Tube feeding at home

Introduction

This information leaflet is for patients being discharged to the community setting (home or care setting) with a feeding tube for nutrition, hydration and/or medications. Your healthcare team will explain what is involved and answer any questions you may have. You will also receive a separate booklet which will explain how to care for your feeding tube.

What is tube feeding?

Tube feeding (also called enteral feeding) is the name given to a method of providing you with nutrition and hydration. Due to your medical condition or surgery, you may be unable to take enough food and/or drinks by mouth to meet your nutritional requirements. A feeding tube can help as it bypasses the need to swallow, meaning nutrition and/or medications can be delivered directly into your stomach or small bowel

How is the feed delivered

The method of feeding is based on the type of enteral feeding tube inserted.

For patients with a nasogastric tube or gastrostomy tubes placed in the stomach

• An enteral feeding pump (given at a prescribed set rate and duration)
• Bolus Feeding (given at prescribed intervals during the day using a syringe)

For patients with a Nasojejunal or Jejunostomy feeding tube inserted in the small bowel (Jejunum)

• An enteral pump (pump feeding) is used

Can I still eat and drink?

Your speech and language therapist (SLT), Dietitian or doctor can discuss with you about continuing to eat and drink even if you have a feeding tube placed. If an underlying swallowing problem is identified, the speech and language therapist (SLT) will perform a detailed assessment of your ability to swallow. SLTs will make recommendations regarding the means of achieving nutrition safely through, for instance, changing the consistency of drinks or food or strategies to improve the safety of the swallow.

What nutrition (feed) is put through the tube

Your dietitian will discuss specialised liquid food (feed) that is designed to provide your body with the nutrients (carbohydrates, protein, fats, minerals, and vitamins) that your body needs. They will also create a plan for you that will explain how much feed you need and when to have it. It is strongly recommended that only prescribed/ approved feed, fluid, and liquid medications are put through the tube to avoid damage and blockages.

Where do I get my feed?

When you leave hospital, you will be provided with a 10-day supply of feed (14 days your discharge date coincides with a Bank Holiday) and the provisions to set up your feed at home (includes feeding pump).

Deliveries at Home

Your dietitian and the nutrition nurse specialists will arrange for further supplies to be delivered to your home address by an enteral feeding company. Registration with a feeding company is essential to ensure you can continue feed and ancillaries (feeding sets and syringes) in the Community. They also provide Nutrition Nurses who can support training and troubleshooting for you at home. The company used will depend on your GP who will receive for feeding prescriptions.

If you plan to move house, use a temporary address or change GP please let your Dietitian or Nutrition Nurse know so that the necessary changes can be made for your deliveries.

The importance of good hygiene

It is important to maintain good hygiene and cleanliness when looking after your tube and setting up your feed. This is to reduce the risk of any harmful bacteria which may cause an infection either at your exit site or give you a stomach bug.

When should I wash my hands?

You should wash your hands before and after you touch your tube, exit site or any other products involved with tube feeding. Use warm soapy water to wash your hands and dry them thoroughly.

If you are looking after yourself, or if a family member is helping, you do not need to wear gloves.

Carers and other healthcare workers

• Personal Protective Equipment must be worn
• Hands must be decontaminated immediately before and after each episode of patient contact
• Wear disposable gloves for all manipulations to feed and tube.

Management of Syringes and Feeding Sets

Management of Syringes and Feeding Sets for:

• Patient in a care setting (residential or nursing home)
• Carers at home
• Patient who are diagnosed as being immunosuppressed
• Patients with a dual-purpose device (PEGJ or MIC KEY Gastrojejunostomy)

How to clean your re-usable syringes

Syringes and extension sets should be cleaned after each use

• Place syringe in warm soapy water
• Clean the end of the syringe by drawing soapy water in and out using the plunger until all traces of feed or medication have been removed
• Separate the syringe and plunger and wash in warm soapy water
• Rinse both parts of the syringe under the tap, shake off excess water
• Leave to air dry or dry with clean, disposable kitchen roll (do not use dishcloths or tea towel)
• Store the syringe still separated in a clean dry container with a lid

Do not place in the dishwasher as it can reduce the life of the syringes

Feed Container or Re-usable bottles

Feed containers or re-usable bottles are sometimes required for enteral feeding at home.

If you are advised to decant your feed into a container or bottle separate instructions for care will be provided by your Dietitian or Nutrition Nurse

When should I flush my feeding tube

It is important to flush your regularly or as advised tube to prevent blockages. Your dietitian may also request that you give some extra water in the day to make sure you have enough fluid and do not get dehydrated.

When to Flush:

• Before and immediately after each feed or medication.
• Between each individual medication dose.
• At least once daily if not feeding, typically every 4-6 hours

Equipment Needed to administer a water flush

• A clean cup
• A clean 60ml enteral syringe
• Water (see table)

Please note

Do not flush your feeding tube with hot water. To get cooled boiled water

1. Boil your kettle
2. Let it cool down
3. Keep in a clean bottle which can be used for water flushes for 24hours

Before completing a water flush

Position: Maintain an upright position (at least 30-45 degrees) when using your feeding tube for administration of feed, medication or water flushed.

Remain upright 30 minutes to an hour after flushing or feeding to prevent reflux

Nasogastric Tube patients: A gastric aspirate pH 5.5 or below must be obtained before introducing any water (flush), feed/supplement or medication

Step-by-Step Water Flushing:

1. Wash your hands with soap and water, dry then assemble your equipment
2. Draw the recommended amount of water into the syringe from a clean cup.
3. Close the clamp (if available) on your feeding tube, open the cap from your feeding tube, attach the syringe (then re-open the clamp if available)
4. Slowly press the plunger, using a "push-pause" technique, pausing briefly every 5mL to push water through until complete
5. Close the clamp (if available) on the tube before removing the syringe, then close the cap on the end of the tube (open the clamp if available).

Can I lie down flat if I am feeding at night?

It is important that your upper body is upright (an angle of about 30 to 45 degrees) when feeding through a feeding pump or bolus feeding and one (1) hour after your feed has completed. This helps to stop you feeling sick whilst feeding and to reduce the risk of chest infections. You will need to use additional pillows to achieve this position.

Pump feeding

Pump training can be provided in community or in hospital to you, your family or carers. Training is completed over a couple sessions to ensure you feel confident before discharge home.

What is bolus feeding?

This is when your feed is given using a syringe at intervals throughout the day.

A 60ml enteral syringe can be used to administer feed, water or medications via an enteral feeding tube. Both packs of enteral feed and oral nutritional supplements can be administered using this method.

Bolus feeding via a syringe can be administered by two different methods:

1. Using the plunger. The plunger remains in the barrel of the syringe. The feed, water or medication is pulled up into the syringe and plunged down the tube at a slow rate
2. By gravity with the plunger removed. The plunger is removed from the barrel of the syringe, prior to attaching it to the feeding tube. The feed, water or medication is poured into the barrel, the clamp on the tube released and allowed to flow down the tube under gravity.

Key safety point: Bolus Feeding through a nasogastric tube

If you are bolus feeding using nasogastric tube, you must check the position before each episode of use by obtaining a gastric aspirate reading of pH 5.5 or below. If the gastric aspirate reading (pH) is 6.0 and above, do not flush your nasogastric tube with water, administer any feed (supplement) or medication as this may cause you serious harm. Please contact your Nutrition Nurse or Dietitian for advice.

How to complete a Bolus Feed

1. Wash hands
2. Ensure feed is at room temperature
3. Check the expiration date
4. Sit upright at a 30 to 45-degree angle to prevent nausea and reduce risk of infection

Nasogastric Tube patients: A gastric aspirate pH 5.5 or below must be obtained before introducing any water (flush), feed/supplement or medication

Patients with a low-profile device: Attach a clean extension set

1. Flush the feeding tube with the prescribed amount of water using a 60ml enteral syringe
2. Draw up the enteral feed into the syringe
3. Attach syringe to your feeding tube or extension (open clamp if available)
4. Gently push plunger to deliver the feed

Rate of Bolus: The recommended rate is 50ml over three (3) minutes. This reduces the risk of reflux and bloating

1. Close clamp if present before removing syringe
2. Re- fill the syringe and repeat until you have completed the prescribed volume
3. Flush with water as per your feeding regime instructions after the required volume is completed
4. Wash, then air dry your syringe and extension set
5. Reseal any left-over enteral nutrition product, refrigerate and reuse within 24 hours

Giving medications through your tube

If you are unable to take your medications by mouth this can be given through the feeding tube.

Before using your feeding tube for medications, it is important that you, your family or Carer:

1. Contact your GP to inform them you are unable to take your medication by mouth and would like to use your feeding tube
2. Speak to your pharmacist who will ensure the medications are dispensed in the correct form with instructions for how they need to be prepared before administration

How do I give my medications?

It is very important to follow these instructions as medications can block your tube.

1. Flush your tube with at least 30mls water.
2. Ensure all medications are prepared separately and are mixed well or thoroughly dissolved in water (following the pharmacist instructions)
3. Give the medication quickly into the tube and flush immediately with at least 10ml water between each medication.
4. Never mix medications together for administration as this can cause tube blockages
5. Flush with at least 10ml water between each medication.
6. Flush your tube with at least 30ml water at the end.

Please note – Omeprazole or Lansoprazole can block the feeding tube

For enteral feeding tubes larger than 8Fr, the FasTab formulation can be dispersed in 10 ml of water and flushed down the feeding tube using a push–pull technique to keep the granules suspended.

What is a tube blockage?

This can usually occur after giving some medications or not flushing the tube at the end of a feed. Though blockages can be resolved, you are encouraged to prevent this by flushing before and immediately after feed and follow the instructions for administration of medications

Can I unblock my nasogastric Feeding tube

No, you must never attempt to unblock your nasogastric tube. It will not be safe to use if you were unable to obtain a gastric aspirate to check the pH 5.5 or below to confirm the tube is still in position in the stomach.

Please follow the nasogastric tube replacement plan which will be provided on discharge. Alternatively, contact your Dietitian or community Nutrition Nurse to arrange a replacement.

You will need to attend your nearest emergency department with your spare tube if your tube is blocked over a weekend or bank holiday and you are unable to maintain your nutrition and hydration by the mouth

For nasojejunal tube, surgical jejunostomy and PEG tube

Tube unblocking information can be found in your specific tube care booklet.

Mouth care

Why is it important?

Although you may not be eating or drinking it is important to keep your mouth and teeth clean to prevent infection or soreness from a dry mouth.

How do I keep my mouth fresh?

Continue to brush your teeth using a toothbrush and toothpaste. You can use a mouthwash if you are safe to drink or if you spit all of it back out. A lip balm can be used to prevent your lips from getting dry and cracking.

For information from the patient’s perspective please see:

PINNT: A Support Group for People Receiving Home Artificial Nutrition (opens in a new tab)

020 3004 6193

comms@pinnt.com

Who to contact about what

You will be trained in all the necessary techniques to look after the feeding tube and what to do if you do have problems. However, your community nurses, GP, dietitian, and nutrition nurse will be available to help and support you. Your dietitian or nutrition team will provide regular follow up. The company delivering your feed also has a nurse helpline.

1. If you have any concerns about your feed or plastics order (including syringes and dressings) – contact your feed company:

• Nutricia Homeward 0800 093 3674
• Abbott Hospital to Home 0800 0183799
• Fresenius Kabi 0808 100 1990

2. If you have any concerns about your PEG site or feeding pump – contact your feed company:

• Nutricia: 03457 623672
• Abbott: 0800 0183799
• Fresenius Kabi: 0808 100 1990

3. Please contact your local dietitian if you have any concerns about:

• any symptoms that suggest you are not tolerating your feed e.g. bloating, nausea
• your weight
• the amount or type of feed you take
• or if you need extra syringes or other supplies ordering
• or you want to discuss tube removal

4. Contact details for Enteral Nutrition Nurse Specialists

Monday – Friday (8am –4pm) excluding weekends and Bank Holidays

• Phone 01223 216 037 Option 1 for Enteral Nutrition
• Mobile 07710 365156