Percutaneous Enteral Feeding Tube Care
Contents
1. solution Feeding solution is run a number of times a day over 30 45 minutes can approximately 276 mL of feeding solution into the gastric cavity 1 Gastrostomy or Jeyjunostomy tubes may be considered for longer term use to ensure that optimum nutrition and comfort needs are met The client or guardian will be consulted and must consent to the insertion of the feeding tube 2 A physician s order is needed to initiate and end enteral feeding The dietitian RD must be consulted for all clients with gastrostomy jejunostomy tube feeds to ensure that the client is receiving optimum nutrition and hydration The type of CAREWEST Care and Service Manual WCarewest Section ADL INNOVATIVE HEALTH CARE Subsection Eating Nutrition Diet PERCUTANEOUS ENTERAL CS 02 01 03 Page 3 of 16 FEEDING TUBE CARE formula need for modular additives rate frequency and volume of water flush is determined by a RD or physician Note Tube feedings usually do not start any sooner than 24 hours after the insertion of a radiological or endoscopically placed gastrostomy tube 3 The feeding solution should be given at room temperature but not left open at room temperature for more than 12 hours Open System Literature suggests that a hang time of 8 to 12 hours is acceptable for commercially sterile ready to feed products when carefully poured from the packaged container into a tube feeding set up Mark the date and time opened and store open cans2. 2005 Enteral Tubes Assessment of Placement Regional Nursing Policy and Procedure Manual T 17 Grant Mary and Martin Sarah 2000 Delivery of Enteral Nutrition AACN American Association of Critical Care Nurses Clinical Issues 11 4 November 507 516 CAREWEST Care and Service Manual W Carewest Section ADL INNOVATIVE HEALTH CARE Subsection Eating Nutrition Diet PERCUTANEOUS ENTERAL CS 02 01 03 Page 16 of 16 FEEDING TUBE CARE Guenter P 2001 Nursing Care of Patients with Enteral Feeding Devices In Guenter P and Silkroski M Tube feeding Practical Guidelines and Nursing Protocols p 69 Gaithersburg Aspen Publishers Heximer Betsy 1996 Troubleshooting G tubes Spontaneous Balloon Rupture RN 1996 July 22 27 Kohn Keeth Carol 2000 How to Keep Feeding Tubes Flowing Freely Nursing 2000 30 3 March 58 59 Goldberg E Kane R Yaworski J amp Liacouras C 2005 Gastrostomy Tubes Facts Fallacies Fistulas and False Tracts Gastroenterology Nursing 28 6 pp 485 493 Reising D and Neal N 2005 Enteral Tube Flushing What You Think Are The Best Practices May Not Be American Journal of Nursing 105 58 63 Southern Alberta Nutrition Support Program 1997 Health Information Home Tube Feeding Calgary Health Region Southern Alberta Nutrition Support Program 2001 How to Replace a Balloon Gastrostomy Tube Insert 8 F5026B 2001 11 Health Information Home Tube
3. Contact the physician Note An x ray may be required to confirm the tube placement 3 Procedure for Flushing Feeding Tubes 3 1 Unless otherwise directed by the registered dietitian or physician flush using the following guidelines Use a minimum of 30 mL room temperature water sterile water for immunocompromised clients in a 60 mL piston syringe Note To prevent exerting too much pressure on the tube it is important to use a large syringe e g 60 mL unless otherwise allowed by manufacturer s recommendations If fluids are restricted flush with less fluid Point of emphasis Regular flushing with water is the single most effective way of ensuring patency of the feeding tubes Flushing with other liquids such as carbonated beverages or cranberry juice is not considered best practice 3 2 When flushing use a push and pause motion several times for first half of flush before a steady push with the last half of the flush 3 3 Discard remaining water Change flushing equipment weekly 4 0 Care of stoma and tube 4 1 Syringes feeding bag and line require secure attachment to the feeding tube Use appropriate adaptors on the end of the feeding tube if necessary to ensure a secure fit e g use a Luer lock 60 mL syringe into feeding tube with a Leur lock or use an adapter to allow a slip tip 60 mL syringe and feeding bag line to attach appropriately Do not use a bulb syringe as this equipment does not allow for push and
4. Occlusion in the 1 Never forcibly remove a tube when the balloon will not deflate balloon channel from deflate yeast formation or inadvertent 2 Attempt to deflate the balloon by injecting 1 2 mL of sterile administration of water or saline into the balloon valve using a Luer tip syringe medication into the and then try to deflate Alternately push balloon further into balloon port the stomach so it is not lying right against the abdominal wall and hyper inflate the balloon with air or sterile water to rupture it 3 Ifthat doesn t work remove the piston from the syringe barrel Insert the syringe into the balloon valve and place it on a clean towel at a level below the balloon Allow it to drain for 5 10 minutes If there is no drainage the problem may be a defective valve rather than an occlusion in the balloon channel 2 Defective valve 1 Ifthe valve is defective contact the physician to discuss the option of cutting off the Y port If this option is agreed upon cut off the entire Y port with scissors and allow the fluid to drain through the balloon channel Stay with client until the G tube is removed to prevent migration of the tube inward 2 Ifremoving the Y port doesn t work contact the physician CAREWEST Care and Service Manual WCarewest INNOVATIVE HEALTH CARE PERCUTANEOUS ENTERAL FEEDING TUBE CARE Section ADL Subsection Eating Nutrition Diet CS 02 01 03 Page 13 of 16 Problem Possi
5. bearing in mind that the jejunum is not a reservoir so fluid is not easily obtained e Observe the contents of the aspirate if obtained Check the pH of the aspirate using litmus paper Compare the aspirate to the chart below Note pH testing is more reliable if performed prior to or 60 minutes after the administration of medications and tube feedings Fluid pH Factors affecting pH Color of Fluid Stomach 1 5 e pH may be due to Histamine H2 receptor Grassy or cloudy blocking agents cimetidine famotidine green tan to off nizatidine and ranitidine omeprazole white bloody or and antacids brown e pH may be due to chronic gastritis On rare occasions refluxing of duodenal and pancreatic clear and colorless secretions into stomach Mucus may be mixed in with NOTE Gastric pH of higher than gastric fluid 3 5promotes bacterial colonization and increases risk of aspiration pneumonia Intestine Greater Medium to deep than 5 golden yellow but less than 7 CAREWEST Care and Service Manual WCarewest Section ADL INNOVATIVE HEALTH CARE Subsection Eating Nutrition Diet PERCUTANEOUS ENTERAL CS 02 01 03 Page 7 of 16 FEEDING TUBE CARE e If pH of the aspirate indicates correct placement re instill the aspirated fluid Note Discard the aspirate if it is bloody mucousy or bile stained 2 4 Hold any flush feeding solution medication if there is any doubt about the location of the tube
6. e Jejunostomy Tube Tip of the tube rests in the jejunum The tube exits the J tube or GJ tube body through a tract created in the abdominal wall CAREWEST Care and Service Manual WCarewest INNOVATIVE HEALTH CARE Section ADL Subsection Eating Nutrition Diet PERCUTANEOUS ENTERAL CS 02 01 03 Page 2 of 16 FEEDING TUBE CARE e Percutaneous Endoscopic Gastrostomy Tube PEG e Balloon anchored tube Flange Open Enteral System Closed Enteral System Continuous feed Intermittent feed POLICY Percutaneous stab into the stomach with endoscopic assistance for a tube placement The tube is anchored by a retention suture not a balloon Removal and reinsertion is a medical procedure Initial change to a PEG Tube is performed by a physician A tube that has an expandable balloon on the end which is inflated with sterile water for the purposes of securing the tube in the correct location once in situ The disk that anchors some tubes on the exterior side of the abdominal wall An enteral system in which the formula is added into the enteral container or bag A closed enteral container or bag pre filled with sterile liquid formula by the manufacturer and considered ready to administer Solution is instilled slowly into the feeding tube often over 12 16 hours using a pump Flush the tube every 4 hours J tubes must have continuous feed as the jejunum has no reservoir for holding a large volume of feeding
7. pause flushing technique 4 2 Post operatively the dressing may be removed from the tube site after 24 to 48 hours However it is important that the tube is secured to prevent movement CAREWEST Care and Service Manual WCarewest Section ADL INNOVATIVE HEALTH CARE Subsection Eating Nutrition Diet PERCUTANEOUS ENTERAL CS 02 01 03 Page 8 of 16 FEEDING TUBE CARE 4 3 Bathing showering and swimming are allowed with an established stoma site Post operatively the surgeon physician determines when the client may start bathing showering and swimming 4 4 Follow standard precautions when providing care to the stoma and tube Q tips and or gloves may be used to protect staff from gastric secretions 4 5 Remove any dressings and note the amount and character of any drainage Examine the skin integrity If the skin around the gastrostomy jejunostomy tube is red or open consider consulting a Skin and Wound Resource regarding appropriate use of skin barriers 4 6 A fresh stoma should be cleansed with normal saline for the first 14 days after insertion or if showing signs of infection A well healed stoma can be cleansed with soap and water or an approved skin cleanser Wipe in widening circles starting from the tube exit site Apply a mild but adequate pressure in cleaning around the entire tube and skin circumference to ensure a clean margin and prevent the adherence of the tube to the skin Remove any build up of oils or for
8. regular change intervals Determine the replacement tube type and size where the reinsertion is to take place in the care center or by a booked appointment at a physician s office or clinic who will re insert the first tube the first replacement is done by a physician unless the tract is very well established greater than 3 months see policy CS 02 01 04 Discuss with pharmacy how medications will be administered through the tube 2 Procedure to Check for the Correct Placement of the Tube 2 1 Check that the external length of the tube extending beyond the exit site has not changed upon subsequent care before each flushing tube feeding and or medication administration by using the ruler marking on the tube or mark placed there with an indelible pen Check the exit length on the Total Team Record and Care Plan CAREWEST Care and Service Manual V Carewest Section ADL INNOVATIVE HEALTH CARE Subsection Eating Nutrition Diet PERCUTANEOUS ENTERAL CS 02 01 03 Page 6 of 16 FEEDING TUBE CARE 2 2 Assess the client s tolerance to feeds or flushes each time e g shortness of breath cough abdominal pain nausea and vomiting leakage at site 2 3 Ifthe placement is in question e G tube Use a 60 mL piston syringe to aspirate the contents of the stomach Reposition the client if unable to aspirate the contents Aspiration is not always possible if the stomach is empty e J tube Attempt to aspirate
9. to continuous feedings CAREWEST Care and Service Manual WCarewest Section ADL INNOVATIVE HEALTH CARE Subsection Eating Nutrition Diet PERCUTANEOUS ENTERAL CS 02 01 03 Page 11 of 16 FEEDING TUBE CARE Possible Causes Action Intervention Skin irritation 1 Gastric fluid leakage 1 Clean area around tube or stoma frequently keep dressing dry or redness around tube change catheter tube holder if soiled check tube placement and around tube or keep 1 2 mm distance between the retention bumper and the skin stoma Reaction to tube material 2 Suggest tube be replaced Tube migration outward 3 Check external tube length If it becomes longer stop feeding and Bumper not in place to consult physician whether tube needs replacement prevent tube from moving Bleeding around 1 Bleeding may occur 1 Minimal bleeding is insignificant The physician should be tube or stoma during tube change consulted if larger amounts of bleeding occur The stoma may become 2 Secure the tube to the client s abdomen using a catheter tube irritated from movement holder Ensure bumper is in place to prevent movement of the of the tube in the stoma tube Tissue build up 1 A small amount of Keep site dry secure the tube well to decrease movement around tube epithelial tissue is If tissue build up is excessive and interferes with care notify the normal and not painful physician Removal of the hypergranulation may be ne
10. Feeding Calgary Health Region Stroud M Duncan H Nightingale J 2003 Guidelines for Enteral Feeding in Adult Hospital Patients Gut 52 Supplement VII vii 1 vii 12 CAREWEST Care and Service Manual
11. RE Subsection Eating Nutrition Diet PERCUTANEOUS ENTERAL CS 02 01 03 Page 4 of 16 FEEDING TUBE CARE e ifthe client feels the placement is in question e after excessive vomiting retching or coughing e after abdominal spasm Use smooth tip to anchor the tube for clients with severe abdominal spasms to prevent the tube being sucked into the stomach Clients with MS may benefit from an anti spasmodic medication e if there is a change in the client s condition such as vomiting and retching abdominal pain cramping bloating fullness or burning with feedings e if there is an unusual leakage around the tube if the balloon type tube is fixated in the tract i e will not rotate 8 Flushing the Tube Percutaneous enteral feeding tubes must be flushed before and after each intermittent feed before and after medication administration at least every 4 hours with continuous feeds or when feeding is interrupted e ifa blockage is suspected To maintain patency of the tube it must be flushed regularly If the gastrostomy PEG tube is not used for nutritional purposes and the client is not on NPO the gastrostomy PEG tube should be flushed twice a day If the jejunostomy tube is not used for nutritional purposes and the client is not NPO it should be flushed every 4 hours PROCEDURE 1 Care of the Newly Inserted Feeding Tube The following are suggested topics to consider when setting up the interdisciplinar
12. UTANEOUS ENTERAL CS 02 01 03 Page 15 of 16 FEEDING TUBE CARE CROSS REFERENCES Medication Administration CS 06 06 01 Percutaneous Enteral Feeding Tube Reinsertion CS 02 01 04 Declogging Percutaneous Enteral Feeding Tube CS 02 01 05 Skin Care Protocol CS 02 04 06 REFERENCES Bankhead R Boullata J Brantley S Corkins M Guenter P Krenitsky J Lyman B Metheny NA Mueller C Robbins S Wessel J ASPEN Board of Directors 2009 A S P E N Enteral Nutrition Practice Recommendations JPEN 33 122 online version available at http pen sagepub com Bockus Sherry 1998 When Your Patient Needs Tube Feedings Nursing CE Handbook http www springnet com ce p507a htm SpringNet CE Connection obtained on 2001 08 30 Bowers Sybil 2000 All About Tubes Your Guide To Enteral Feeding Devices Nursing 2000 30 12 41 47 Broscious S 1995 Preventing Complications of PEG Tubes Dimensions of Critical Care Nursing 14 1 37 41 Care in the Community Service Performance Committee Gastric tube Ad Hoc Working Group April 2002 Towards the Development of an Operational Guideline to Support Enteral Nutrition in Calgary Health Region Continuing Care Facility Settings Ad hoc Committee Report Calgary Health Region Calgary Health Region 2005 Enteral Tubes Percutaneous Tube Maintenance Troubleshooting and Reinsertion of Balloon Type G Tubes Regional Nursing Policy and Procedure Manual T 16 Calgary Health Region
13. Y C Section ADL arewest Subsection Eating Nutrition Diet INNOVATIVE HEALTH CARE PERCUTANEOUS ENTERAL CS 02 01 03 Page of 16 FEEDING TUBE CARE Related terms Date Dates Revised Tube Feeding Changing Gastrostomy Jeyunostomy Care Established March 1999 March 2006 March 2009 May 2012 Authorized by Date For Review Clinical Directors May 2015 RATIONALE To provide direction for the safe administration of enteral feeding solution through a percutaneous enteral tube APPLICABILITY MD RD Registered Dietitian RN LPN Resident Assistants RAs at Nickel House and Signal Pointe and Therapy Aides TAide at YADS can administer feedings after completion of a G tube course provided by Education Services DEFINITION Reinsertion Inserting a balloon tip gastrostomy tube that has accidentally been removed or has fallen out or when an in situ tube requires replacing into the stomach Mature tract A tract between the abdominal wall and the stomach is considered mature after 6 weeks Percutaneous Enteral A tube that is inserted through an artificial opening in the Tube stomach or small intestine usually for the purpose of long term feeding Such as e Gastrostomy Tube The tip of the tube rests in the stomach and exits the body G tube through a tract created in the abdominal wall e Gastro duodenal Stomach gastro duodenal tube inserted through the Tube GD tube abdominal wall into stomach and advanced into duodenum
14. ble Causes Action Intervention Diarrhea 1 Contaminated 1 Change feeding bag and feeding line and pay close attention formula equipment to proper hand washing before and after providing care to feeding tube or feeding solution 2 Rapid infusion rate 2 Initiate and advance formula rate gradually reduce rate 3 Post anti biotic use 3 Change antibiotic to treat C diff if indicated Consider a check for C diff probiotic clostridium difficile ay Medication Side epee 4 Review medication use hyperosmolar meds may cause diarrhea 5 Cold formula 5 Ensure feeding solution is given at room temperature extremes in temperature may stimulate peristalsis 6 Malabsorption short 6 Change formula in consultation with dietitian physician bowel syndrome radiation enteritis compromised pancreatic function severe Crohn s disease Dumping syndrome sensation of fullness faintness palpitation diarrhea occurs more frequently when tube placed in jejunum 7 Possible gastroenteritis 7 Consult Physician Reflux 1 Too fast a rate 1 Stop feed Provide feeds at a slower rate Regurgitation 2 Client laying too flat 2 Keep patient in 30 preferably 45 during feed and for about 1 hour after feeds 3 Underlying medical condition 3 Contact physician if symptoms continue CAREWEST Care and Service Manual WCarewest INNOVATIVE HEALTH CARE PERCUTANEOUS ENTERAL FEEDING TUBE CARE Section ADL Subsection Eating Nutriti
15. cessary by physician often with silver nitrate two three times wk for 2 3 weeks Tube Normal usage Notify physician Tube will need to be replaced deterioration Irrigations not performed regularly Faulty Anchoring device Gastrostomy Insufficient water or 1 Insert re placement gastrostomy tube as soon as possible tube falls out saline in balloon or balloon rupture If the correct size of gastrostomy tube is not available a Foley catheter or another similar size gastrostomy tube can be inserted until a proper replacement tube can be obtained Smaller size tube can be used for constricted tract CAREWEST Care and Service Manual W Carewest Section ADL INNOVATIVE HEALTH CARE Subsection Eating Nutrition Diet PERCUTANEOUS ENTERAL CS 02 01 03 Page 12 of 16 FEEDING TUBE CARE Possible Causes Action Intervention Balloon rupture 1 Over inflation of Insert new tube as ordered Inflate new balloon to half balloon manufacturer s recommendations Increased intra For clients alert physician and obtain order for antispasmodic abdominal pressure to help relax abdominal muscles from coughing crying spasticity or seizure disorders Deterioration of the G 3 Monitor for deterioration by checking water volume in balloon tube balloon from yeast weekly The best time to do it is before a feeding when the formation or exposure stomach is empty to gastric and pancreatic juices Balloon won t 1
16. hable tape If needed use hypoallergenic tape To prevent unnecessary tugging on the device the tube may be coiled and secured to the client s clothing Although use of a Foley catheter as a feeding tube is NOT recommended if one is in place it is critical that a cross piece or tape flag be added to the Foley catheter exiting the stoma to prevent the migration of the catheter balloon beyond the pylorus of the stomach 4 12 Deflate the feeding tube balloon if present monthly to check colour and amount of water in the balloon If the water is brown tinged or the amount withdrawn is less than was originally placed in balloon usually half the amount recommended on the tube consider changing the tube as these may be signs that the balloon is degrading 4 13 Dispose of the equipment and wash your hands CAREWEST Care and Service Manual WCarewest INNOVATIVE HEALTH CARE PERCUTANEOUS ENTERAL FEEDING TUBE CARE Section ADL Subsection Eating Nutrition Diet CS 02 01 03 Page 10 of 16 Troubleshooting common gastrostomy jejunostomy tube and skin care problems Possible Causes Action Intervention Leakage around tube or stoma Improper client positioning Decreased gastrointestinal function Balloon mushroom or catheter has slipped away from wall of stomach Balloon of the catheter may have become less inflated Tube is too small for size of stoma Tube migration inward causing partial pylo
17. in the refrigerator Discard refrigerated product if not used within 48 hours Closed System Ready to hang products may hang for 24 to 48 hours depending on manufacturer s guidelines when a new ready to hang container is spiked with a new feeding set using aseptic technique Otherwise hang no longer than 24 hours Mark the date and time spiked on the container 4 The client should be in an upright position minimum 30 and preferably to 45 during feeding medication administration and or flushes and for 30 60 minutes afterward if tolerated to avoid reflux into the esophagus and possible aspiration 5 Strict adherence to clean technique is required in the preparation and administration of enteral formulas All devices tubing for an open system are to be changed at least every 24 hours as per manufacturer s directions Closed system feeding sets must be changed as per manufacturer s guidelines every 24 to 48 hours 6 Medications modular additives such as protein powder or juice are not added directly into the formula Consult Dietitian for further direction 7 Placement of Tube Check the tube placement immediately after reinsertion and e before each intermittent feeding e before medication administration e ifthe tube is accidentally pulled e if the mark on the tube is in a different position than indicated on the Health Record CAREWEST Care and Service Manual WCarewest Section ADL INNOVATIVE HEALTH CA
18. mula around the tube opening or connectors 4 7 Check the tube tension daily making sure that it is secure and that it is not causing undue pressure Expect some in and out play of about 0 5 cm but no side to side motion 4 8 Fora radiologically inserted PEG do not do 360 tube rotation which may uncoil and dislodge the tube Do not rotate a jejunostomy tube Tube rotation is also not advised when there is purse string suture around the stoma and for at least 3 weeks after suture removal or for the duration as directed by the physician For other types of gastrostomy tubes gently rotate the tube daily 4 9 For tubes with an external retention device gently lift the edges of the retention disc or bumper away from the skin while cleaning While drying the skin and disc gently turn the disc For Button low profile gastrostomy device or skin level device turn the button while drying the skin to make sure the skin under the tabs is dry 4 10 Apply a dressing if exudate is present Usually a dressing is no longer required several days post initial tube insertion If dressing changes are required perform daily or more frequently as required CAREWEST Care and Service Manual WCarewest Section ADL INNOVATIVE HEALTH CARE Subsection Eating Nutrition Diet PERCUTANEOUS ENTERAL CS 02 01 03 Page 9 of 16 FEEDING TUBE CARE 4 11 Anchor the gastrostomy jejunostomy tube securely with a tube holder flexi track duoderm or breat
19. on Diet CS 02 01 03 Page 14 of 16 Problem Constipation Abdominal distention nausea and vomiting 1 Possible Causes Inadequate water intake Inadequate fibre intake Low Activity Reduced gastric motility Medications side effect Feeding solution too great a volume and at too rapid of an infusion rate Gastric Retention Cold Formula Dumping syndrome sensation of fullness faintness palpitation diarrhea occurs more frequently when tube placed in jejunum Client laying to flat Action Interventions 1 Increase free water intake 2 Consult Dietitian to assess fibre intake 3 Increase activity as able 4 Reassess bowel routine 5 Consult Physician Pharmacist 1 Consider a slow rate of infusion Consider smaller more frequent feeding schedule q i d instead of t i d 2 Check residual gastric contents prior to next feed Hold feed for two hours if more than 4 previous infused amount is residual or more than 50 of the hourly rate for continuous infusions 3 Bring formula to room temperature before use 4 Contact physician Consult dietitian to assess delivery schedule and to assess appropriateness of current formula 5 Ensure resident is upright for feeds Raise head of bed greater than 30 check gastric residuals CAREWEST Care and Service Manual W Carewest Section ADL INNOVATIVE HEALTH CARE Subsection Eating Nutrition Diet PERC
20. ric obstruction Tube migration outward allowing feeding to enter tract Anti reflux valve failure Feeding rate too rapid or volume too large 1 Place client in upright position at 30 during feedings and for at least one hour following intermittent feedings 2 Hold feedings and alert physician Assess for decreased or absent bowel sounds abdominal distension nausea vomiting and increased residual volume 3 Gently pull back on catheter or tube to ensure that balloon is snug against stomach wall and secure in place 4 Check contents of the balloon if amount is less than was originally used to inflate balloon or if balloon contents are brown tinged in colour consider changing tube as this may indicate the balloon is degrading 5 Stabilize tube to abdomen to prevent tension on the tract Reinflate balloon to manufacturer s recommended capacity Consult with physician to evaluate further 6 Check external tube length If tube is shorter than when inserted stop feeding Assess for nausea vomiting and abdominal distension If symptoms are present alert physician X ray may be needed to determine tube placement 7 Check external tube length If tube is longer stop feeding and consult physician whether tube needs replacement 8 Notify the physician for consultation re necessity for tube replacement 9 Consult physician and dietitian about necessity to decrease the rate or volume of feedings or switch
21. y care plan for a client with a newly inserted feeding tube e Determine the type of tube that was inserted to help establish care of the current tube Check the physician s orders e Determine when and how any retention sutures are to be removed Retention sutures are used to help form the track by holding the stomach CAREWEST Care and Service Manual WCarewest Section ADL INNOVATIVE HEALTH CARE Subsection Eating Nutrition Diet PERCUTANEOUS ENTERAL CS 02 01 03 Page 5 of 16 FEEDING TUBE CARE against the abdominal wall Often they are removed 10 14 days post surgery by the surgeon in a booked clinic appointment Consult the dietitian to determine formula frequency rate of flow gravity or pump and amount of flushes e Discuss any need to check residual gastric contents to monitor tolerance to feeds e Discuss how best to monitor client condition lab work weight bowel function urine output blood glucose monitoring etc e An enteral feeding pump may be required if the client is returned to care center before progressing to an intermittent feeding schedule or a gravity feed If required contact Education Services for just in time education Determine stoma site care including when showering or bathing swimming can resume e The plan for reinsertion of the tube if tube becomes blocked or is accidentally removed 1 immature tract 2 initial tube change in mature tract and 3 mature tract
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