Medical Management

1. PURPOSE:

 1.1 To provide nutrition to patients with malnutrition or whose health condition is at risk due to chronic medical
    condition and reduce the adverse clinical impact of their disease
 1.2 To equip IHHC staff with protocol in provision of nutritional support to ensure that patients receive the
   ;appropriate nutrition that is acceptable and meets their physiologic needs/body requirements

2. POLICY:

 2.1 All IHHC Staff will ensure that patient’s nutritional and fluid requirements are met, to prevent and
   treat disease-related malnutrition and complications induced by poor nutritional status.
 2.2 All IHHC Staff will ensure that the safe practice of administration of enteral feed is maintained.

3. DEFINITION:

 3.1 Nutrition Support - The provision of nutrients and any necessary adjunctive therapeutic agents to patients orally and/or by administration into the stomach or intestine (enterally) and/or by intravenous infusion (parenterally) for the purpose of improving or maintaining a patient’s nutrition status
  3.1.1 Enteral Nutrition-The delivery of nutrition (macro and micronutrients) via the digestive tract.
  3.1.2 Percutaneous Endoscopic Gastrostomy (PEG)-An opening made into the stomach to allow feeding
   directly into the gut. Indicated where long term enteral feeding is required.
  3.1.3 Percutaneous Endoscopic Jejunostomy (PEJ)-An opening on the abdomen through to the jejunum,
   where a feeding device is placed to allow direct feeding into the small bowel
  3.1.4 Nasogastric tube feeding- A nasogastric tube, or NG tube, is a special tube that carries food and
   medicine to the stomach through the nose. It can be used for all feedings.

4. PROCEDURE:

 4.1 Initiation of Feeding
  4.1.1 Verify doctor’s order for enteral feeding
  4.1.2 Check for diet specification
  4.1.3 Check for the expiration of enteral feeding prior to administering
 4.2 Storage of feed
  4.2.1 It is not necessary to store unopened feed in the fridge. However, once feed has been opened it can
     be stored in a refrigerator for 24 hours providing it has not been attached to an extension set. When
     administrating feed, it should be given at room temperature.
  4.2.2 Once sterile bags of feed are punctured open by the giving set, they can be hung for a maximum of
     24 hours
  4.2.3 In the event of a break in feeding, disconnect giving set from feeding tube, clamp giving set and
     replace cover on giving set.
  4.2.4 Flush tube as ordered
  4.2.5 Keep cover of giving set clean and try to avoid contamination.
  4.2.6 Keep feed at room temperature.
  4.2.7 Use within 24 hours.
  4.2.8 Discard any unused feed after 24 hours.
 4.3 Delivery of Feed
  4.3.1 Position of patient
     4.3.1.1 Never feed with patient lying flat
     4.3.1.2 Feed sitting up or elevated to 45° during feed and for 30 minutes after.
  4.3.2 Equipment
     4.3.2.1 Appropriate feeding fluid
     4.3.2.2 Feeding bag and feeding pump
     4.3.2.3 Syringe for aspiration
     4.3.2.4 Extension set (for pediatric patients)
  4.3.3 Procedure
     4.3.3.1 Perform hand hygiene
     4.3.3.2 Check gastric residual as directed
       4.3.3.2.1 Place syringe and aspirate stomach content
       4.3.3.2.2 Measure the volume aspirated
       4.3.3.2.3 Residual fluid may be returned or discarded depending on the amount, as per order
       4.3.3.2.4 Assess the skin around the tube for excoriation, redness, drainage
     4.3.3.3 Place patient in a comfortable position, with head slightly elevated
     4.3.3.4 Instill water, amount will be determined by the dietician.
     4.3.3.5 Attach reservoir syringe or primed feeding bag to the tube or extension set. Unclamp the tube.
     4.3.3.6 When feeding is completed, flush the recommended amount of water. Clamp tube.
     4.3.3.7 Keep patient elevated at least 30 minutes post feeding
     4.3.3.8 Hand hygiene to be performed after feeding
 4.4 Pump Feeding
   4.4.1 It is recommended that enteral feeding pumps are used to deliver enteral feed. The rate, volume and
     timing of feed will be determined by the dietitian.
   4.4.2 The enteral feeding pumps are obtained from the discharging hospital or from any hospital which the
      patient has been enrolled.
   4.4.3 Staff must have attended training and achieved competencies to use the device.
 4.5 Complications Associated with Enteral Feeding
   Familiarity with potential complications is important in helping to prevent them from developing.
   4.5.1 Misplaced/Displacement of the tube
     If there is any suspicion that this has occurred, the feed must be stopped and the position of the tube
     should be checked.
   4.5.2 Blockage of the tube
     Make sure there are no kinks in tube. Water has always been the best choice in declogging tubes. Try
     to flush the tube with 25-50 ml warm water. Allow up to 30 minutes for the tube to clear then flush
     again. Note: Never push any guide wire into the tube
   4.5.3 Nausea and Vomiting
     4.5.3.1 Avoid giving the feed too quickly or in too large a volume. Seek advice of dietitian with regards
     to rate of feed or frequency of bolus feeds.
     4.5.3.2 Introduce the feed slowly (continuous or slow gravity bolus) as per dietitians advice
     4.5.3.3 Ensure the patient is not lying flat
     4.5.3.4 If the patient has a nasogastric tube and if vomiting occurs, check tube position
     4.5.3.5 Consider the use of antiemetic’s or gastric motility agents
     4.5.3.6 If symptoms are severe contact the managing dietitian. If out of working hours, do not feed for
     12 hours then restart feeding regime from the initial rate.