffee (not digestives)


LOW RESIDUE DIET

Sweets: Boiled sweets, mints, jellies

Sugar: Brown or white, honey, syrup, jelly-type jam or marmalade (no bits)

Desserts: Jelly

Drinks: Water, tea, coffee (milk from ½ pint), Lucozade, fizzy drinks, Ribena, Oxo,

Marmite

Seasonings: Salt, pepper, vinegar

NOTE: All high-fibre foods should be avoided, i.e. fruit, vegetables, salad, high-fibre /

wholemeal cereals / bread, jacket potatoes.

*If a patient requires advice on modifying the fibre content of their diet for any other

condition, please contact the ward dietitian for advice.


OTHER SPECIAL/THERAPEUTIC DIETS

Community hospitals can only cater for some therapeutic diets and the management of conditions requiring a therapeutic diet and food allergies/hypersensitivities will need to be considered on an individual basis. This will involve liaison between ward staff, the ward dietitian and hotel services.

TVF Talking Technical Allergen and Dietary Information on Chilled Products 2013 contains further information on the presence of common allergens in menu items including:

– Milk

– Wheat

– Soya

– Celery

– Mustard

– Peanuts

– Sulphur dioxide and sulphites

– Egg

– Gluten

– Fish

– Nuts

– Crustaceans

– Sesame seeds


OTHER SPECIAL/THERAPEUTIC DIETS

From 13th December 2014 if a product contains any of these common allergens they will have to be highlighted on the menu. These will be shown in CAPITAL letters on TVF labels.

The Catering Resource Guideline contains detailed information regarding special / therapeutic diets.


HOW TO IDENTIFY & TREAT MALNUTRITION

WHY DO PATIENTS BECOME MALNOURISHED? CONSEQUENCES OF

MALNUTRITION

Weight loss

Weakness and fatigue

Depression and apathy

Poor wound healing

Impaired immune function

Prolonged recovery

Reduced quality of life

Increased risk of infection


HOW TO IDENTIFY & TREAT MALNUTRITION

The LNDS Nutrition Screening Tool should be completed for each patient within 24 hours

of admission, and fortnightly subsequently.

If the NST score is > 10 action should be taken to increase the patients nutritional intake

by: – Offering snacks between meals

– Encouraging milky drinks

– Offering Build Up Soups and milkshakes

– Encouraging energy-dense menu choices (i.e. menu code E)

Additional food fortification may be possible, e.g. – Add extra butter/margarine on vegetables, potatoes and bread

– Add sugar to drinks (unless patient is diabetic)

– Add preserves to bread and puddings

If the NST score is > 15, please refer to the dietitian – offer high protein, high energy diet

as above.

The dietitian will assess the need for nutritional supplements in addition to high protein,

high energy diet.


NUTRITION CHECKLIST

Ability to eat Suggested action

Able to eat independently

Poor dentition/chewing problems Consider referral to community dentist

Ill fitting dentures Consider referral to community dentist

Poor oral hygiene Consider referral to community dentist

Requires help with feeding Develop treatment plan for behaviours

Swallowing problems Refer to Speech and Language Therapist

Choke risk Refer to Speech and Language Therapist

Symptoms/side effects of drugs

Nausea Request review of meds

Vomiting Request review of meds

Constipation Request review of meds

Diarrhoea Request review of meds

Psychological state

Does not enjoy mealtimes Offer support during meal times

Mental state not affecting food intake

Loss of interest in food

Disruptive behaviour at meal times Develop treatment plan for behaviours


NUTRITION CHECKLIST

Psychological state (continued) Suggested action

Easily distracted by noise/other clients Develop treatment plan for behaviours

Regurgitates/self induces Develop treatment plan for behaviours

History of erratic or chaotic eating

Severe depression

Mild anxiety/confusion relating to food

Paranoia relating to food Offer support during mealtimes

Extreme anxiety/agitation Offer support during mealtimes

Appetite and dietary intake

Normal appetite, all meals eaten

On special diet, e.g. supplements, liquidized Follow nutrition care plan

Reduced appetite, ½ - ¾ of meals eaten Follow nutrition care plan

Poor appetite, less than ½ of meals eaten Follow nutrition care plan

Can manage finger foods Contact catering

Has particular cultural dietary requirements Contact catering

Seems to have foods they do not like Discuss with relations/carers

Needs specially adapted cutlery Refer to OT for assessment


NUTRITION CHECKLIST

Skin type Suggested action

Healthy

Oedematous

Poor wound healing

Grade 4 pressure ulcers Refer to Tissue Viability Nurse

Dry and flaky

Other issues

Difficulties with posture when eating Refer to Physiotherapy Department


TOP TIPS FOR GIVING SUPPLEMENTS

IT IS IMPORTANT THAT THE DIETITIAN ASSESSES THE NEED FOR

NUTRITIONAL SUPPLEMENTS AND MONITORS THEIR EFFECTIVENESS

If a patient is admitted to the ward on prescribed oral nutritional supplements (this does

not include Build Up Shakes or Build Up Soup) they should be referred to the ward

dietitian for review, regardless of their NST Score

– Give supplements as stated on the prescription chart

– Serve chilled to improve acceptance

– Serve supplements in an appropriate container

– Offer a variety of flavours

– Offer appropriate help and encouragement

– Record intake and inform dietitian if the patient does not take full amount prescribed

– Check the ‘use by’ date and make sure all stock is used in rotation

– Contact the dietitian if the patient wants to change their supplement

The dietitian will give guidance to the patient’s GP regarding whether continued use of

supplements is appropriate


BENEFITS OF ORAL NUTRITIONAL SUPPLEMENTS

Improves nutritional intake

Does not affect normal food intake

Improves clinical outcome

Maintains muscle function

Cost effective


AVAILABLE ORAL NUTRITIONAL SUPPLEMENTS

Fortisip Compact

(Nutricia) Milkshake style

High energy (2.4kcal/ml)

Nutritionally complete

125ml bottle

Vanilla

Strawberry

Banana

Forest Fruit

Mocha

Fortisip Compact

Fibre (Nutricia) Milkshake style


Enriched with

3.6g fibre/100ml


125ml bottle

Vanilla

Strawberry

Mocha

Fortisip Compact

Protein (Nutricia) Milkshake style


14.4g protein/100ml


125ml bottle

Vanilla

Fortisip Multi Fibre



Enriched with

2.3g fibre/100ml


200ml bottle

Vanilla

Fortisip Bottle




200ml bottle

Vanilla

Fortisip Extra


High energy

(1.6kcal/ml)

10g protein/100ml

Nutritionally

complete

Fortimel Regular


High energy

(1.0kcal/ml)

10g protein/100ml

Nutritionally

complete

200ml bottle

Vanilla

Strawberry

Chocolate

200ml bottle

Vanilla

Strawberry

Forest Fruit

Fortijuce

(Nutricia) Juice style

High energy

(1.5kcal/ml)

Fat free

200ml bottle

Blackcurrant

Forest Fruit

Lemon

Orange

Fortisip Yogurt

Style (Nutricia) Drinking yogurt style

High energy

(1.5kcal/ml)


200ml bottle

Peach & Orange

Raspberry

Vanilla & Lemon

Scandishake Mix

(Nutricia) Milkshake style powder

for reconstituting with

240ml milk. If full cream

milk: 588kcal & 12.4g

protein/serving

85g sachet

Vanilla

Strawberry

Banana

Chocolate

Unflavoured

Forticreme

Complete

(Nutricia) Semi solid

200kcal/pot

High protein

(11.9g/pot)

125g pot

Vanilla

Banana

Chocolate

Forest Fruit


AVAILABLE ORAL NUTRITIONAL SUPPLEMENTS

Build Up Soup*

(Nestlé) Sachet

Mixed with hot water contains

200kcal and up to 7.6g protein

49g sachet

Potato and Leek

Chicken

Vegetable

Tomato

Build Up Shake*

(Nestlé) Powder

Mixed with full cream milk contains

240kcal & 14g protein per 200ml

38g sachet mixed with 200ml whole milk

Vanilla

Strawberry

Chocolate

Banana

Calogen**

(Nutricia) Liquid energy (fat) supplement

135kcal per 30ml

500ml bottle

Strawberry

Neutral

Polycal Powder**

(Nutricia) Powdered energy (carbohydrate)

supplement

19kcal per scoop

5g powder

Used to fortify food

and drinks

400g resealable tin

Unflavoured

*These products can be used as a nurse-led intervention

**Use under guidance of the ward dietitian

Build Up Original*

(Nestlé) Powder

20g serving (approximately 2 tbsp)

provides 72kcal and 4.8g protein

Neutral – can be added to sweet and savoury

food and drinks, e.g. tea, coffee, custard and

yoghurt

Calogen Extra**

(Nutricia) Liquid energy (fat) supplement

containing some protein and

vitamins and minerals

160kcal and 2g protein per 40ml

200ml bottle

Strawberry

Neutral


ENTERAL FEEDING

Enteral feeding is used for people who are unable to obtain some, or all of, their

nutritional needs from food or oral supplements.

The majority of patients who need to be fed via a tube will have either a nasogastric tube

(NG) or gastrostomy tube (PEG).

The following pages illustrate:

– What equipment is required to set up a feed

– Recommended procedure for setting up a feed

– Starter regimen for NG or PEG feed

– Use of Flocare 800 enteral feeding pump

– Gravity feeding

– Bolus feeding

– Medication and enteral feeding

– What to do if… (problem solving)


BEFORE SETTING UP

THE ENTERAL FEEDING SYSTEM

Make sure preparation area is clean

The tube feed is sterile until opened (it should be stored in a cool, dry place, out of direct

sunlight, but does not need to be kept in a fridge)

Before opening a feed container, check the expiry date. Do not use if date has expired or

if you notice any sign of damage to the pack

Ensure all equipment is to hand before opening feed container (see following page)

Wash and dry hands before opening the feed

Do not allow the connection points, e.g. of giving set, to come into contact with other

surfaces, e.g. floor


ENTERAL FEEDS & EQUIPMENT

VARIANT 500ML

PACK

1000ML

PACK

1500ML

PACK

Nutrison

Multi Fibre

Energy

Energy Multi Fibre

Sterile Water

If you require other feed types please contact your Dietitian

FLOCARE INFINITY PUMP (Pumps allocated to wards)

NG TUBE PUR FG8 110cm Code No: 41651 (Box of 10)

(500ml x 8) (1000ml x 8) (1500ml x 6)

For variant name

see label (sample below)

* Please note, individual connectors are not provided separately – each giving set pack contains one connector

FLOCARE INFINITY PACK SET *CODE NO: 50562 (Box of 30)

(Order Giving Sets via Stores)


SETTING UP AN ENTERAL FEED

1. Attach pump to drip stand, ensuring it is level.

2. Wash hands thoroughly.

3. Check expiry date on feed Pack and shake thoroughly.

4. Stand the Pack of feed upside down, with the purple cap end upwards. Remove the purple

cap from the end of the giving set, taking care not to touch the ENPLUS spike under the

purple cap. Pierce the foil seal on the feed and screw the purple end onto the feed Pack.

5. Remove purple plastic top from feed Pack and attach giving set. For pre-filled Packs, do

not attempt to remove or touch foil seal. Ensure giving set is tightly connected to the feed

Pack to avoid leakage.

6. Close the purple roller clamp on the giving set. Hang the feed Pack on the drip stand.

Insert the drip chamber into the drip detector slot.

7. Remove the cap from the end of the giving set, and slowly open the roller clamp. The

tubing will then fill with feed. Control the speed at which the tubing fills by adjusting the

roller clamp. Close the roller clamp once the feed has run through to the end of the giving

set.



8. Stretch the tubing around the pump rotor wheel and insert the plastic retainer into the

pump bracket. Then pull the tubing through the tubing guide, the tubing will then be

correctly positioned on the pump. Replace the end cap on the giving set to keep it

clean.

9. Flush the feeding tube with sterile water before starting the feed.

10. Switch the pump on by pressing the ‘ON/OFF’key for two seconds. Set the desired

flow rate (ml/hr) by pressing the ‘+/-’ button until the desired rate is reached. Once

the correct rate appears on the display panel press the ‘START/STOP’key to start

the feed.

11. Connect the giving set to the feeding tube, open the roller clamp fully to begin

feeding.

12. Once the feed is completed, switch off the pump by pressing the ‘ON/OFF’ key,

holding it down until the alarm stops and the display appears. Flush the feeding tube

with sterile water.


STARTER REGIMEN FOR ENTERAL FEED

In the event of your dietitian being unavailable, it is important to establish whether the patient may be

at risk of refeeding syndrome.

The Enteral Nutrition policy for Community Hospitals is currently being updated but will contain the

following starter regimens depending on refeeding risk.

Nutrison (Nutrison 1.0 kcal) feed to be used.

Starting a feed for a patient who is NOT AT RISK of re-feeding syndrome

– Refer to ward dietitian

– Commence feed at 25ml/hour for 10 hours (observe for diarrhoea, nausea or vomiting, or signs of

abdominal distension)

– If tolerating feeds, increase rate to 50ml/hour for 10 hours (consider total fluid requirements, adjust

IV fluids if necessary; observe for diarrhoea, nausea or vomiting, or signs of abdominal distension)

– Give 4 hour break from feed

– If tolerating feeds, continue at 50ml/hour for 20 hours

– Give 4 hour break from feed

– Continue feeds as per regimen from ward dietitian



J2. Starting a feed for a patient who is AT RISK of re-feeding problems.

Initiating feeds in this situation may be undertaken in community hospitals ONLY where appropriate consultant

medical input is available.

Refer to Ward Dietitian

Check urea and electrolytes to identify low levels of potassium, magnesium and phosphate. If depressed, refer to

Appendix J. If, with medical input, it is decided to continue to treat in community hospitals, bloods should be checked daily

until normalised and the need to prescribe thiamine and vitamin B co strong or Forceval should be considered.

Commence feed at 25ml per hour for 20 hours

Consider total fluid requirements; adjust IV fluids if necessary

Observe for diarrhoea, nausea or vomiting, or signs of abdominal distension

Give 4 hour break from feed

If tolerating feed, recommence at 25ml per hour for 20 hours

Check serum biochemistry 24-48 hours after commencing feeds, for levels of potassium, phosphate and magnesium. If the

levels are depressed covering doctor should be contacted and asked to correct. Potassium, magnesium and phosphate

should be monitored every 24 hours until corrected

Give 4 hour break from feed

Increase feeds as per regimen from Ward Dietitian if biochemistry normal (review biochemistry if indicated) (Currie, 2006)



J3. Starting a feed for a patient who is AT HIGH RISK of re-feeding problems.

In this situation for Learning Disabilities and Mental Health the patient is generally referred back to UHL to initiate

enteral feeds safely, however patients with eating disorders are usually at high risk but have been dealt with

successfully on both CAMHS and adult unit. This must be discussed with a Senior Clinician on an individual

patient basis

For community hospitals a medical decision is required, based on clinical condition, to determine if the patient

should be referred back to UHL/acute.


FLOCARE INFINITY ENTERAL FEEDING

PUMP – PROBLEM SOLVER CHART

PROBLEM INSTRUCTIONS

No Set

Press ‘on/off’ to switch of the pump

Insert the Flocare Infinity set into the pump following instructions for use

Restart the pump

Push Strt

The pump has been untouched in hold mode for over 3 minutes

Extend the hold mode by a further 3 minutes by pressing ‘ start/stop’

Program the pump and press ‘start/stop’ to start the pump

End of Dose

The programmed dose/volume has been administered

Switch off the pump by pressing ‘on/off’ for 2 seconds

Clear the memory by pressing ‘clr’

Prog No flow rate is installed

Make sure the correct flow rate is programmed

Door The door is not correctly closed

Make sure the door is properly closed prior to starting a feeding programme

Air Check if the set is inserted correctly and check the air sensor

Remove the air in the set by using ‘fill set’ key


FLOCARE INFINITY ENTERAL FEEDING

PUMP – PROBLEM SOLVER CHART

PROBLEM INSTRUCTIONS

Batt Connect the adaptor to the pump and mains and charge the pump for approx 6 hours – the pump can be used during charging

Batt E+F Battery failure – please refer the pump for service

Occ In

Out Out

Press ‘start/stop’

Check the feeding set (IN) or feeding tube (OUT) for blockages

Reinsert the set and start the pump, if necessary clean the sensors

Occ Out (repeated)

Stop the pump by pressing ‘start/stop’ or let it run briefly by pressing ‘start/stop’ key

Stop the pump again with ‘start/stop’, ensuring there has been no OCC OUT alarm

Remove the set from the pump and reinsert it into the pump, restart the pump by pressing ‘start/stop’

Lock The programming feature is blocked in the set up mode of the pump

Refer to instruction booklet to de-block

ER01-ER99 Electronic error – switch the pump off, make sure the pump door is closed and turn the pump back on; if the error persists please refer the pump for service

No Plug Symbol

The wall outlet or the adaptor does not work, connect to another wall outlet

If there is still no symbol request replacement of the adaptor


GRAVITY FEEDING

In the event of problems with a feeding pump, or further pumps being required, please

contact the dietitian. Even if there is a delay in obtaining a pump please do not delay

starting a feed as this may compromise patient treatment and recovery.

Gravity feeding can be used as follows:

– Connect the giving set to the feed container and feeding tube as normal. The feed container should

hang approximately one metre above patient’s head during gravity feeding

– Open the roller clamp to commence feeding and set the flow rate by counting drips per minute in

the drip chamber, and use the roller clamp to adjust the flow rate

– The following table shows how drip rate equates to flow rate in ml per hour:

Flow rate (ml/hr) Drip rate (drips/min)

125

100

75

50

25

35

28

21

14

7


BOLUS FEEDING

In some circumstances bolus feeding may be used rather than pump-assisted or gravity feeding.

Patients may already be on bolus feeds before arriving on the ward, or consultation with the dietitian

may have led to regimen change. Important points to remember are:

– Wash hands thoroughly before assembling equipment and administering bolus feed

– Shake the contents of the feed container and check expiry date

– Flush the feeding tubes (NG or PEG) with 30-50ml of sterile water using a 50ml syringe

– Using the same syringe, remove the plunger and attach the tip of the syringe to the end of the tube, using a

connector if needed

– Pour the required amount of feed into the syringe, it may be necessary to refill the syringe depending on the

amount of feed needed.

– Hold the syringe and allow the feed to run through the tube. If the feed is running too slowly, raise the syringe

slightly. If the feed will not run through at all replace the plunger and apply gentle pressure. Ensure the feed does

not run in too quickly

– Never attempt to rush bolus feeding – a feed should take at least 20 minutes

– When the feeding is finished, flush the tube with 30-50ml of sterile water

– Remove the syringe and replace the cap / stopper on the feeding tube

– Discard the syringe, which should be for single use only

– Store any unused feed in the fridge, but discard after 24 hours if not used


WHAT TO DO IF…

The tube is blocked:

– Prevention is better than cure! Always flush with the recommended amount of water

before and after feed and medication

– If blocked, try flushing with 30-50ml warm water and allow up to 20 minutes for the

tube to clear. Then flush again with the same amount of water. It may be necessary to

use gentle pressure from the syringe

– If this does not work, try very gentle manipulation of the tube by rolling between finger

and thumb, then re-flush if clear

The patient feels full and uncomfortable after feeding

– Slow the rate of feeding and extend the feeding time. If the problem persists, contact

the dietitian


WHAT TO DO IF…

The patient develops diarrhoea:

– Do not discontinue the feed

Discuss the prescription of anti-diarrhoeal agents with medical / pharmacy staff and

check the following:

– Is the patient receiving antibiotics or have they received antibiotics in the past few

weeks?

– Check the flow rate – it may be too fast, so slow down if necessary

– Check recent food intake. If patient has not eaten for a long period prior to

commencing feed, then a very low rate initially may be required. Discuss with your

dietitian

– Check clean handling procedures are being used to set up feed

– Is the patient receiving any laxatives or syrups containing sorbitol?

– Could the cause be infective (i.e. send stool culture)?


TUBE FEEDS

FREQUENTLY ASKED QUESTIONS

Q. How should I use Nutricia tube feeds?

A. Shake well before opening immediately prior to use at room temperature.

Maximum hanging time is 24 hours and then any unused contents should be discarded.

Nutrison Packs can be attached directly to a Flocare 800 giving set.

Q. What are the recommended hanging times for your enteral tube feeds in the Pack

presentation?

A. The recommended maximum hanging times for Nutricia tube feeds are in accordance with the

Parenteral and Enteral Group of the British Dietetic Association guidelines:

For sterile feeds provided in pre-filled nutrient containers (i.e. Pack) ensuring that a ‘clean‘

technique is used at ward level the maximum hanging time is 24 hours.

However, reference should always be made to local Infection Control Policies.

Q In what volume are Nutricia feeds nutritionally complete?

A. The Nutricia range of enteral tube feeds comply with the EC Directive (1999/21/EC) for Foods for

Special Medical Purposes and are suitable as a sole source of nutrition in adults. The Nutricia

enteral tube feeds used in Leicestershire are nutritionally complete in 1500kcals.


TUBE FEEDS


Q. Are Nutricia tube feeds suitable for patients with Diabetes?

A. When providing nutritional support to patients with diabetes, a main treatment aim should be to avoid the

extremes of hyperglycaemia and hypoglycaemia. It is important to note that, as with any patient who is

not managing to achieve an adequate diet from 'normal' foods, it is essential that a diabetic patient

receives some form of nutritional support to ensure that their nutritional requirements are met. In

addition, patients with diabetes on medication should receive a regular intake of carbohydrate in order to

prevent hypoglycaemia.

The management of enterally fed patients with diabetes (using Nutricia tube feeds) is in accordance with

the Parenteral and Enteral Group of the British Dietetic Association guidelines.

All Nutricia feeds are suitable for use in diabetic patients. The main source of carbohydrate in these

feeds is maltodextrin and the tube feed range contains an average of 1g sugars per 100ml.

Enteral feeds have been found to produce a more rapid rise in blood glucose levels than a nutritionally

equivalent solid meal. However, as the majority of feeds are delivered via a pump at a relatively slow

rate, this is more of an issue in bolus fed patients.

If blood glucose levels regularly exceed 11mmol/l then request a review of diabetes treatment first. It is

essential that blood glucose levels are monitored regularly and oral hypoglycaemics / insulin are

modified accordingly. Discuss with your diabetes specialist nurse and dietitian.

There is evidence to suggest that some fibre containing foods slow the rate of glucose absorption.

Nutrison Multi Fibre and Nutrison Energy Multi Fibre are liquid products and the carbohydrate in any

liquid product will be absorbed more rapidly than carbohydrate that is part of a food.


TUBE FEEDS


Q. Are Nutricia tube feeds Nut Free?

A. Yes, all Nutricia enteral tube feeds are free from any source of nuts.

Q. Are Nutricia tube feeds Lactose Free?

A. Yes, all Nutricia enteral tube feeds are clinically lactose free.

Q. Are Nutricia tube feeds suitable for vegetarians and / or vegans?

A. Unless detailed below, Nutricia feeds are suitable for vegetarians/vegans:

- Nutrison, Nutrison Energy, Nutrison Multi Fibre, Nutrison Energy Multi Fibre,

Nutrison Protein Plus, Nutrison Protein Plus Multi Fibre and the Nutrison Complete

Multi Fibre range contain fish oils and may not be suitable for strict vegetarians or

vegans.

- Vitamin D in feeds is prepared from the wool of healthy living sheep and may not

be suitable for strict vegetarians or vegans.

- Nutrison Peptisorb uses Trypsin (pork enzyme) in the manufacture of the product

and may not be suitable for strict vegetarians or vegans.

Please see Appendix 1 for more details.


TUBE FEEDS


Q. Do you have any guidelines on the interactions of medications with enteral

feeds?

A. A comprehensive document relating to various drug interactions with enteral feeds

has been produced by Nutricia in conjunction with Brenda Tan (pre-registration

pharmacist, Queen Elizabeth Hospital, Birmingham). You can obtain this document

via the Nutricia Resource Centre Helpline: 01225 751098.


TUBE FEEDS


Q. Are Nutricia products suitable for Kosher and Halal diets?

A. KOSHER DIETS – According to Jewish dietary law

Forbidden foods

1. Pork and all products of the pig

2. Birds of prey

3. All shellfish and seafood without fins and scales

4. Meats must not be cooked with milk or milk derivatives, or be served at the same

meal. Utensils, pots, pans, plates, cutlery used for meat and milk must be washed,

dried and stored separately

5. Animals and birds must be ritually slaughtered and soaked in salt to render it

‘kosher’, which means permitted

Nutricia products do not contain any ingredients forbidden in a Kosher diet

Nutricia products are Kosher approved, with the exception of Fortisip Savoury

Multi Fibre Chicken flavour

Please see Appendix 1 for more details


TUBE FEEDS


Q. Are Nutricia products suitable for Kosher and Halal diets?

A. HALAL DIETS – According to Islamic dietary law

In Islamic tradition all foods permitted are “lawful” (Halal) unless declared “unlawful”

(Haram)

Forbidden (Haram) foods

1. Pork and all products of the pig

2. Any meat that has not been ritually slaughtered including any meat derivatives

3. All shellfish and seafood without fins and scales

4. Alcohol – including any in foods or medicines

All of the ingredients used in the Nutricia products (with the exception of Fortisip

Savoury Multi Fibre Chicken flavour & products containing Carminic acid) are suitable

for a Halal diet. However, our manufacturing process is not observed by the relevant

religious body and therefore our products do not have official Halal certification

Please see Appendix 1 for more details


TUBE FEEDS


Q. How should Nutricia tube feeds be stored?

A. The recommended storage temperature for all Nutricia products is 5-25°C. At this temperature

the product will be stable and contain the levels of vitamins and minerals stated on the label

throughout its shelf life

Our manufacturers have looked at the possible effects of storing products at a temperature higher

than recommended and have the following comments:

- All Nutricia tube feeds are supplied sterile so microbiologically the product will remain safe

whilst sealed

- The vitamins (in particular vitamins A, C and E) present in the feeds are likely to degrade faster

at higher temperatures. It is extremely difficult to say by how much as factors such as the

products remaining shelf life, storage temperature and duration of storage at a high temperature

will have an impact. This will not make the product unsafe

- It is possible that over a long period of storage at a high temperature separation of the product

may occur, although this is unlikely. This can be checked visually, and if separated should, as a

matter of precaution, not be given to the patient

Q. Where can I find the expiry date on the Pack and plastic bottle?

A. The expiry date on the Pack can be found at the top of the Pack on the back below the drip stand

cut out area


POLICIES AND PROCEDURES

The following policies are available from Leicestershire Partnership NHS Trust

staff resource:

Protected Mealtimes Policy, August 2012

Procedure for Monitoring Food and Fluid Intake (the Red Tray System) within Adult

Inpatients, September 2013

Adult Nutrition and Hydration Policy for Hospitals, May 2012

Guideline for the Prevention and Management of Pressure Ulcers, July 2013

Enteral Tube Feeding Clinical Guidelines, July 2014.


WEBSITES

Leicestershire Nutrition & Dietetic Service www.lnds.nhs.uk

Partnership NHS Trust eSource www.leicspart.nhs.uk

Nutricia Advanced Medical Nutrition www.nutricia.co.uk

British Association of Parenteral & Enteral Nutrition www.bapen.org.uk

Department of Health www.dh.gov.uk

Food Standards Agency www.food.gov.uk

National Institute for Clinical Excellence www.nice.org.uk

Coeliac UK www.coeliac.org.uk

Diabetes UK www.diabetes.org.uk

Flocare 800 Online Training www.nutriciaflocare.com

NHS National Patient Safety Agency www.npsa.nhs.uk and www.rcn.org.uk


Appendix 1: Patient Suitability Chart

Core Tube Feed Range


Product Name Contains

gluten

Contains

wheat

Contains

egg

Contains

fish

products

Contains

milk

Contains

nuts

Contains

soya

Contains

lactose

Suitable

for

vegetarians

Suitable

for

vegans

Suitable

for

Kosher

Suitable

for

Halal

Nutrison 1

2

3 3,4,8

5 6

Nutrison

Multi Fibre 1

2 3

3,4,8 5

6

Nutrison

Energy 1

2 3

3,4,8 5

6

Nutrison

Energy

Multi Fibre

1 2

3 3,4,8

5 6

Nutrison

800 Complete

Multi Fibre

1 2

3 3,4,8

5 6

Nutrison

1000 Complete

Multi Fibre

1 2

3 3,4,8

5 6

Nutrison

1200 Complete

Multi Fibre

1 2

3 3,4,8

5 6

1. To the best of our knowledge following confirmation from our suppliers, our ingredients do not contain nuts or nut products. 2. Lactose level below 300mg/kg. 3. Product not suitable as it

contains fish oil. 4. Product not suitable as vitamin D is prepared from the wool of healthy living sheep. 5. Nutricia has Kosher approval for these products. 6. These products do not have any

ingredients that are forbidden in the Halal diet; however, the manufacturing process is not observed by the relevant religious bodies so do not have official Halal status. 7. Trypsin (pork enzyme)

is used in the manufacture of the product. 8. Product not suitable as it contains milk.



Specialised Tube Feed Range



gluten

Contains

wheat

Contains

egg

Contains

fish

products

Contains

milk

Contains

nuts

Contains

soya

Contains

lactose

Suitable

for

vegetarians

Suitable

for

vegans

Suitable

for

Kosher

Suitable

for

Halal

Nutrison

Advanced

Protison

1

2 4,8

5 6

Nutrison

Protein Plus 1

2 3

3,4,8 5

6

Nutrison

Protein Plus

Multi Fibre

1 2

3 3,4,8

5 6

Nutrison Soya 1

2 4

5 6

Nutrison Soya

Multi Fibre 1

2 4

5 6

Nutrison

Concentrated 1

2 4,8

5 6

Nutrison

Low Sodium 1

2 4,8

5 6

Nutrison

Peptisorb 1

7 4,7,8

5 7

Nutrison MCT 1

2 4,8

5 6




is used in the manufacture of the product. 8. Product not suitable as it contains milk.



Core Oral Nutritional Supplements

Revised: August 2014


gluten

Contains

wheat

Contains

egg

Contains

fish

products

Contains

milk

Contains

nuts

Contains

soya

Contains

lactose

Suitable

for

vegetarians

Suitable

for

vegans

Suitable

for

Kosher

Suitable

for

Halal

Fortisip

Compact 1

8

4,8,10 5,8

6,8

Fortisip

Compact

Fibre

1 8

4,8,10 5,8

6,8

Fortisip

Compact

Protein

1 8

4,8,10 5,8

6,8

Fortisip Extra 1

8 4,8,10

5,8 6,8

Fortisip Bottle 1

2 8

4,8,10 5,8

6,8

Fortisip

Multi Fibre 1

2 8

4,10 5

6

Fortimel

Regular 1

8 4,8,10

5,8 6,8

Fortijuce 1

2 8

4,10 5

6

Fortisip

Yogurt Style 1 trace

8 4,8,10

5,8 6,8




is used in the manufacture of the product. 8. Except for those flavours which contain carminic acid. 9. These products do not contain any ingredients that are forbidden in the Kosher diet. 10.

Product now suitable as it contains milk.



Specialised Oral Nutritional Supplements

Revised: August 2014


gluten

Contains

wheat

Contains

egg

Contains

fish

products

Contains

milk

Contains

nuts

Contains

soya

Contains

lactose

Suitable

for

vegetarians

Suitable

for

vegans

Suitable

for

Kosher

Suitable

for

Halal

Calogen 1

8

8 5,8

6,8

Calogen

Extra 1

8 4,8,9

5,8 6,8

Calogen

Extra Shots 1

8 4,8,9

5,8 6,8

Renilon 7.5 1 trace

8 4,8,9

5,8

6,8

Nutricia preOp 1

2 5

6

FortiCare 1 trace

2 3

3,4,8,9 5,8

6,8

Respifor 1

8 4,8,9

5,8

6,8

Nutilis Clear 1

5 6

Nutilis Powder 1

5

6




is used in the manufacture of the product. 8. Except for those flavours which contain carminic acid. 9. Product now suitable as it contains milk.



Specialised Oral Nutritional Supplements



gluten

Contains

wheat

Contains

egg

Contains

fish

products

Contains

milk

Contains

nuts

Contains

soya

Contains

lactose

Suitable

for

vegetarians

Suitable

for

vegans

Suitable

for

Kosher

Suitable

for

Halal

Nutilis Complete

Stage 1 1

8 4,8,9

5,8 6,8

Nutilis Complete

Stage 2 1

8 4,8,9

5,8 6,8

Nutilis Fruit

Stage 3 1

2 8

4,8,9 5,8

6,8

Protifar 1

9 5

6

Polycal Powder 1

2 5

6

Polycal Liquid 1

2

5 6




is used in the manufacture of the product. 8. Except for those flavours which contain carminic acid. 9. Product now suitable as it contains milk.


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