Gastrostomy Feeding...> Frequently asked questions 9 > Accessory items 10 Enteral Nutrition Introduction This booklet aims to provide you with information about your gastrostomy feeding

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

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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

01

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

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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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Enteral Nutrition

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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Enteral Nutrition

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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Enteral Nutrition

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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Enteral Nutrition

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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Enteral Nutrition

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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Enteral Nutrition

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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Enteral Nutrition

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