Childrens Nursing Enteral Feeding Protocols · • Protocol for the use of a Kangaroo Joey Pump...

These are official Northern Trust policies and should not be

edited in any way

CHILDREN’S NURSING – ENTERAL FEEDING PROTOCOLS

• Statement & Protocol for Enteral feed/administration of medication via a balloon retained Percutaneous Endoscopic Gastrostomy (PEG) Device

• Protocol for general care and troubleshooting of a balloon retained Percutaneous Endoscopic Gastrostomy (PEG) Device

• Statement & Protocol for Enteral feed/administration of medication via a Button Gastrostomy Device

• Protocol for general care and troubleshooting of a Button Gastrostomy Device

• Statement & Protocol for Enteral feed/administration of medication via a Naso-Gastric (NG) Tube

• Protocol for general care and troubleshooting of a Naso-Gastric (NG) Tube

• Statement & Protocol for Enteral feed/administration of medication via a Percutaneous Endoscopic Gastrostomy (PEG) Device

• Protocol for general care and troubleshooting of a Percutaneous Endoscopic Gastrostomy (PEG) Device

• Protocol for the use of a Flocare Infinity Pump with Enteral Feeding System

• Protocol for the use of a Kangaroo Joey Pump with Enteral Feeding System

• Enteral Feeding Equipment List

��Ĥ��Ŧ��Ą�Ą�Ą�Ą�Ć�Ć��0�Reference Number: NHSCT/10/362

Target audience: Registered nursing staff within the paediatric nursing service

Sources of advice in relation to this document: Peter Johnston, Clinical Educator for Community Paediatrics Brenda McConville, Assistant Director Paediatrics Fiona Brown, Head of Children’s Nursing

Replaces (if appropriate): Legacy Homefirst and Causeway Trust protocols

Type of Document: Directorate Specific

Approved by: Policy, Standards and Guidelines Committee

Date Approved:18 March 2010

Date Issued by Policy Unit: 2 December 2010

NHSCT Mission Statement To provide for all the quality of services we would expect for our families

and ourselves

Aim To provide registered nurses within the paediatric nursing service:-

• With an evidence based framework for theoretical and skills based training when delegating nursing care to non registrants

• With an evidence based framework when undertaking nursing care during their day to day professional role.

Responsibilities Assistant Director The Assistant Director for Children’s and Related Services has overall responsibility for monitoring the implementation and operation of this policy. Lead Nurse The Lead Nurse in paediatrics has operational responsibility for monitoring the implementation and operation of this policy. Paediatric Clinical Educator The Paediatric Clinical Educator has responsibility for reviewing and updating the children’s nursing protocols in line with evidence based practice. Paediatric Nursing Staff The paediatric nursing staff have responsibility to familiarise themselves with the children’s nursing protocols of care and utilise them appropriately within their scope of practice. They will also be expected to support the Paediatric Clinical Educator to review protocols of care. Target Audience Registered nursing staff within the paediatric nursing service. Equality, Human Rights and DDA These protocols are purely clinical/technical in nature and will have no bearing in terms of its likely impact on equality of opportunity or good relations for people within the equality and good relations categories. Alternative formats These protocols can be made available on request on disc, larger font, Braille, audio-cassette and in other minority languages to meet the needs of those who are not fluent in English. Sources of Advice in relation to this document The Policy Author, responsible Assistant Director or Director as detailed on the policy title page should be contacted with regard to any queries on the content of this policy.

CHILDREN’S NURSING

ENTERAL FEEDING VIA A BALLOON RETAINED PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)

DEVICE

Child’s Name: DOB: / /

Statement: Type of device in use with named child: Balloon retained Percutaneous Endoscopic Gastrostomy (PEG) Type Size Fr / Gauge Gastrostomy care needs to be carried out on a daily basis. Meticulous inspection and cleansing of the gastrostomy site are essential to prevent infection, excoriation and breakdown of skin. The tube and the surrounding skin should be observed for redness, oozing, swelling, bleeding, leakage, overgranulation and excessive movement of tube. Parents will be aware of how the site normally looks at its best and can assist in assessment of the gastrostomy site. Parents should be informed of any deviation from normal and concerns documented. If a gastrostomy device has been manipulated in any manner where it is possible to cause dislodgement or the child displays any signs of tube dislodgement it must be checked using pH indicator paper prior to the device being used. The following protocols and associated competencies must be adhered

to in the care of the above child Protocol for (delete as appropriate) General care and troubleshooting of a balloon retained PEG device Enteral feed / Administration of medication via a balloon retained PEG device Use of a flocare infinity enteral feeding system Use of a kangaroo Joey enteral feeding system


PROTOCOL FOR ENTERAL FEED / ADMINISTRATION OF MEDICATION VIA A BALLOON RETAINED PERCUTANEOUS

ENDOSCOPIC GASTROSTOMY (PEG) DEVICE Child’s name: DOB: / / Storage: Unopened pre-packed enteral feeds generally do not need to be stored in a fridge and if cold should be allowed to come to room temperature before administration. However staff should follow any individual manufacturer’s guidelines regarding the storage of enteral feeds.

ACTION RATIONALE Explain to child what you are going to do

All procedures should be explained to child

Wash and dry hands and put on gloves and apron

To ensure optimum hygiene

Check expiry date of enteral feed to be administered

Enteral feeds that are out of date must NOT be administered

Check correct feed is available as directed by dietitian / doctor

Feeds should NOT be administered without a written advice sheet

Check volume to be administered To facilitate safe administration of all enteral feeds

Check time to be administered To ensure feed is given over prescribed time

Check route enteral feed to be delivered

Check position of gastrostomy device Staff should look for any evidence of dislodgement of the tube / button device:

• unusual leakage of stomach contents around site

• unusual redness or swelling around site

• parents report any vomiting since the previous feed

• abdominal distension or pain

If there is any evidence that the gastrostomy device has moved check placement of tube using ph indicator paper. (see protocol for general care and trouble shooting a balloon retained PEG device

If there are no signs of tube dislodgement staff may commence the enteral feed

Ensure external tube clamp is closed prior to attaching to gastrostomy device

To minimise air entry

ACTION RATIONALE Attach 50-30ml syringe (no plunger) and add prescribed amount of flush (cooled boiled water) as directed by dietician’s / doctor’s sheet. Open clamp to allow flush to flow Close clamp tube following flush

Where medication has been prescribed each solution may be given in individual syringes using an appropriately sized syringe (0.5, 1, 2, or 5ml syringe)

• clamp extension set

• remove 50ml syringe

• attach prepared medication syringe

• slowly give medication by depressing plunger

• clamp tube

• attach 50ml syringe (no plunger) and flush with 2 – 5mls of cooled boiled water

• repeat for each medication

stop administration if any resistance is felt or child displays any signs of discomfort Ensure external tube is clamped before removal of each syringe and released when required All medication should be correctly recorded and staff should observe for effects and side effects of all medications

Each medication must be checked against prescription sheet including Name of child Name of medication Amount of medication Method of dissolving if not in solution form Time and date of administration Time and date of last administration Expiry date of medication Only those staff who have completed their administration of medication course may give prescribed medication to a named child. Staff should be familiar with the effects and side effects of each medication they have been asked to give

Following flush immediately dispense enteral feed into syringe and allow to drain downwards. This may need repeated several times to deliver the entire feed. Bolus feeds should be given over a specified period of time usually not less than 20 minutes

In the case of a pump feed the primed giving set may be attached at this point – see protocol for use of a named enteral feeding pump To reduce the possibility of discomfort and vomiting

Child should be observed throughout feed for any signs of distress. If signs of discomfort or distress are evident the feed should be stopped immediately and reason for discomfort ascertained (e.g. speed of feed, wind etc.)

To ensure child’s comfort and prevent any complications

ACTION RATIONALE If at any point enteral feed or flush appears to be difficult to administer by gravity check child for any signs of discomfort. If child is comfortable the syringe may be held higher to increase the flow If this does not resolve the poor flow the carer can attach the plunger to the top of the 50 ml syringe to release any vacuum that has formed If this does not work stop feeding

The plunger should not be used to administer the feed but only to break any vacuum in the circuit The syringe can be lowered and raised to control the rate of flow Follow protocol for general care an troubleshooting of a balloon retained PEG device and report to parent/ CCN for advice if required

Close external clamp when end of feed reaches the bottom of the syringe

Remove used syringe/ pump giving set and attach a fresh 50 ml syringe for final flush.

To ensure effective flushing of device and prevent blockage

Add prescribed amount of cooled boiled water to syringe, release clamp and allow to drain. Close clamp before external tube fills with air.

To flush external tube fully and prevent air being taken into device at end of flush.

Observe for any leakage around site, redness or irritation

To promptly identify any problems with device and prevent skin breakdown

Dispose of gloves, apron, syringe (&pump giving set and reservoir if used) Wash and dry hands

To reduce risk of infection Syringes are for single use only and must be disposed of once used

If there are any concerns relating to administration of enteral feed , contact parent/Community Children’s Nurse/emergency services if appropriate

Record administration of feed on diet sheet To ensure parents are aware of all administration of feeds

December 2009 Signature ……………………………… Position ………………………………. Date ……………………………………. Review Date ………………………….. Signature ………………………………

Review Date ………………………….. Signature ………………………………

Review Date ………………………….. Signature ………………………………

Review Date ………………………….. Signature………………………………


COMPETENCY –ENTERAL FEED / MEDICATION ADMINISTRATION VIA A BALLOON RETAINED

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) DEVICE

Performance criteria: Knowledge The carer will be able to :

Taught Date/Sign

Competency Assessment Date/Sign

Competency Achieved

Demonstrate knowledge of correct storage of enteral feed

Discuss information required in relation to enteral feeds prior to administration

Demonstrate knowledge of equipment required for administration of enteral feeds via a gastrostomy device

Explain the checking procedure prior to administration

Explain procedure for enteral feeding via a balloon retained PEG device

Discuss steps to be taken if child vomits or complains of /exhibits discomfort during or after administration of enteral feed

Demonstrate knowledge of medications to be given if applicable

Performance Criteria Skills The carer will be able to :

Demonstrate dates

Practiced Dates

Competency Assessment

Date Demonstrate checking procedure prior to administration

Demonstrate administration of enteral feed via gastrostomy device (including preparation, checking placement, flushing and cleaning of equipment.)

Demonstrate completion of the NHSCT administration of medication course if applicable

Demonstrate completion of general care and troubleshooting of a balloon retained PEG device protocol including pH testing of gastrostomy devices

I have received training and consider myself competent in all of the above Name …………………………………. Assessor ………………………………… Signature ………………………………Signature ……………………………….

Date …………………………………… Qualifications ……………………………

Signature ………………………………… Date …………………………………...


PROTOCOL FOR GENERAL CARE AND TROUBLESHOOTING OF A BALLOON RETAINED PERCUTANEOUS

GASTROSTOMY (PEG) DEVICE Child’s Name: DOB: / / Daily care of a balloon retained PEG device

ACTION RATIONALE Wash hands and dry thoroughly prior to working with the stoma. Put on gloves and apron.

Minimise risk of infection.

Open external locking device on tube noting measurement in child’s notes.

Any change in measurements should be reported immediately to the parents / CCN.

Stoma site should be cleansed with mild soap and water, using cotton bud applicators or gauze to remove any crust and debris. Observe site for any signs of infection or dislodgement of tube

Minimise risk of infection. To identify potential and actual problems before use of device

Keep area clean and dry at all times.


Apply cream as required (as prescribed).

To reduce redness or excoriation of skin.

Apply any dressing prescribed for the child

Rotate the skin level device 360 degrees daily.

To prevent the tube and balloon from adhering to the abdominal wall.

Close external locking device ensuring that tube remains at the correct measurement recorded in the child’s notes. External locking device should be flush with the skin neither loose nor pressing into the child.

To ensure correct positioning of the device

Balloon volume is checked on a weekly basis by parents. Attaching a 5/10ml side tip syringe onto the inflation valve of the balloon gastrostomy

• Hold the tube in place to ensure it does not become dislodged

• Gently withdraw the plunger of the syringe until all the water has been withdrawn from the internal balloon

• Using fresh cooled boiled water, reinsert the recommended volume (as per manufactures instructions ) through the inflation valve to re-inflate the balloon

• Never fill the balloon with air

To prevent skin level feeding tube dislodging or being inadvertently removed and to detect any leakage. Support staff are not required to carry this procedure out but may be asked to assist the parent by holding the device in place whilst the balloon volume is checked Air will rapidly migrate from the balloon and the skin level device will become displaced.

ACTION RATIONALE If balloon volume has been checked, it is essential to check the external measurement of the device and the pH of the aspirate from the device.

Record care and report to parents/ CCN as appropriate

Ph testing of a balloon retained PEG device If on checking an enteral device prior to a feed / flush / medication administration staff suspect that the device may have become dislodged it must be checked to ensure correct placement. If an enteral device has been manipulated in any way such as being replaced or a retention balloon being checked it must be checked to ensure correct placement. If during a feed staff suspect that there is any dislodgement of the enteral device they must stop and check to ensure correct placement

ACTION RATIONALE Explain procedure to child reassure throughout.

Instil confidence.

Gather equipment Wash and dry hands and put on gloves and apron

Ensure external tube is clamped prior to procedure

To minimise air entry when checking placement of device

Attach a 50-30ml syringe to external tube. Release clamp and withdraw a small amount of gastric contents.

It may be necessary to discard the first 2 -5 mls of aspirate as this may only be flush remaining in the tube from the previous feed

Clamp extension device and remove syringe

Place a small amount of gastric contents onto pH indicator paper and observe reaction. pH must be 5 or below for feed to commence

To check that device is in correct position prior to feed

If the pH is 6 or above the feed must not be given and an appropriate member of staff / parents must be called for assistance

Tube may not be in child’s stomach

Potential problems Carers should be aware of potential problems and be confident in procedures to follow in the event of:

• Tube blocking

• Leakage around stoma

• Over-granulation of gastrostomy site

• Vomiting

• Dislodgement of tube

• Excess wind

NB: Report and record any vomiting, diarrhoea, constipation,

abdominal swelling, cramps, nausea, dehydration, weight loss, weight gain. The above factors may indicate the need to alter child’s feeding regime

Enteral tube Blocking:

• Do not use excessive force when attempting to unblock an enteral tube. This has the potential to damage the tube and increase the risk of administering the feed in the wrong place.

• Do not attempt to unblock the tube using sharp instruments.

• Blockage may be caused by inadequate flushing or a burst balloon.


To reassure child and gain consent


To maintain optimum standards of hygiene

Ensure all clamps are open and there are no ‘kinks’ in tubing.

Use a 30/50ml syringe to attempt gentle flushing (at least 10mls of warm water) Push/pull technique to instil.

Smaller size syringe may damage the tube. Water used should have been previously boiled

Gently squeeze the extension set between fingers and along its length (milking the tube).

To dislodge blockage.

If blockage persists, very gently draw back on the syringe and attempt to flush as before.

As above

Always flush tube with water before and following feeds, and medications.

To prevent blockage

Ensure tube is clamped following above. Remove gloves and apron and wash and dry hands.

If this does not resolve the blockage report to CCN and record

Device may need replaced

Leakage around Stoma: Possible causes:

• Balloon deflation

• Stoma site too large

• Delayed gastric emptying

• Constipation

If leakage is persistent medical advice should be sought

ACTION

RATIONALE

Test leakage with ph indicator. Gastric contents will give an acid reaction i.e. reading should be 5 or less

Refer to parents/CCN to establish if this is routine for child

Some leakage may be considered usual for the named child

If leakage is unusual for the child report to parents/ CCN and do not progress with feed / flush or medication

This may indicate damage to the tube and it may need replaced This may indicate a change in the child’s condition requiring further assessment

Ensure leakage is cleaned as per general care of the device reapplying any dressing

To prevent skin damage

Record care and report to parents/ CCN as required

Over-granulation of Gastrostomy Site Possible Causes

• Insufficient rotation of the tube

• Friction around the stoma

• Tube dragging downwards Indications are:

• Overgrowth of pink, bleeding, ‘cauliflower’-like moist tissue from stoma

ACTION RATIONALE Keep stoma site dry and clean and ensure gentle handling of tube.

To prevent overgranulation and bleeding from site.

Ensure there is no excessive pull/tension on feeding tube by clothing, straps or giving set.

To prevent friction, excessive tension and possible leakage.

Swab site-if granulation tissue is present.

For bacterial/fungal presence.

Absorbent dressing can be applied (if prescribed)

Helps to compress overgranulation and control excessive moisture.

Administer medication as prescribed To promote healing. Record care and report as required to parents/CCN

Vomiting

ACTION RATIONALE If vomiting has occurred prior to a feed do not commence until pH reading has been checked

If child vomits during feed stop the feed immediately

To minimise risk of further vomiting.

Ensure child is in the upright position and well supported when vomiting. Stay with child.

To help prevent aspiration To assess, comfort and reassure child.

Ensure child is washed and clothes changed as required

To prevent skin damage and ensure comfort of child

If vomiting stops and child remains settled recommence feed as appropriate. If vomiting continues DO NOT RESTART FEED. Contact parents / CCN as rate of feed may need adjusted

To gain further advice.

Record care and report as required to parents / CCN

Balloon retained PEG device falls out Possible causes

• Balloon bursts / deflates

• Child pulls out tube

Support carers are not routinely trained to replace a dislodged enteral device and should immediately seek an appropriately trained person:-

Parents / CCN / A&E / children’s ward

Action:

• Cover site with sterile gauze or if tube not fully dislodged secure with tape and then cover with gauze.

• Contact parents/community children’s nurse immediately

• If parents or Community Children’s Nurse cannot be contacted TAKE CHILD TO HOSPITAL WITH SPARE BALLOON RETAINED PEG DEVICCE INSERTION.

NB: AVOID DELAY AS STOMA SITE MAY BEGIN TO CLOSE WITHIN 20

MINUTES. If you are concerned at any time contact the parent or Community Children’s Nurse

Venting of excess wind Children with gastrostomy devices can suffer from trapped wind which may need released by the carer. Signs of trapped wind may be slight abdominal distension or signs of discomfort. The carer should seek the advice of the parent as to what is normal for the child as these may also indicate other problems with an enteral tube. To release wind the carer should follow the protocol for administering an enteral flush but not insert any water into the 30/50ml syringe rather allowing any trapped wind to escape for 1- 2 minutes and then clamping the external tube. If this does not resolve the child’s difficulty the parent / CCN should be contacted

December 2009 Signature ……………………………… Position ………………………………. Date …………………………………… Review Date ……………………………. Signature …………………………… Review Date ……………………………. Signature …………………………… Review Date ……………………………. Signature ……………………………


COMPETENCY – GENERAL CARE AND TROUBLESHOOTING OF A BALLOON RETAINED PERCUTANEOUS

GASTROSTOMY (PEG) DEVICE Child’s Name: DOB: / / Type of device in use with above child Performance Criteria Knowledge The carer will be able to :

Taught Date/Sign


Competency Achieved

Discuss why child needs a gastrostomy and the type of tube in position

Discuss the procedure for cleaning the gastrostomy site and the frequency with which this intervention should be undertaken

Discuss the observations to be undertaken when caring for the gastrostomy site including measurement of external tube

Discuss the rationale for rotating the enteral feeding device

Discuss the procedure and precautions that should be taken when assisting checking the balloon volume

Discuss the potential problems associated with enteral devices

Discuss the steps to be taken in the event of dislodgement of tube


Demonstrate dates

Practiced Dates


Date Identify a healthy looking stoma

Demonstrate daily care of gastrostomy site including care of external locking device

Demonstrate ‘rotating’ the enteral feeding device

Demonstrate assisting with checking balloon volume if applicable

Demonstrate venting of excess wind if appropriate

Demonstrate correct recording of care and reporting as appropriate

I have received training and consider myself competent in all of the above Name ……………………………… Assessor …………………………………… Signature ………………………… Qualifications ……………………………… Date …………………………. Signature ………………………………… Date ……………………………………….


ENTERAL FEEDING VIA A BUTTON GASTROSOTOMY DEVICE


Statement: Type of device in use with named child: Size Fr / Gauge Gastrostomy care needs to be carried out on a daily basis. Meticulous inspection and cleansing of the gastrostomy site are essential to prevent infection, excoriation and breakdown of skin. The tube/ button and the surrounding skin should be observed for redness, oozing, swelling, bleeding, leakage, overgranulation and excessive movement of tube. Parents will be aware of how the site normally looks at its best and can assist in assessment of the gastrostomy site. Parents should be informed of any deviation from normal and concerns documented. If a gastrostomy device has been manipulated in any manner where it is possible to cause dislodgement or the child displays any signs of tube dislodgement it must be checked using pH indicator paper prior to the device being used. The following protocols and associated competencies must be adhered

to in the care of the above child Protocol for (delete as appropriate) General care and troubleshooting of a button gastrostomy device Enteral feed / Administration of medication via a button gastrostomy device Use of a flocare infinity enteral feeding system Use of a kangaroo Joey enteral feeding system


PROTOCOL FOR ENTERAL FEED / ADMINISTRATION OF

MEDICATION VIA A BUTTON GASTROSTOMY DEVICE Child’s name: DOB: / /

Storage: Unopened pre-packed enteral feeds generally do not need to be stored in a fridge and if cold should be allowed to come to room temperature before administration. However staff should follow any individual manufacturer’s guidelines regarding the storage of enteral feeds.




to ensure optimum hygiene standards



Check correct feed is available as directed by dietitian/ doctor





Check position of button gastrostomy device Staff should look for any evidence of dislodgement of the tube / button device:

• device may be visibly dislodged





If there is any evidence that the button gastrostomy device has moved check placement of tube using ph indicator paper. (see Protocol for general care and troubleshooting of a button gastrostomy device)

If there are no signs of tube dislodgement or placement has been confirmed by pH testing staff may commence the enteral feed

ACTION RATIONALE Prime enteral feed extension set with cooled boiled water

To reduce air entry and begin flush of system

Ensure extension set is clamped prior to attaching to gastrostomy device

Attach the primed and clamped extension set the button gastrostomy device by lining up the marks on the extension tube and the device. Ensure the extension tube is securely ‘locked’ in place by turning tube until resistance is felt

To prevent leakage at device site

Attach 50-30ml syringe (no plunger) and add prescribed amount of flush (cooled boiled water) as directed according to dietician’s / doctor’s sheet. Open clamp to allow flush to flow Clamp extension tube following flush






• clamp tube





Following flush immediately dispense enteral feed into syringe and allow to drain downwards. This may need repeated several times to deliver the entire feed. In the case of a pump feed the primed giving set may be attached at this point Bolus feeds should be given over a period of time usually not less than 20 minutes

In the case of a pump feed the primed giving set may be attached at this point – see protocol for use of a named enteral feeding pump

ACTION RATIONALE

Child should be observed throughout feed for any signs of distress. If signs of discomfort or distress evident the feed should be stopped immediately and reason for discomfort ascertained (e.g. speed of feed, wind etc.)


If at any point enteral feed or flush appears to be difficult to administer by gravity check child for any signs of discomfort. If child is comfortable the syringe may be held higher to increase the flow If this does not resolve the poor flow the carer can attach the plunger to the top of the 50 ml syringe to release any vacuum that has formed If this does not work stop feeding

The plunger should not be used to administer the feed but only to break any vacuum in the circuit The syringe can be lowered and raised to control the rate of flow Follow protocol for general care and troubleshooting of a button gastrostomy device and report to parent/ CCN for advice if required

Clamp extension set when end of feed reaches the bottom of the syringe or pump feed is completed

Remove used syringe/ pump giving set and attach a fresh 50 ml syringe for final flush .


Add prescribed amount of cooled boiled water to syringe, release clamp and allow to drain. Close clamp before extension tube fills with air. Detach extension set and close cap on gastrostomy device.

To flush device fully and prevent air taken into device at end of flush



Wash extension set in warm soapy water. Rinse and air dry, store in box in fridge ready for next feed. Dispose of gloves, apron, syringe (&pump giving set and reservoir if used) Wash and dry hands




December 2009

Signature …………………………………………………. Position …………………………………………………... Date ……………………………………………………….. Review Date ………………… Signature …………………………………………

Review Date …………………Signature …………………………………………




COMPETENCY – ENTERAL FEED / ADMINISTRATION OF MEDICATION VIA A BUTTON GASTROSTOMY DEVICE

Performance criteria: Knowledge The carer will be able to :

Taught Date/Sign


Competency Achieved



Demonstrate knowledge of equipment required for administration of enteral feeds via a button gastrostomy device


Explain procedure for enteral feeding via a button gastrostomy device

Discuss steps to be taken if child vomits or complains of /exhibits discomfort during or after administration of enteral feed


Demonstrate dates

Practiced Dates



Demonstrate administration of enteral feed via button gastrostomy device (including preparation, checking placement, flushing and cleaning of equipment.)


Demonstrate completion of general care and troubleshooting a button gastrostomy device protocol including pH testing of gastrostomy devices

I have received training and consider myself competent in all of the above Name …………………………………. Assessor ………………………………… Signature …………………………….. Qualifications…………………………..… Date …………………………………… Signature……………………………….. Date ………………………………….…


PROTOCOL FOR GENERAL CARE AND TROUBLESHOOTING

OF A BUTTON GASTROSTOMY DEVICE

Child’s Name:

DOB: / /

Daily care of Button Gastrostomy site



Stoma site should be cleansed with mild soap and cooled boiled water, using cotton bud applicators or guaze to remove any crust and debris. Observe site for any signs of infection or dislodgement of device









ACTION RATIONALE Balloon volume should be checked on a weekly basis by parents or Community Children’s Nurse. Attaching a 5/10ml side tip syringe onto the inflation valve of the button device

• Hold the button in place to ensure it does not become dislodged

• Gently withdraw the plunger of the syringe until all the water has been withdrawn from the internal balloon

• Using fresh cooled boiled water, reinsert the recommended volume (as per manufactures instructions ) through the inflation valve to re-inflate the balloon

• Never fill the balloon with air

To prevent device dislodging or being inadvertently removed and to detect any leakage. Support staff are not required to carry this procedure out but may be asked to assist the parent by holding the device in place whilst the balloon volume is checked Air will rapidly migrate from the balloon and the skin level device will become displaced.

If balloon volume has been checked, it is essential to check the position of the button device.

Record care and report to parents/ CCN as appropriate

Ph Testing of Button Gastrostomy Device

Ensure extension set is clamped prior to procedure


Attach a clamped extension set to button device by lining up the marks on the extension tube and the device. Ensure the extension tube is securely ‘locked’ in place by turning tube until resistance is felt

To prevent leakage at device site

Attach a 50-30ml syringe to extension set. Release clamp and withdraw a small amount of gastric contents. It is not necessary to fill the extension set with gastric contents as only a small amount is needed to check placement of device.

Clamp extension set and remove from device ensuring cap is replaced

Place a small amount of gastric contents onto pH indicator paper and observe reaction. pH must be 5.0 or below for feed to commence

To check that device is in correct position prior to feed – Current indicator paper does not allow for a result of 5.5 to be observed




• Device blocking

• Leakage around stoma site

• Over-granulation of button gastrostomy site

• Vomiting

• Dislodgement of device

• Excess wind NB: Report and record any vomiting, diarrhoea, constipation,


Button Gastrostomy Device Blocking:

• Do not use excessive force when attempting to unblock an enteral device. This has the potential to damage the device and increase the risk of administering the feed in the wrong place.

• Do not attempt to unblock the device using sharp instruments.


ACTION RATIONALE Ensure all clamps are open and there are no ‘kinks’ in extension tubing.

Use a 30/50ml syringe to attempt gentle flushing at least 10mls of warm water(Previously boiled and cooled) Push/pull technique to instil.


Gently squeeze the extension set between fingers and along its length (milking the tube).



As above

Always flush tube with water before and following feeds, and medications.

To prevent blockage



Leakage around Stoma Site: Possible causes:

• Balloon deflation



• Constipation


ACTION

RATIONALE





This may indicate damage to the device and it may need replaced This may indicate a change in the child’s condition requiring further assessment




Over-granulation of Button Gastrostomy Site Possible Causes

• Insufficient rotation of the device


• Extension tube dragging downwards Indications are:




Ensure there is no excessive pull/tension on extension tube by clothing, straps or giving set.




Absorbent dressing can be applied on prescription.



Vomiting








If vomiting stops and child remains settled recommence feed as appropriate. If vomiting continues DO NOT RESTART FEED. Contact parents/CCN as rate of feed may need adjusted



Button Gastrostomy Device Falls Out Possible causes

• Balloon bursts / deflates

• Child pulls out tube Support carers are not routinely trained to replace a dislodged enteral device and should immediately seek an appropriately trained person:- Parents / CCN / A&E / children’s ward

Action:

• Cover site with sterile gauze or if button device not fully dislodged secure with tape and then cover with gauze.


• If parents or Community Children’s Nurse cannot be contacted TAKE CHILD TO HOSPITAL WITH SPARE BUTTON DEVICE FOR INSERTION.



Venting of excess wind

Children with gastrostomy devices can suffer from trapped wind which may need released by the carer. Signs of trapped wind may be slight abdominal distension or general signs of discomfort in the child. The carer should seek the advice of the parent as to what is normal for the child as discomfort may also indicate other problems with an enteral tube. To release wind the carer should follow the protocol for administering an enteral flush but not insert any water into the 30/50ml syringe rather allowing any trapped wind to escape for 1- 2 minutes and then clamping the extension tube If this does not resolve the child’s difficulty the parent / CCN should be contacted

December 2009 Signature ……………………………… Position ………………………………. Date ………………………………….. Review Date …………………… Signature …………………………… Review Date …………………… Signature …………………………… Review Date …………………… Signature ……………………………


COMPETENCY – GENERAL CARE AND TROUBLESHOOTING OF A BUTTON GASTROSTOMY DEVICE

Child’s Name:

DOB: / /

Type of device in use with above child

Performance Criteria Knowledge The carer will be able to :

Taught Date/Sign


Competency Achieved

Discuss why child needs a button gastrostomy and the type of tube in position


Discuss the observations to be undertaken when caring for the gastrostomy site

Discuss the rationale for rotating the button device

Discuss the procedure and precautions that should be taken when assisting checking the balloon volume.

Discuss the potential problems associated with button gastrostomy devices

Discuss the steps to be taken in the event of dislodgement of DEVICE


Demonstrate dates

Practiced Dates



Demonstrate care of gastrostomy site

Demonstrate ‘rotating’ the button gastrostomy device

Demonstrate assisting with checking balloon volume



I have received training and consider myself competent in all of the above Name ……………………………… Assessor …………………………………… Signature ………………………… Qualifications ……………………………… Date …………………………. Signature ………………………………… Date ……………………………………..


ENTERAL FEEDING VIA A NASOGASTRIC (NG) TUBE


Statement: Type of device in use Guide wire Length Fr / gauge External measurement Carers must carry out meticulous routine care of a child with a nasogastric tube in order to prevent potentially life threatening complications such as aspiration of enteral feed. However routine care of the insertion site is also important to ensure that skin integrity is maintained and to reduce the likelihood of non compliance from the child or family. All ng tubes must be checked for correct positioning in the stomach on each use, without exception NB: Report any vomiting, diarrhoea, constipation, abdominal swelling,

cramps, nausea, dehydration, weight loss or weight gain. The above factors may indicate the need to alter child’s feeding regime. The following protocols and associated competencies must be adhered

to in the care of the above child Protocol for (delete as appropriate) General care and troubleshooting of a Nasogastric tube Enteral feed / Administration of medication via a nasogastric tube Use of a flocare infinity enteral feeding pump Use of a kangaroo Joey enteral feeding pump


PROTOCOL FOR ENTERAL FEED / ADMINISTRATION OF

MEDICATION VIA A NASO-GASTRIC (NG) TUBE Child’s Name: DOB: / /

Storage: Unopened pre-packed enteral feeds generally do not need to be stored in a fridge and if cold should be allowed to come to room temperature before administration. However staff should follow any individual manufacturer’s guidelines regarding the storage of enteral feeds.

ACTION

RATIONALE

Explain to child that you are going to give him/her a feed

Child has the right to be prepared

Position child upright in chair or as he/she wishes, with head above the level of the stomach

To prevent aspiration

Wash hands thoroughly, dry them and put on a plastic apron and gloves

To minimise the risk of infection

Inspect skin surrounding nose for any redness, excoriation and ensure ng remains securely applied

Refer to protocol for general care and trouble shoot of enteral feeding device (nasogastric tube)

Measure external length of tube and check against records


Check time feed is to be administered To ensure feed is given over prescribed time

Check correct feed is available as directed by dietitian / doctor.


Check expiry date of feed. Ensure feed is at room temperature. Shake feed prior to use.

To ensure feed has not expired and to prepare feed for administration

ACTION RATIONALE

Ensure naso-gastric tube is in stomach Connect a 50ml syringe to the end of the naso-gastric tube Gently withdraw the plunger until fluid appears in the syringe (only a small amount ½ -1ml) is required Disconnect the syringe and close end of naso-gastric tube Put contents of the syringe on to the testing part of the PH indicator paper PH aspirate reading should be 5 or less If PH aspirate is 6 or above refer to trouble shooting advice. DO NOT FEED If no aspirate obtained try re-positioning the child and aspirating the tube again. If still no fluid can be withdrawn and if appropriate give child a small amount of water, juice or milk (approx 5mls) orally and then aspirate the tube again.

NB There are high-risk children who cannot receive oral fluids under any circumstances. The above direction must be undertaken on a child specific basis only and as directed by a Community Children’s Nurse

If it is still not possible to obtain aspirate contact parent or community children’s nurse- DO NOT FEED CHILD

Safety – to ensure correct placement

of naso-gastric tube

To ensure that the fluid originates from the stomach and the tube is correctly positioned This step must only be carried out following assessment by the CCN

Following aspiration and confirmation of tube position, record PH value and external length of tube on naso-gastric recording sheet

Attach 30/50ml syringe to naso-gastric tube without plunger Pour in the prescribed amount of cooled boiled water

Allow to flow slowly by gravity down the tube

To ensure naso-gastric tube is not blocked and to maintain patency

ACTION RATIONALE Prescribed medication may now be given using gravity feed technique clamp extension set

• Place prescribed medication into 50 ml syringe

• and flush with prescribed amount of cooed boiled water



Each medication must be checked against prescription sheet including Name of child Name of medication Amount of medication Method of dissolving if not in solution form Time and date of administration Time and date of last administration Expiry date of medication Only those staff who have completed their administration of medication course may give prescribed medication to a named child and staff should be familiar with the effects and side effects of each medication they have been asked to give

Immediately following flush, dispense enteral feed into syringe and allow to

drain downwards. This may need to be repeated several times to deliver the

entire feed.

Bolus feeds should be given over a specified period of time usually not less than 20 minutes

In the case of a pump feed the

primed giving set may be attached

at this point – see protocol for use

of a named enteral feeding pump

To reduce the possibility of

discomfort and vomiting

If at any time throughout the procedure, the child appears distressed, has difficulty breathing, becomes blue, remove the nasogastric tube by removing tape, grip tube between finger and thumb near nasal area and quickly pull out.

To minimise risk of aspiration Refer to protocol for general care and trouble shoot of enteral feeding device (nasogastric tube)

ACTION RATIONALE

If at any point the enteral feed or flush appears to be difficult to administer by gravity check the child for any signs of discomfort

If the child is comfortable the syringe may be held higher to increase the flow If this does not resolve the poor flow the carer can attach the plunger to the top of the 50ml syringe to release any vacuum that has formed If this does not work stop feeding

The higher the tube is raised, the faster the flow rate

Follow protocol for general care and

troubleshooting of a ng tube and

report to parent / CCN for advice if

required

When feed is complete, flush the feeding tube with the prescribed amount of cooled boiled water. Close off end of feeding tube

To maintain patency of tube

To prevent leakage

Praise child following procedure

Where possible, child should remain seated approximately 15-20 minutes following a feed

To minimise the risk of vomiting

Dispose of syringes, gloves and aprons Wash and dry hands N.B. Syringes are for single use only and must be disposed of once used

To reduce risk of infection

December 2009 Signature ……………………………………………………….. Position ……………………………………………………….... Date …………………………………………………………….. Review Date …………………………… Signature …………………………… Review Date …………………………… Signature …………………………… Review Date …………………………… Signature ……………………………


COMPETENCY – FOR ENTERAL FEED / ADMINISTRATION OF MEDICATION VIA A NASO-GASTRIC TUBE


Performance Criteria Knowledge The carer will be able to :

Taught Date/Sign


Competency Achieved

Discuss the potential risks of nasogastric feeding

Discuss the reasons for the named child to receive enteral feeds

Discuss knowledge of correct storage of enteral feeds

Demonstrate knowledge of equipment required for named child

Explain the observations to be made of the insertion site of the ng tube

Demonstrate knowledge of the correct procedure for obtaining and recording an aspirate

Discuss the steps to be taken in the event of the child experiencing distress

Discuss the events that would lead to removal of an ng tube and the technique of removal



Taught Date/Sign


Competency Achieved

Demonstrate preparation of the child.

Demonstrate preparation of equipment and checking of prescription / feed to be administered

Demonstrate checking of naso-gastric tube placement.

Demonstrate feeding procedure. Demonstrate completion of the NHSCT administration of medications course if applicable

Demonstrate the removal of an NG tube (may be simulated practice)

Demonstrate disposal of waste. Cleaning and storage of equipment.

Demonstrate correct recording and reporting of care as appropriate

I have received training and consider myself competent in all of the above Name: ……………………… Assessor: ………………………..

Signature/ Date: …………… Qualifications: ……………………….

Signature/Date: ………………..


PROTOCOL FOR GENERAL CARE AND TROUBLESHOOING OF A NASOGASTRIC (NG) TUBE

Child’s Name: DOB: / / Type of device in use with named child All ng tubes must be checked for correct positioning in the stomach on each use, without exception NB: Report any vomiting, diarrhoea, constipation, abdominal swelling,

cramps, nausea, dehydration, weight loss or weight gain. The above factors may indicate the need to alter child’s feeding regime. General care of nasogastric tube

ACTION RATIONALE Explain to the child what you are going to do

To reassure child and gain compliance

Gather equipment as required

Wash and dry hands and put on apron

To minimise risk of infection transmission

Check child’s notes for measurement of ng tube

To ensure tube has not moved since last check

Check actual measurement of tube at opening of nostril and record

Change in measurement may indicate a change in the position of the tube – report to parents / CCN for advice

Check any securing tape around nose and face and replace if required

If tape needs replacing it is advisable to have two people to carry this out One person to hold the child comfortably whilst holding the tube in position The other person to remove old tape, wash and dry skin beneath and then renew tape

Wash face carefully with warm soap and water and ensure face is carefully dried

Observe and report any skin redness, breakdown to parents and CCN

The area around the nose is particularly prone to skin breakdown and must be observed regularly to allow early intervention

ACTION RATIONALE Apply any prescribed cream and record same

It may be necessary to tuck a tube that is not in immediate use into the back of the child’s clothes. Ensure that tube is not pressing into child whilst sitting or lying Ensure that child can comfortably move their head and neck without pulling on the tube

To reduce risk of entanglement in tube To minimise the risk of pressure damage to child’s skin from tube To reduce risk of causing child discomfort and accidental dislodgement of tube

Following general care / feed / medication dispose of used equipment , remove apron and gloves, wash and dry hands

Record above in nasogastric record sheet and notes as appropriate Report any concerns to parents / CCN

Removal of a nasogastric tube

ACTION RATIONALE Constant observation must be maintained of child during feed. If at any time during naso-gastric feed the child becomes blue or has difficulty breathing, stop the feed immediately

The biggest risk of naso-gastric feeding is the tube becoming misplaced. This can cause the feed to be delivered into the lungs or the feed to be aspirated.

Removing tape, grip tube between finger and thumb near nasal area and quickly pull out.

To minimise risk of aspiration

If the child does not quickly recover suction may be required if prescribed and emergency help summoned

To observe child’s progress and maintain safety.

Contact parents / CCN when appropriate and document in notes

To ensure communication and to arrange for replacement of tube as appropriate

Naso-Gastric Tube Blocking Blocking may be caused by inadequate flushing. Attempting to unblock a ng tube must only be carried out if the tubes position has been confirmed by aspiration – you may not attempt to unblock a tube in any other circumstances. Do not use excessive force when attempting to unblock a naso-gastric tube. This has the potential to damage the tube and increase the risk of administering the feed into the wrong place. Do not attempt to unblock the naso-gastric tube using sharp instruments. Contact parent/Community Children’s Nurse to ensure spare replacement tube is delivered.

ACTION RATIONALE

Ensure all clamps are open and there are no “kinks” in tubing.

To allow feed to flow freely.

Use a 30/50ml syringe to attempt gentle flushing (at least 10mls of warm water) using push / pull technique

Smaller size syringe may damage the tube.

Gently squeeze the extension set between fingers and along it’s length (milking the tube).


If blockage persists, very gently draw-back on the syringe and attempt to flush as before.


If still unable to dislodge blockage, remove tube and ensure child is not showing any signs of respiratory distress contact the CCN/ parents for replacement of tube If the child is showing any signs of respiratory distress it must be removed immediately Remove any securing tape Grip the tube between finger and thumb near nasal opening and smoothly remove.

Only trained persons may replace an ng tube

Naso-gastric tubes must be flushed before and after a feed. During continuous feeding or when not in use, tubes must be flushed regularly (eg) every 4 hours during daytime.

To maintain patency and prevent blockage of naso-gastric tube.

Vomiting

Vomiting can be caused by migration of the tube to the small intestine as well as by general illness. Staff should be aware that the act of vomiting may itself cause a tube to migrate away from the stomach and the device must be aspirated before use and may need removed

ACTION RATIONALE Ensure feed is not given too fast. To decrease risk of vomiting.

Administration of the feed should take the same length of time as it would take a similar age child to have the same amount orally – usually 15-30 minutes.

Ensure child is positioned with his/her head above the level of the stomach.

To prevent aspiration and vomiting.

Ensure naso-gastric tube is correctly fitted and secured.

To ensure naso-gastric tube does not migrate into the small intestine. This may cause diarrhoea/vomiting or intestinal obstruction.

December 2009

Venting of excess wind Children with ng tubes can suffer from trapped wind which may need released by the carer. Signs of trapped wind may be slight abdominal distension or signs of discomfort. The carer should seek the advice of the parent as to what is normal for the child as these may also indicate other problems with a nasogastric tube. To release wind the carer should follow the protocol for administering an enteral feed but not insert any water into the 30/50ml syringe rather allowing any trapped wind to escape for 1- 2 minutes and then removing the syringe and closing end of ng tube. If this does not resolve the child’s difficulty the parent / CCN should be contacted. Signature ……………………………… Position …………………………….. Date …………………………………. Review Date …………………… Signature ……………………………………… Review Date …………………… Signature ……………………………………… Review Date …………………… Signature ………………………………………


COMPETENCY – FOR GENERAL CARE AND TROUBLESHOOING OF AN ENTERAL FEEDING DEVICE

(Nasogastric tube)

Performance Criteria Knowledge

The Carer will be able to:

Taught Date/Sign


Competency Achieved

Discuss why the child needs an ng tube

Discuss the procedure for general cleaning of the insertion site

Discuss the observation of the child’s skin around the insertion site

Discuss the importance of recording position of tube and condition of skin

Discuss the correct reporting method in the event of any difficulties

Discuss the steps to follow in the event of Misplacement of tube Dislodgement of tube Blocking of tube Vomiting Excess wind

Discuss the possible symptoms that may lead to a child’s feed regime being changed

Discuss the risks associated with ng feeding

Discuss infection control measures required and their relevance to care

Discuss the relevance of pH testing of aspirate and when this should be carried out

Performance Criteria Skills

The Carer will be able to:

Taught Date/Sign


Competency Achieved

Demonstrate collection of equipment required to carry out general care of ng tube and insertion site

Demonstrate infection control measures taken during procedure

Demonstrate observation to be made of ng tube and skin surrounding insertion site

Demonstrate routine care of ng tube and insertion site

Demonstrate changing of securing tapes in use with child

Demonstrate removal of ng tube and venting of excess wind (simulated practice if applicable)

Demonstrate correct recording of care and appropriate reporting

I have received training and consider myself competent in all of the above Name …………………………………Assessor …………………………………… Signature ……………………………Qualifications ……………………………… Date …………………………. Signature ………………………………… Date ……………………………………..


ENTERAL FEEDING VIA A PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) DEVICE


Statement: Type of device in use with named child: Percutaneous Endoscopic Gastrostomy (PEG) Type Size Fr / Gauge Gastrostomy care needs to be carried out on a daily basis. Meticulous inspection and cleansing of the gastrostomy site are essential to prevent infection, excoriation and breakdown of skin. The tube and the surrounding skin should be observed for redness, oozing, swelling, bleeding, leakage, overgranulation and excessive movement of tube. Parents will be aware of how the site normally looks at its best and can assist in assessment of the gastrostomy site. Parents should be informed of any deviation from normal and concerns documented. If a gastrostomy device has been manipulated in any manner where it is possible to cause dislodgement or the child displays any signs of tube dislodgement it must be checked using pH indicator paper prior to the device being used. The following protocols and associated competencies must be adhered

to in the care of the above child Protocol for (delete as appropriate) General care and troubleshooting of a PEG device Enteral feed / Administration of medication via a PEG device Use of a flocare infinity enteral feeding system Use of a kangaroo Joey enteral feeding system


PROTOCOL FOR ENTERAL FEED / ADMINISTRATION OF MEDICATION ADMINISTRATION VIA A PERCUTANEOUS

ENDOSCOPIC GASTROSTOMY DEVICE (PEG) Child’s name: DOB: / / Storage: Unopened pre-packed enteral feeds generally do not need to be stored in a fridge and if cold should be allowed to come to room temperature before administration. However staff should follow any individual manufacturer’s guidelines regarding the storage of enteral feeds.




To ensure optimum hygiene standards



Check correct feed is available as directed by dietitian / doctor





Check position of gastrostomy device Staff should look for any evidence of dislodgement of the tube / button device:





If there is any evidence that the gastrostomy device has moved check placement of tube using ph indicator paper. (see protocol for general care and trouble shooting a PEG device)

If there are no signs of tube dislodgement staff may commence the enteral feed

Ensure external tube clamp is closed prior to attaching to gastrostomy device

To minimise air entry

ACTION RATIONALE Attach 50-30ml syringe (no plunger) and add prescribed amount of cooled boiled of flush (cooled boiled water) as directed according to dietician’s doctor’s sheet. Open clamp to allow flush to flow Close clamp following flush.






• clamp tube





Following flush immediately dispense enteral feed into syringe and allow to drain downwards. This may need repeated several times to deliver the entire feed. Bolus feeds should be given over a specified period of time usually not less than 20 minutes

In the case of a pump feed the primed giving set may be attached at this point – see protocol for use of a named enteral feeding pump To reduce the possibility of discomfort and vomiting

Child should be observed throughout feed for any signs of distress. If signs of discomfort / distress evident the feed should be stopped immediately and reason for discomfort ascertained (e.g. speed of feed, wind etc.)


ACTION RATIONALE If at any point enteral feed or flush appears to be difficult to administer by gravity check child for any signs of discomfort. If child is comfortable the syringe may be held higher to increase the flow If this does not resolve the poor flow the carer can attach the plunger to the top of the 50 ml syringe to release any vacuum that has formed If this does not work stop feeding

The plunger should not be used to administer the feed but only to break any vacuum in the circuit The syringe can be lowered and raised to control the rate of flow Follow protocol for general care and troubleshooting of an a PEG device and report to parent/ CCN for advice if required

Close external clamp when end of feed reaches the bottom of the syringe

Remove used syringe/ pump giving set and attach a fresh 50 ml syringe for final flush.


Add prescribed amount of cooled boiled water to syringe, release clamp and allow to drain. Close clamp before extension tube filled with air.

To flush device fully and prevent air taken into device at end of flush



Dispose of gloves, apron, syringe (&pump giving set and reservoir if used) Wash and dry hands




December 2009 Signature …………………………………………………. Position ………………………………………………..…. Date …………………………………………………….…. Review Date …………………… Signature ………………………………………

Review Date …………………… Signature ………………………………………




COMPETENCY –ENTERAL FEED / ADMINISTRATION OF MEDICATION VIA A PERCUTANEOUS ENDOSCOPIC

GASTROSTOMY DEVICE (PEG) Performance criteria: Knowledge The carer will be able to :

Taught Date/Sign


Competency Achieved



Demonstrate knowledge of equipment required for administration of enteral feeds via a gastrostomy device


Explain procedure for enteral feeding via a PEG device

Discuss steps to betaken if child vomits or complains of /exhibits discomfort during or after administration of enteral feed



Demonstrate dates

Practiced Dates



Demonstrate administration of enteral feed via gastrostomy device (including preparation, checking placement, flushing and cleaning of equipment.)


Demonstrate completion of general care and troubleshooting of a PEG device protocol including pH testing of gastrostomy devices

I have received training and consider myself competent in all of the above Name ………………………………… Assessor ………………………………..… Signature …………………………… Qualifications ……………………………… Date …………………………………. Signature ………………………………..… Date ……………………………………….


PROTOCOL FOR GENERAL CARE AND TROUBLESHOOTING

OF A PERCUTANEOUS GASTROSTOMY (PEG) DEVICE Child’s Name: DOB: / / Daily care of a balloon retained PEG device



Open external locking device on tube noting measurement in child’s notes.

Stoma site should be cleansed with mild soap and water, using cotton bud applicators or gauze to remove any crust and debris. Observe site for any signs of infection or dislodgement of tube









Close external locking device ensuring that tube remains at the correct measurement recorded in the child’s notes. External locking device should be flush with the skin neither loose nor pressing into the child.

To ensure correct positioning of the device

Ph testing of a PEG device If on checking an enteral device prior to a feed / flush / medication administration staff suspect that the device may have become dislodged it must be checked to ensure correct placement. If an enteral device has been manipulated in any way it must be checked to ensure correct placement. If during a feed staff suspect that there is any dislodgement of the enteral device they must stop and check to ensure correct placement.

ACTION RATIONALE Explain procedure to child reassure throughout.

Instil confidence.

Gather equipment Wash and dry hands and put on gloves and apron

Ensure external tube is clamped prior to procedure


Attach a 50-30ml syringe to external tube. Release clamp and withdraw a small amount of gastric contents.

It may be necessary to discard the first 2 -5 mls of aspirate as this may only be flush remaining in the tube from the previous feed

Clamp extension device and remove syringe

Place a small amount of gastric contents onto pH indicator paper and observe reaction. pH must be 5 or below for feed to commence

To check that device is in correct position prior to feed




• Tube blocking

• Leakage around stoma

• Over-granulation of gastrostomy site

• Vomiting

• Dislodgement of tube

• Excess wind NB: Report and record any vomiting, diarrhoea, constipation,


Enteral tube Blocking:

• Do not use excessive force when attempting to unblock an enteral tube. This has the potential to damage the tube and increase the risk of administering the feed in the wrong place.

• Do not attempt to unblock the tube using sharp instruments.


ACTION RATIONALE

Ensure all clamps are open and there are no ‘kinks’ in tubing.

Use a 30/50ml syringe to attempt gentle flushing (at least 10mls of warm water) Push/pull technique to instil.


Gently squeeze the external tube between fingers and along its length (milking the tube).



As above

Always flush tube with prescribed amount of cooled boiled water before and following feeds / medications.

To prevent blockage



Leakage around Stoma: Possible causes:



• Constipation


ACTION

RATIONALE





This may indicate damage to the tube and it may need replaced This may indicate a change in the child’s condition requiring further assessment




Over-granulation of Gastrostomy Site Possible Causes

• Insufficient rotation of the tube


• Tube dragging downwards Indications are:




Ensure there is no excessive pull/tension on feeding tube by clothing, straps or giving set.




Absorbent dressing can be applied (if prescribed)



Vomiting








If vomiting stops and child remains settled recommence feed as appropriate. If vomiting continues DO NOT RESTART FEED. Contact parents +/- CCN as rate of feed may need adjusted



PEG device falls out Possible causes

• Child pulls out tube

• Internal fixation device is broken A dislodged PEG tube may only be reinserted surgically and the child should be transferred to hospital as soon as possible to ensure rapid assessment. This may require a 999 call for ambulance assistance.

Action:

• Cover site with sterile gauze or if tube not fully dislodged secure with tape and then cover with gauze.


• If parents or Community Children’s Nurse cannot be contacted contact the hospital directly as the child may have a portion of the internal fixation device remaining in their stomach.

• The dislodged PEG tube should be taken to the hospital with the child so it may be examined to ensure it is intact.



Venting of excess wind Children with gastrostomy devices can suffer from trapped wind which may need released by the carer. Signs of trapped wind may be slight abdominal distension or signs of discomfort. The carer should seek the advice of the parent as to what is normal for the child as these may also indicate other problems with an enteral tube. To release wind the carer should follow the protocol for administering an enteral flush but not insert any water into the 30/50ml syringe rather allowing any trapped wind to escape for 1- 2 minutes and then clamping the external tube. If this does not resolve the child’s difficulty the parent / CCN should be contacted.

December 2009 Signature ……………………………… Position ………………………………. Date ………………………………….... Review Date …………………… Signature ……………………………………… Review Date …………………… Signature ……………………………………… Review Date …………………… Signature ………………………………………


COMPETENCY – GENERAL CARE AND TROUBLESHOOTING OF A PERCUTANEOUS GASTROSTOMY (PEG) DEVICE

Child’s Name: DOB: / / Type of device in use with above child Performance Criteria Knowledge The carer will be able to :

Taught Date/Sign


Competency Achieved

Discuss why child needs a gastrostomy and the type of tube in position


Discuss the observations to be undertaken when caring for the gastrostomy site including measurement of external tube

Discuss the rationale for rotating the enteral feeding device

Discuss the potential problems associated with enteral devices

Discuss the steps to be taken in the event of dislodgement of tube


Demonstrate dates

Practiced Dates



Demonstrate daily care of gastrostomy site including care of external locking device

Demonstrate ‘rotating’ the enteral feeding device



I have received training and consider myself competent in all of the above Name …………………………………. Assessor ………………………………… Signature ………………………………Qualifications …………………………… Date …………………………………….Signature ………………………………… Date ………………………………………


PROTOCOL FOR THE USE OF A FLOCARE INFINITY PUMP WITH ENTERAL FEEDING SYSTEM

Child’s Name: DOB:

ACTION RATIONALE

Explain to child what you are going to do and reassure throughout procedure


Follow child specific protocol for enteral feeding device in use

All checks regarding position of device and flushing of device must be complete before commencing a pump feed

Open packaging of reservoir and giving sets, ensure both within expiry date and have not been damaged

Pour prescribed Enteral feed into reservoir and connect to giving set using appropriate screw cap

In the case of pre packed feeds the screw cap should attach directly to the giving set.

Insert giving set into pump: Open pump door Align loop of giving set with rotor and stretch slightly to allow set to slot into position in the pump. (Set can only be inserted in one position which allows the chamber door to shut and feed then commence. Close pump door

It is not necessary to prime the giving set at this stage of the process

Press ON/OFF for 2 seconds To activate pump self test system

Press CLR To clear previous settings on pump Pump should be cleared of previous settings at the beginning of each feed

Press and hold FILL SET until ‘fill set’ appears on the screen

To prime the giving set

The pump should automatically fill to the end of the giving set If the pump stops before the giving set is fully primed press and hold FILL SET again – once the tube is fully primed press FILL SET again to stop the flow

The priming process can be halted at any point by pressing FILL SET

Set the prescribed flow rate by pressing the + or – key

The display should read ml/hr

Set the prescribed volume by pressing DOSE=VOL and using the + or - key

If feeding continuously use the + or – key until CONT appears The volume to be given should be displayed in mls

ACTION RATIONALE The pump may now be connected to the child either via an extension set or directly to the enteral feeding device dependent on the device in use. Ensure that device or extension set has been flushed prior to administration of feed.

Button devices – extension set PEG device – directly to integral extension set using spigot on end of giving set NG tube – directly to NG tube using leur lock on end of giving set when spigot removed

Press START on the pump to commence the feed

Once the feed is completed the pump should alarm and stop automatically and staff should ensure that any prescribed flush is given as per the child specific protocol

The final flush may be given via the pump reservoir.

Press the ON/OFF key to turn the pump off

Ensure child is comfortable and adjust clothing if required

Disconnect the giving set and any removable extension set Ensure enteral feeding device is flushed as per protocol for enteral feed administration Ensure enteral device is clamped or closed as appropriate following flush

Wash extension set in warm soapy water, rinse and allow to air dry

Discard giving set and reservoir in normal domestic waste unless otherwise indicated

Flocare reservoirs and giving sets are single use only items

Remove gloves and apron and wash hands

Record administration of feed and flush in appropriate documentation

Trouble shooting flocare infinity pump If the pump is not operating properly it should alarm and one of the messages below should be displayed Alarm display Cause Action NO SET The set is not fitted

correctly or the pressure sensor is dirty

Reinsert he giving set

PUSH START Start button has not be pressed or pump has remained on hold

Press start button

OCC IN Blockage in giving set between reservoir and pump Pump senor may be dirty

Check giving set for air bubbles or blockage. Set may need disconnected from child and re primed or replaced Clean pump sensor

OCC OUT Blockage in giving set between pump and child Pump sensor may be dirty

Check giving set for air bubbles or blockage. Set may need disconnected from child and re primed or replaced Ensure extension set if used is clamped before disconnecting giving set Clean pump sensor

AIR The giving set is empty The sensor is dirty The giving set is incorrectly fitted The giving set has been in use for 24 hours

Replace empty set Clean sensor Ensure set correctly fitted Replace the giving set

END OF DOSE Set dose complete Press and hold ON/OFF for 2 seconds Clear memory of the total and re- set if required

BATT Battery is running low Connect pump to mains to charge for 6 hours

BATT E F Battery has failed Contact parents / CCN for replacement

LOCK Settings locked into pump Press and hold the ON/OFF & the + key at the same time Press the fill set key Press + to lock the pump Press – to unlock pump

ERRA-ERZZ Self test has detected a fault

Switch off and on again if this does not resolve contact parents/CCN for replacement pump

FILL SET The pump is priming the giving set

Press FILL SET to stop prime if completed


COMPETENCY FOR THE USE OF A FLOCARE INFINITY PUMP WITH ENTERAL FEEDING SYSTEM

Name of Child DOB / / Performance Criteria

Knowledge The carer will be able to:

Taught Date/Sign


Date/Sign

Competency Achieved

Discuss the use of the flocare infinity pump

Discuss why the named child requires enteral feeding

Discuss the infection control measure to be taken during use of pump and administration of feed

Discuss the steps to be taken in the event of pump alarm / malfunction

Performance Criteria

Skills The carer will be able to:

Demonstrated Dates

Practiced Dates


Date Demonstrate collection of equipment Demonstrate setting of pump prior to feed Demonstrate connection of giving set to enteral device

Demonstrate disconnection of giving set from enteral device

Demonstrate disposal of used equipment Demonstrate correct recording and reporting of care as appropriate

I have received training and consider myself competent in all of the above Name: ……………………………….… Assessor: …………………………..…

Signature: ………………………..…… Qualifications: ……………………….

Date: ………………………………………. Signature: ………… ………………..

Date: ………………………………..


PROTOCOL FOR THE USE OF A KANGAROO JOEY PUMP WITH ENTERAL FEEDING SYSTEM


ACTION RATIONALE Explain to child what you are going to do and reassure throughout procedure


Follow child specific protocol for enteral feeding device in use

All checks regarding position of device and flushing of device must be complete before commencing a pump feed

Open packaging of reservoir and giving set, ensure both within expiry date and have not been damaged

Giving set and reservoir may be packaged as a complete unit

Pour prescribed Enteral feed into reservoir and connect to giving set using appropriate screw cap (if required)

In the case of pre packed feeds the screw cap should attach directly to the giving set.

Press power on button on lower right hand corner of screen

Press CLEAR SETTINGS The pump should be cleared of previous settings at the start of each feed

To load the giving set With the pump facing you open the blue transparent door Hold the finger tab on the valve and insert into the valve slot on the left side Grasp the black retainer and wrap the tubing counter clockwise around the rotor (avoid overstretching the silicone tubing) Fit the black retainer into the slot on the remaining slot Close the door ensuring the finger tab is captured by the slot in the blue door

The pump should now display SET LOADED

Hang the feed bag on the stand at least 6 inches above the pump

Press AUTO PRIME to prime the giving set Press STOP at any time to stop the prime

The pump should now display AUTO PRIME COMPLETE

Visually check the giving set is fully primed

If you require further priming press and hold HOLD TO PRIME and release when set is fully primed then press DONE

Press ADJUST FEED

ACTION RATIONALE Press FEED RATE

Press the arrow buttons to enter prescribed feed rate

Press ENTER

Press VTBD

Volume To Be Delivered

Press the arrow buttons to enter the prescribed feed volume

Press ENTER

The pump may now be connected to the child either via an extension set or directly to the enteral feeding device dependent on the device in use. Ensure that the extension set or device has been flushed prior to the administration of a feed

Button devices – extension set PEG device – directly to integral extension set using spigot on end of giving set NG tube – directly to NG tube using leur lock on end of giving set when spigot removed

Press RUN on the pump to commence the feed

Once the feed is completed the pump should alarm and stop automatically and staff should ensure that any prescribed flush is given as per the child specific protocol

The final flush may be given via the pump reservoir.

Press the POWER key to turn the pump off

Ensure child is comfortable and adjust clothing if required

Disconnect the giving set and any removable extension set Ensure enteral feeding device is flushed as per protocol for enteral feed administration Ensure enteral device is clamped or closed as appropriate following flush

Wash extension set in warm soapy water, rinse and allow to air dry

Discard giving set and reservoir in normal domestic waste unless otherwise indicated

Flocare reservoirs and giving sets are single use only items

Remove gloves and apron and wash hands

Record administration of feed and flush in appropriate documentation

Trouble shooting Kangaroo Joey pump If the pump is not operating properly it should alarm and one of the messages below should be displayed Alarm display Cause Action Feed error Feed may be blocked

between the feed and the pump

Check giving set, if occlusion seen it may be removed by disconnecting the system from the child(ensuring enteral device is clamped or closed) then using the prime function to flush the giving set or otherwise replace the giving set

Rotor error Rotor may be damaged or set is incorrectly loaded

Inspect rotor for damage and correctly fit giving set

Flush error Only used if flush system in use

Flow error Feed may be blocked between the pump and the patient

Check giving set, if occlusion seen it may be removed by disconnecting the system from the child(ensuring enteral device is clamped or closed) then using the prime function to flush the giving set or otherwise replace the giving set

Pump set dislodged Giving set is not correctly fitted in pump

Open blue door and fit set correctly

Low battery Battery charge low Ensure pump is plugged into mains for charge

Feeding complete Set feed volume complete Ensure feed complete

December 2009


COMPETENCY FOR THE USE OF A KANGAROO JOEY PUMP WITH ENTERAL FEEDING SYSTEM

Name of Child DOB / / Performance Criteria

Knowledge The carer will be able to:

Taught Date/Sign


Date/Sign

Competency Achieved

Discuss the use of the Kangaroo Joey pump

Discuss why the named child requires enteral feeding

Discuss the infection control measure to be taken during use of pump and administration of feed

Discuss the steps to be taken in the event of pump alarm / malfunction

Performance Criteria

Skills The carer will be able to:

Demonstrated Dates

Practiced Dates


Date Demonstrate collection of equipment Demonstrate setting of pump prior to feed Demonstrate connection of giving set to enteral device

Demonstrate disconnection of giving set from enteral device

Demonstrate disposal of used equipment Demonstrate correct recording and reporting of care as appropriate

I have received training and consider myself competent in all of the above Name: …………………………….… Assessor: ……………………………..

Signature……………………………. Qualifications: ……………………….

Signature……………………………..

Date: …………………………………..



Equipment required

All equipment should be maintained according to the manufacturers’ guidelines and within local Trust policy where appropriate. Staff should ensure that the family have adequate supplies of consumable equipment. Delete as appropriate Equipment Home stock level Enteral pump Extension sets Reservoirs Stand Carry bag Type of enteral feeding device (e.g. button) Size Enteral syringes mls mls mls Ph indicator paper Preferred tape in use Preferred dressing Aprons and gloves

Prescribed enteral feed Recording sheet Cooled boiled water (for flushing and priming) Additional syringes for medication mls mls Prescription sheet

Enteral feeding

Statement Nasogastric

feeding

Statement Balloon

gastrostomy

Statement PEG

Statement Button device

Equipment list

Protocol for general Care/

troubleshooting

Protocol for enteral feed /

Admin of medicines

Nasogastric


troubleshooting


Admin of medicines

Balloon


troubleshooting


Admin of medicines

PEG


troubleshooting


Admin of medicines

Button

Protocol for

pump in use

Protocol for

pump in use

Protocol for

pump in use

Protocol for

pump in use

Childrens Nursing Enteral Feeding Protocols · • Protocol for the use of a Kangaroo Joey Pump...

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Transcript of Childrens Nursing Enteral Feeding Protocols · • Protocol for the use of a Kangaroo Joey Pump...