HOME TUBE FEEDING BASICS UBC DIETETICS PROGRAM Module 1 of 2
SCOPE OF THESE MODULES Modules 1 & 2 address the following Nutrition Care Process steps • Intervention • Monitoring and Evaluation Assessment and Diagnosis are not explicitly addressed in these modules, but are critical parts of providing tube feeding nutrition care Refer to your prior learning on assessment and diagnosis related to tube feeding nutrition care 2
LEARNING OBJECTIVES FOR THIS MODULE 1. Demonstrate knowledge of indications for home tube feeding 2. Determine a home tube feeding care plan 3
OUTLINE FOR THIS MODULE • Overview of home tube feeding • Development of a tube feed schedule • Tube feed delivery methods 4
OVERVIEW OF HOME TUBE FEEDING Indications for home tube feeding • For individuals with a functional GI tract • When oral intake is not possible or safe – tube feed exclusively • When oral intake is not sufficient to meet nutritional needs – tube feed to supplement intake • Need for tube feeding may be short-term or longer-term, depending on situation 5
OVERVIEW OF HOME TUBE FEEDING Situations that may require home tube feeding • Dysphagia, related to: Cancer (e.g. esophageal, gastric, laryngeal) Stroke Achalasia GI surgery • Inflammatory Bowel Disease with malnutrition • Chemotherapy/radiation treatment • Palliative prognosis • 6
OVERVIEW OF HOME TUBE FEEDING Home Tube Feeding is Suitable When: • It is acceptable to the individual and their family • The benefits outweigh the burdens and risks • The individual has resources, and is competent to manage tube feeding at home safely • Tube access is appropriate Long-term tube type (e.g. PEG, G-tube or J-tube) is optimal If NG/NJ tube is used - can individual and caregiver(s) manage? Most often not appropriate 7
DEVELOPMENT OF A TUBE FEED SCHEDULE 1. Determine the type and required volume of tube feed formula • Selection of formula depends on a number of factors • Refer to site-specific list(s) of enteral products for formula choices • Try to not mix two types of formula or recommend half cans/boxes when possible • Individuals may choose to use a formula available in hospital or an equivalent made by another company 8
DEVELOPMENT OF A TUBE FEED SCHEDULE Common formula types Indications Isotonic Standard product used for management of (1.0 kcal/ml) many conditions Elevated calorie and protein needs Calorie dense (1.2, 1.5 or 2.0 kcal/ml) Shortened feeding schedules Also often contain higher protein Fluid restriction/volume sensitivity Fibre-containing Maintain bowel function Some products may also contain higher calories and protein Increased protein requirements High protein Pressure ulcers (tissue maintenance/repair) 9
DEVELOPMENT OF A TUBE FEED SCHEDULE Specialty formulas Indications (selected examples) Acute or chronic renal failure Renal-specific Electrolyte restriction Diabetes Diabetes-specific Impaired glucose tolerance Acute stress-induced hyperglycemia Gastrointestinal impairment Semi-elemental or elemental Malabsorption Allergies/intolerances Food-based formulas Intolerance to standard formulas Some individuals may choose to Option for those who desire a real food make these at home, or purchase a component commercially made version 10
DEVELOPMENT OF A TUBE FEED SCHEDULE • Establish volume of formula needed based on calculated nutrition and fluid requirements • Gradual progression to goal volume may be needed depending on factors such as tube feed tolerance and refeeding risk • Consider changing to a more concentrated formula (e.g. 1.5 or 2 cal/ml) if you want to limit the volume of tube feeds (however, may need additional water flushes to meet fluid requirements) 11
DEVELOPMENT OF A TUBE FEED SCHEDULE 2. Design the administration schedule Options: • Continuous • Intermittent • Nocturnal/Cyclic 12
DEVELOPMENT OF A TUBE FEED SCHEDULE Continuous Feeds • Tube feeds are run 24 hours per day, often at a steady rate • Not commonly used for home tube feeding • Useful for individuals that can only tolerate small feed volumes or have hard to control blood sugars Considerations Restricts ambulation/activity Requires a pump 13
DEVELOPMENT OF A TUBE FEED SCHEDULE Intermittent Feeds • Tube feeds only run for part of the day, typically split into 3-4 feeds per day • Can be used to simulate mealtimes (when tube feeding is used exclusively) or as “ top-up feeds ” to supplement oral intake Useful for Individuals that can tolerate medium to large feed volumes Individuals who do not want to be hooked up to tube feeds all day 14
DEVELOPMENT OF A TUBE FEED SCHEDULE Cyclic (Nocturnal) Feeds • Tube feeds are delivered at night time only, often while asleep • Useful for individuals that can tolerate at least medium volumes and who may be eating during the day • May be preferred by individuals who work/study during the day Considerations Increased need to use the bathroom at night Head of bed must be > 30 degrees while sleeping May need to get up and add more feed during the night Requires a feeding pump 15
DEVELOPMENT OF A TUBE FEED SCHEDULE 3. Determine water flushes Water flushes are administered to: • Provide hydration • Keep tube clear • Administer medications Considerations: Free water in tube feed formula and flushes contribute to overall fluid requirement Extra water needed for emesis, diarrhea, fever 16
TUBE FEED DELIVERY METHODS Options • Syringe • Gravity • Pump • Closed Systems • Open Systems 17
TUBE FEED DELIVERY METHODS Syringe • Fastest and most cost-effective method; becoming more prevalent as first choice for intermittent feeding • Sometimes referred to as “ bolus feeding ” • Tolerated better when tube terminus is in the stomach (e.g. G tube, PEG) • Individual or caregiver(s) must have manual dexterity and strength to administer feeds with syringe • IV pole not needed 18
SYRINGE FEEDING Demonstration of syringe feeding: https://www.youtube.com/watch?v=EYs2xR-e3To 19
TUBE FEED DELIVERY METHODS Gravity • Typically recommended for intermittent feeds, and when tube terminus is in the stomach (e.g. G tube, PEG tube) • May be used in combination with syringe method if tolerated • IV pole not always required • Gravity feeding may be used instead of pump feeding for a variety of reasons: cost, convenience, minimal skill needed to operate, ease of use 20
GRAVITY FEEDING Demonstration of gravity feeding: https://www.youtube.com/watch?v=LD5bPwArd2Q 21
TUBE FEED DELIVERY METHODS Pump • Typically recommended for Small bowel feeding (e.g. J tube), but can also be used in other parts of the GI tract Thicker/energy dense formulas (e.g. 2.0cal/ml) Continuous or nocturnal feeds Slower feeding rates Hospital-based feeding • May be required for intermittent feeds if cannot tolerate syringe or gravity • IV pole needed for some pumps 22
PUMP EXAMPLES EnteraLite Infinity (Bowers Medical) • Max rate 600 ml/hr • Small pump (<1 lb) ideal for active lifestyles • IV pole not required Refer to Health Authority site specific information for available pumps 23 Image source: http://infinityfeedingpump.com/virtual-pump/
PUMP EXAMPLES Compat (Medline) • Max rate 295 ml/hr • Large pump ideal for more sedentary lifestyles or when dexterity or vision are issues (has large buttons) • IV pole recommended for use Refer to Health Authority site specific information for available pumps 24 Image source: http://www.medline.com/product/Compat-Enteral-Feeding-Pumps/Pumps/Z05-PF10589;ecomsessionid=JjwvzQ2kdAEDzc136y7Mcw__?_requestid=10480993
PUMP FEEDING Demonstration of pump feeding (with an open system): https://www.youtube.com/watch?v=XZh0XZ_pTIk 25
TUBE FEED DELIVERY METHODS Closed System • Pre-filled 1 liter or 1.5 liter container or pouch of formula • Containers are spiked/pierced with a feeding set before feeding • Typically used with pumps, some products may be suitable for gravity delivery (check with product guides and reps) • Feeding sets need to be compatible with the brand of pump Syringe for flushes 26 Images sourced from: https://www.nestlehealthscience.ca/en and https://www.cardinalhealth.ca/en/docs/05_NUTRITION.pdf
TUBE FEED DELIVERY METHODS Closed System Advantages • More convenient (no cleaning involved) • Sterile- less risk of contamination • Typically 48 hour hang time (refer to product guides for details) Disadvantages • Only available in 1 liter or 1.5 liter sizes • Not refillable or reusable • Requires a new spike set for each bottle or pouch 27
TUBE FEED DELIVERY METHODS Open System • Ready-to-use liquid formula in tetras, bottles or cans • Formula is poured into a feeding bag or administered with a syringe for feeding • Can be used for pump, gravity or syringe feeding • Different equipment required for pump vs. gravity vs. syringe feeding 28
TUBE FEED DELIVERY METHODS Syringe feeding with an open system requires: syringes for formula and water flushes, formula (images are examples only) 29 Images sourced from: https://www.nestlehealthscience.ca/en/brands/isosource/isosource and https://www.nestlehealthscience.ca/en/mytubefeedingadult
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