Acute Nutrition Policy

Nutrition Policy for
East Kent Hospitals University

NHS Foundation Trust
Document Reference No: To be allocated by Policy Development Manager when

document is approved.
Status: Ratified
Version Number: 5.0
Replacing/Superseded Policy or Replacing Nutrition Guidelines
Documents:
Number of Pages: 79
Target Audience/Applicable To: All acute hospital staff involved in supporting the
nutritional needs of patients
Author: Abi Mogridge
Acknowledgements: Acute Hospital Staff
Dietetics
Contact Point of Queries: abi.mogridge@eastcoastkent.nhs.uk
Date of Implementation: 1st December 2009
Circulation Group: Membership of Dietetics, all relevant stakeholders
across East Kent Hospitals University NHS
Foundation Trust, Acute Governance groups, Dietetic
Clinical Governance, Nutrition Steering Group, Acute
Therapies Governance Group and all acute Hospital
staff
Review Date: December 2011
Expiry date: December 2012
Copyright NHS Eastern and Coastal Kent Community Services &
East Kent Hospitals University NHS Foundation Trust
1st December 2009 Page 1 of 79

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East Kent Hospitals University NHS Foundation Trust Nutrition Policy
1.0 EXECUTIVE SUMMARY
Scope of Policy
This policy has been developed by a multidisciplinary group of professionals from across the health
economy of East Kent to establish best practice with regard to the nutritional support of adult
patients.
Governance Arrangements
Governance or Function Dietetics and Nutrition.
Group responsible for
developing document
Consultation Membership of Dietetics, Adults Services and Childrens
Governance Groups. All acute Hospital staff
Authorised/Ratified by Clinical Management Board
Governance or Function
Group
Authorised/Ratified On 20th November 2009
Review Date December 2011
Review criteria This document will be reviewed on review date or if a legislative
change or other event otherwise dictates.
Key References
NICE Guidance 32 Nutrition Support in Adults (February 2006)
http://www.nice.org.uk/page.aspx?o=cg032quickrefguide
Department of Health guidelines; Reference guide to consent for examination or treatment 2001
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/D
H_4006757
Mental Capacity Act 2007 http://www.dca.gov.uk/legal-policy/mental-capacity/mca-cp.pdf
Clinical Resource Efficiency Support Team (CREST) 2004 Guidelines for the management of
enteral tube feeding in adults http://www.crestni.org.uk/tube-feeding-guidelines.pdf
A Guide to Equality Impact Assessment, NHS Eastern and Coastal Kent Community Services
2008
http://www.easternandcoastalkent.nhs.uk/EasysiteWeb/getresource.axd?AssetID=39762&type=F
ull&servicetype=Attachment
Related Policies/Procedures
Protected Mealtimes
Red Tray
Vascular Guidelines

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Document Tracking Sheet
Multi-Agency Public Protection Arrangements Policy & Procedure
Version Status Date Issued Comments

to/approved by
5.0

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CONTENTS
Page
1. EXECUTIVE SUMMARY 2
Cope of Policy 2
2. INTRODUCTION 6
3. THE ETHICAL PRINCIPLES OF NUTRITION 8

3.1 Considerations 8
3.2 The Dying / Terminally Ill Patient 9
3.3. Nutrition Screening 10
3.4 Screening for Malnutrition Risk 11
3.5 Outcome of MUST 12
3.6 General Advice for Improving Nutritional Intake 13
3.7 Referral to Dietetic Department 14
4. PROVISION OF FOOD FOR ADULT INPATIENTS 15

4.1 Availability of Food 15
4.2 Menus 15
4.3 Meals 156
4.4 Snacks 16
4.5 Drinks 16
4.6 Therapeutic Diets 16
4.7 Equipment 16
5. ROLES AND RESPONSIBILITIES 17

5.1 General 17
5.2 Nursing Staff 17
5.3 Hotel Service Staff 17
5.4 Other Healthcare Professionals 17
5.5 Dietitian 17
5.6 Pharmacist 17
6. ORAL NUTRITIONAL SUPPLEMENTS (ONS) 18

6.2 Key Points 18
6.3 Use of ONS 18
6.4 ONS on Discharge from Hospital 19
6.5 First Line ONS Used Within East Kent Hospitals University NHS Trust 19
7. ENTERAL FEEDING 20
7.3 Indications 20
7.4 Contraindications 20
7.5 Decision making for Alternative Feeding 20
7.5.3 Decision making for Alternative Feeding (Cont.) 21
7.6 Commencing Enteral Nutrition 22
7.7 Nasogastric Feeding (NG) 22
7.8 Key Points for Nursing Care Of NG Feeding Tubes 23
7.9 Tube Placement and Care of Patient with NG Tube 23
7.10 Discharge of adult patients into the community with a nasogastric tube 25
7.11 Gastrostomy Feeding 25
7.12 Pre-placement Patient Care of a gastrostomy 26
7.13 Patient Care immediately Post-placement of a gastrostomy 26
7.14 Care of the Stoma Site 26

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7.15 Care / Replacement of a PEG 28

7.16 Care / Replacement of a RIG 29
7.17 Prophylactic Tube Placement 31
7.18 Nasojejunal Feeding 32
7.19 Jejunostomy Feeding 34
7.20 Discharge of Enterally Fed Patients from Hospital 36
7.21 Discharge to Patient’s Home and Nursing Homes 37
7.21.1 Nursing Responsibilites 37
7.21.2 Dietetic Responsibilities 38
7.22 Enteral Feed Problem Solving 39
7.24 Commencing oral diet 41
7.25 Oral Hygiene 412
7.26 Mouthwashes 412
7.27 Stimulating saliva production 412
7.28 Mouth Care 412
8. PRESCRIBING, PREPARING AND ADMINISTERING MEDICINES FOR USE IN

ENTERAL FEEDING SYSTEMS 43
8.1 Prescribing 43
8.2 Medication Review 44
8.3 Formulations suitable for use in enteral feeding systems 43
8.4 Administration 44
8.5 Documentation 45
8.6 Sources of Information 45
8.7 Disposal of pharmaceutical waste 45
9. PARENTERAL NUTRITION (PN) 466

9.1 Indications 46
9.2 Contraindications 46
9.3 Complications 46
9.4 Assessment 47
9.5 Route of Access 47
9.6 Management of Catheters 47
9.7 Commencing PN 48
9.8 Mode of Delivery 48
9.9 Pumps 48
9.10 Feeding Solutions 48
9.11 Administration 49
9.12 Biochemistry and Monitoring 50
9.13 Stopping PN 51
10.0 RE-FEEDING SYNDROME 52

10.1 Mechanism of Refeeding Syndrome 52
10.2 Consequences of Refeeding Syndrome 52
10.3 Degree of Risk of Refeeding Syndrome 52
10.4 Standard Pharmaceutical Recommendations for Supplementation 53
10.5 Standard Dose Regime 55
10.6 High Dose Regime 55
10.7 Feeding Recommendations 56
11. IMPLEMENTATION INCLUDING TRAINING AND AWARENESS 57
12. STAKEHOLDER, CARER AND USER INVOLVEMENT 57
13. APPENDICES 58
14. REFERENCES 78

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2. INTRODUCTION
2.1 It is widely accepted that nutrition plays an important role in maintaining optimal health.
Under-nutrition results from decreased dietary intake, increased nutritional requirements or
impaired ability to absorb or utilise nutrients. The results of under-nutrition vary from
structural changes, such as loss of body tissue, to widespread physiological and functional
effects. These may include:
• Impaired immune function
• Delayed wound healing
• Increased risk of tissue breakdown
• Muscle wasting and weakness affecting respiratory function, cardiac function or
mobility.
• Altered structure of small intestine resulting in mal-absorption
• Apathy and depression
• General sense of weakness and illness
2.2 The NICE guidance 32 Nutrition Support in Adults (February 2006) identified that currently,
knowledge of the causes, effects and treatment of malnutrition among healthcare
professionals in the UK is poor. This policy aims to help healthcare professionals working
within the East Kent Hospitals University NHS Hospitals Foundation Trust (EKHUFT) and
the NHS Eastern and Coastal Kent Community Services (ECKCS) to correctly identify
people in care who need nutrition support, and enable them to deliver timely and
appropriate interventions to ensure cost effective use of resources.
2.3 Purpose
To achieve and maintain a high quality nutritional care for all, the policy provides
comprehensive instructions on oral, enteral and parenteral nutrition. It contains information
and practical instruction on equipment, management and monitoring and infection control.
2.4 Rationale
Malnutrition is a state in which a deficiency of nutrients such as energy, protein, vitamins
and minerals causes measurable adverse effects on body composition, function or clinical
outcome. Under-recognised and under-treated, malnutrition affects at least 2 million people
in the UK. It leads to delayed recovery, increased visits to GP and increases the frequency
and length of hospital stay. Public expenditure on disease-related malnutrition in the UK in
2007 has been estimated at in excess of £13 billion per annum. In summary, under-nutrition
can lead to considerable increases in morbidity, mortality and associated cost to both the
patient and the health service. Nutritional screening and appropriate referral can assist in
the prevention and treatment of malnutrition. The department of Nutrition & Dietetics has
adopted the approved screening tool MUST. (Appendix 1)
2.5 Malnutrition is both a cause and a consequence of ill health, increasing a patient’s
vulnerability to disease. Methods to improve or maintain nutritional intake are known as
nutrition support. These include:
• Oral nutrition support – for example, fortified food, additional snacks and/or Oral
Nutritional Supplements
• Enteral tube feeding – the delivery of a liquid feed directly into the gut via a tube
• Parenteral nutrition – the delivery of nutrition intravenously.

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2.6 Treatment and care should take into account patients’ needs and preferences. People with
malnutrition should have the opportunity to make informed decisions about their care and
treatment, in partnership with their health professionals. When patients do not have the
capacity to make decisions, healthcare professionals should follow the Department of
Health guidelines – guide to consent for examination or treatment (2001)
2.7 It is the responsibility of all healthcare professionals to ensure that nutritional care is an
integral part of their practice.

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3. THE ETHICAL PRINCIPLES OF NUTRITION
3.1 Considerations
3.1.1 Key Points
The provision of food and water constitutes ‘basic care’ and is mandatory for all patients
(BAPEN 2004).
The administration of nutrition via a feeding tube is a medical intervention and requires
consent (verbal or written, being documented in the patient records), subject to the mental
capacity of the patient (see below).
• A patient’s nutritional care plan must focus on their needs and wishes.
• Patients should have the opportunity to make informed decisions about their care and
treatment, in partnership with their health professionals.
When patients do not have the capacity to make decisions, healthcare professionals should
follow the Department of Health guidelines – Reference guide to consent for examination or
treatment (2001):
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuida
nce/DH_4006757
and the Mental Capacity Act 2007:
http://www.dca.gov.uk/legal-policy/mental-capacity/mca-cp.pdf
3.1.2 Carers and relatives should have the opportunity to be involved in decisions about the
patient’s care and treatment, if the patient agrees to this. Carers and Healthcare
professionals involved in starting or stopping nutrition support should:
• obtain consent from the patient if he or she has capacity
• act in the patient’s best interests if he or she lacks capacity
• be aware that the provision of nutrition support is not always appropriate. Decisions on
withholding or withdrawing of nutrition support require a consideration of both ethical
and legal principles and staff should always consider taking legal advice from the
Trust’s Legal Services Department
3.1.3 For further information see withholding and withdrawing life prolonging treatments: Good
practice in decision making. General Medical Council. Available from:
http://www.gmc-uk.org/guidance/current/library/witholding_lifeprolonging_guidance.asp

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3.2 The Dying / Terminally Ill Patient
3.2.1 People at the end of their lives may eat very little; this is a natural process and should be
accepted.
3.2.2 When a patient enters the Care of the Dying Pathway (Liverpool care pathway),
consideration should be given to their individual nutrition and hydration needs.
3.2.3 If nutritional support is to be withheld /withdrawn on the grounds that this will prolong the
dying period for patients with poor prognosis, oral fluid and food should still be offered as
“basic care” as appropriate. Intravenous or subcutaneous hydration should not be initiated /
continued as this will prolong the dying process. A careful explanation of this to the patient
and family should take place and be documented in the patient’s records. See the Care of
the Dying Pathway for further information
3.2.4 A trial period of artificial feeding may be appropriate e.g. in a patient suffering a dense
stroke, but withdrawn after an agreed period where there are no signs of recovery. Careful
explanation to the family is necessary and should be recorded in the patient’s records. For
guidance see:
http://www.gmcuk.org/guidance/current/library_witholding_guidance.asp#Artificial%20nutriti
on%20and%20hydration2

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3.3 Nutrition Screening
3.3.1 This is the first step in identifying subjects who may be at nutritional risk or potentially at
risk, and who may benefit from appropriate nutritional intervention. It is a rapid, simple and
general procedure used by nursing, medical, or other staff on first contact with the subject
so that clear guidelines for action can be implemented and appropriate nutritional advice
provided. Some subjects may just need help and advice with eating and drinking; others
may need to be referred for more expert advice.
3.3.2 NICE 32 (2006) recommend screening for malnutrition and risk of malnutrition across all
healthcare settings.
3.3.3 Patients within all healthcare settings across East Kent will be screened using the
Malnutrition Universal Screening Tool (MUST). This tool was developed by the Malnutrition
Advisory Group which is a standing committee of the British Association of Parenteral and
Enteral Nutrition (BAPEN) www.bapen.org.uk it is a nationally validated tool for use in both
acute and community settings.
3.3.4 MUST screens for malnutrition by looking at current weight, weight history and likely
nutritional intake. MUST categorises patients into three groups; low (Score 0), medium
(Score 1) and high risk (Score ≥2) of malnutrition

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3.4 Screening for Malnutrition Risk
3.4.1 Key Points

Patients admitted to East Kent Hospitals University NHS Foundation Trust will be screened
using the Malnutrition Universal Screening Tool (MUST) within 24 hours of admission and
weekly thereafter. See Appendix 1.
Copies of MUST are available on all wards.
All staff using the screening tool must be trained in its application. Training is provided on
an on-going basis by local Dietetic teams, via ‘Train the trainer’ route or e-learning.
MUST should aid rather than replace clinical judgement
Improving the food intake of malnourished patients is the first step in nutritional intervention.
Oral nutritional supplements are only to be used when this has not been successful
Action Rationale
Adult patients will be screened using To ensure that:
MUST within 24 hours of admission to a 1. Patients are assessed using the same
ward and appropriate action taken and criteria.
documented weekly thereafter. 2. Intervention for malnutrition or risk of
malnutrition is commenced early.
Adult patients admitted to the Renal To ensure that:
Wards will be screened using the Renal 1. Patients are assessed using the same
Screening Tool (see Resource Folder on criteria.
Renal Wards), within 24 hours of 2. Intervention for malnutrition or risk of
admission to the ward and appropriate malnutrition is commenced early.
action taken and documented Renal patients have specialised needs
and therefore a different screening tool is
used.
Patients admitted to ITU and women Patients admitted to ITU are deemed at
admitted to give birth will not be high risk of malnutrition.
screened. Women giving birth are considered to be
healthy.
A summary of the patients’ weight, To ensure that interventions can be
MUST scores and nutritional care plan continued on discharge
will be included on the discharge
summary if appropriate.

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3.5 Outcome of MUST
Step 1: BMI Score

+
Step 2: Weight Loss Score
+
Step 3: Acute disease effect score
= MUST Score
Score 1
Score 0
Medium Score 2 +
Low Risk of
Risk of High Risk of
Malnutrition
Malnutrition Malnutrition
Encourage oral
Intervention Urgent action
intake
required required
Screen weekly
• Monitor intake with Food Record Chart and • As for Score 1 and:
other systems (e.g. red tray) • Use oral nutritional
• Encourage and support patient’s intake of supplements in addition to
energy-dense choices from the menu, energy / protein dense meals
• Encourage energy dense snacks between and snacks to help improve
meals and aim for 1 pint of full cream milk nutritional status
per day to help improve nutritional status • Refer to the Dietitian
Improvement No improvement
• Continue to • Refer to Dietitian for
support using the assessment
monitoring • Use first line oral nutritional
systems supplements daily as well as
• Screen weekly to the energy dense meals and
assess status snacks
• Continue to monitor closely

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3.6 General Advice for Improving Nutritional Intake
3.6.1 The first course of action for treating malnutrition is through normal food. Exploring the
underlying reasons for a patient’s poor nutritional status, and treating those conditions, is
an effective way of dealing with their malnutrition. Wherever possible, the aims of the
nutritional intervention needs to be discussed with the patient, and documented in their
notes.
3.6.2 Making the mealtime experience as conducive to eating as possible is essential in ensuring
the patient’s nutritional care. Protected Mealtimes are implemented on all wards.
3.6.3 Please refer to the specific EKHUFT Protected Mealtime Policy, found at:
http://www.ekhut.nhs.uk/EasysiteWeb/getresource.axd?AssetID=24528&type=full&servicet
ype=Attachment
3.6.4 Please refer to the EKHUFT Red Tray Clinical Guidelines

ype=Attachment
3.6.5 For patients with a MUST score of 1 or above, there are certain procedures to follow:
• Serve meals on a Red Tray. This indicates it should not be removed until a record of
the food consumed has been made.
• Use the Trust’s Food Record Chart to document the food consumed so an estimation of
intake can be calculated, thus aiding planning of nutrition care. See Appendix 2
• Extra help and encouragement should be given to these patients to eat and drink,
giving help if necessary and enlisting the help of relatives / carers if appropriate and
acceptable to the patient.
• Patients with a MUST score of 1 or above need an energy and nutrient dense diet.
They should be encouraged and helped to pick the high energy choices highlighted on
the menu and have high protein / energy snacks between their meals. See Appendix 3
for further details.
• Ensuring that the patient is in a comfortable and appropriate position for eating can help
to increase their food intake.

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3.7 Referral to Dietetic Department
3.7.1 Dietitians are experts in conducting nutritional assessment, intervention and monitoring. All
patients must have comprehensive nutritional screening. Patients with a MUST score of 1
or above should be referred to the Dietetic Department as per the flow chart in 3.5 Outcome
of MUST. Patients should also be referred to the Dietetic Department if they require
specialised nutritional input e.g. low phosphate / potassium diet for renal failure, newly
diagnosed Type 1 diabetes etc or alternative feeding. Dietitians accept electronic referrals
from all Healthcare Professionals.
3.7.2 Special considerations should be given to the following patient groups:
3.7.2.1 Patients with Clostridium Difficile:

Patients who have Clostridium Difficile are at an increased risk of developing malnutrition.
These patients must be referred to the dietitian immediately.
3.7.2.2 Patients with Suspected bowel obstruction:

Patients who have a suspected small bowel obstruction must be referred to the dietitian
immediately.
3.7.2.3 Patient on enhanced recovery programme:

Patients who are part of the Enhanced Recovery Programme should be referred to the
dietitian when they attend pre-assessment clinic.
3.7.3 Renal patients should be referred directly to the Renal Dietitians: electronic referrals are not
accepted for renal patients at Kent and Canterbury hospital.
3.7.4 Key Points

• All wards have a designated Dietitian to support patient care as part of the
Multidisciplinary Team.
• The Dietetic Department will only accept electronic referrals for adult inpatients
• The Dietitian will respond to an electronic referral within 2 working days.
• A patient who is refusing to eat and drink, or who is in a terminal phase of their illness
may not be appropriate for referral.

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4. PROVISION OF FOOD FOR ADULT INPATIENTS
Patients will be provided with a choice of appetising and nutritious food and drink which
reflects and meets their dietary needs and tastes. This includes religious, cultural and
ethnic needs as well as healthy eating choices and therapeutic diets such as high protein /
energy and modified texture.
4.1 Availability of Food
4.1.1 Food will be available for patients 24 hours per day.
4.1.2 Ad hoc meals will be provided for:

• Inpatients who are admitted outside scheduled meal times, or are receiving treatment
during scheduled meal times;
• Patients in the Diagnostic and Treatment Centres
• Upon request during kitchen opening times
4.1.3 Hot meals will be supplied during normal kitchen hours. Outside these hours meals will be
supplied via local arrangements utilising ward kitchens / snack boxes and ‘mini bites’.
4.2 Menus
The menus will provide between 1200 and 2500 kcal/day with an average of between 1800
and 2200 kcal/day
4.2.1 There will be a choice of 5 menu items of fruit and vegetables per day within the menu
selection.
4.2.2 Patients are to be given help with choosing from the menu where necessary and
appropriate menus must be provided to meet the needs of the patient for example language
other than English or pictorial menus.
4.2.3 The menus are coded to help with appropriate choices. Meals will be coded for the
following options:
• Healthier Choice
• Energy Dense Choice
• Vegetarian
4.2.4 Separate menus are available for modified texture diets at the William Harvey and Kent and
Canterbury hospitals. The textures available are soft and pureed. For soft mashable meals,
the soft option should be mashed by the nursing staff at ward level. At QEQM, modified
textured meals are available on the ‘Steamplicity’ menu.
4.2.5 A separate menu is available for use by the Dietetic Department to order specialised meals
to meet specific individual dietary needs.

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4.3 Meals
4.3.1 Food is to be presented in an attractive manner.
4.3.2 At KCH and WHH, A choice of small, medium and large portion sizes is provided. At
QEQM, a standard portion size is provided.
4.3.3 Sufficient time is to be allowed for patients to finish their meals as per the Protected
Mealtime Policy.
4.3.4 At all sites elderly patients and patients on special diets shall have the option of a cooked
breakfast in the morning.
4.4 Snacks
4.4.1 Biscuits are to be offered as snacks at mid morning and after supper. Patients who have
difficulty swallowing will be offered an alternative e.g. custard dessert.
4.4.2 ‘Mini bites’ are available for patients under the care of the Dietitians. ‘Mini bites’ are snacks
that can be stored at ambient temperature for the patient to eat throughout the day. They
are delivered on the lunch trolley and should be kept by the patient’s bedside. There are
two types of ‘mini bites’ available, sweet (cakes and biscuits) and savoury (crisps, cheese
and cheese sandwich biscuits). ‘Mini bites’ can only be ordered by the Dietitian for patients
who have been referred to them for additional nutritional support.
4.5 Drinks
4.5.1 Patients are to be provided with 7 hot beverages daily.
4.5.2 Water jugs and glasses on patients’ bedside lockers are to be changed twice a day. The
water jugs must be cleaned when the water is changed.
4.5.3 Patients will be provided with one pint of full fat milk daily as a beverage by catering as
standard. Lower fat milks are available on request.
4.6 Therapeutic Diets
4.6.1 If a patient requires a therapeutic diet ward staff should liaise with catering staff to ensure
the correct meals are provided.
4.6.2 Fortified soups and puddings can be arranged by the Dietitian for patients requiring a high
protein / calorie diet.
4.6.3 Gluten free meals will be provided on request of the nursing staff. A Dietitian will only be
involved in gluten free meals if the patient is newly diagnosed as Coeliac or requires
another therapeutic diet as well as a gluten free diet.
4.7 Equipment
4.7.1 Specialist crockery and cutlery for patients with special requirements will be available from
catering.
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5. ROLES and RESPONSIBILITIES
5.1 General
All registered nurses must ensure they are competent and confident to deliver any care
they provide for a patient (Nursing Midwifery Council 2004). The involvement of Health
Care Assistants (HCA) in the delivery of patient care is increasing. Registered nurses must
ensure that before they delegate any aspect of patient care to a HCA, she/he has the
understanding and competency to fulfil the care required.
5.2 Responsibilities of hospital staff – Nursing
• Assess and monitor nutritional status on a regular basis and act on assessment
outcomes
• Ensure patient receives appropriate nutrition and hydration
• Ensure patients are given modified fluid and diet if required.
• Ensure patients receive assistance to eat and drink
• Ensure Protected Mealtimes Policy is adhered to
• Ensure Food charts are completed correctly and acted on
• Refer to appropriate healthcare professional to support patient’s nutritional needs
• Ensure all patients are discharged appropriately, with referral to relevant healthcare
professionals within the community
5.3 Responsibilities of Hotel Services Staff
• Provision of meals 24 hours a day

• Meal provision ensures the needs of all patients are met, including clinical, cultural and
religious needs
5.4 Responsibilities of other Healthcare Professionals (Speech and Language Therapist

(SLT); Occupational Therapist; Physiotherapist)
• Holistic management of the patient, including nutrition

• Inform nursing / medical staff of any potential nutritional issue which may not be met
• SLT are specialists in assessing swallow and advising on appropriate textures for food
and fluids.
5.5 Responsibilities of Hospital Dietitian
• On receipt of a referral liaise with the nursing and medical teams

• Assess and develop an individual nutritional care plan
• Monitor and review nutritional care plan until patient is discharged
• Prior to discharge, liaise with appropriate healthcare professionals
• Post discharge arrange for suitable healthcare professional to visit the patient i.e. Home
Enteral Nutrition (HEN) Team for patients with artificial nutrition.
5.6 Responsibilities of Pharmacist
• Dispensing of feed for parenterally fed patients

• Dispensing of medicines in suitable form for optimal up-take
• Advising on suitability and timing of administration of medicines for enterally fed
patients

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6. ORAL NUTRITIONAL SUPPLEMENTS (ONS)
6.1 General
Oral nutritional supplements can be liquid, semi-solid or powder formulations that are
designed to increase nutritional intake. There are a variety of types of supplements, from
single macronutrient e.g. fat supplements to provide energy, to supplements which can be
used as a sole source of nutrition.
6.2 Key Points
6.2.1 ONS are costly and must be used appropriately.
6.2.2 If sufficient nutrition cannot be achieved via normal food, ONS can be a useful addition to
the diet and can improve clinical outcome.
6.2.3 ONS should only be used when efforts to improve a patient’s nutritional intake using normal
food have been unsuccessful.
6.2.4 First line ONS should be offered to patients as per section 3.5 Outcome of MUST
6.2.5 The Dietitian will assess referred patients to decide the need for more specialised
nutritional products.
6.2.6 No samples of ONS are to be given to patients or healthcare professionals by Company

Representatives.
6.3 Use of ONS
6.3.1 Patients must be correctly identified as being at risk of malnutrition using MUST and
documented as such before oral nutrtional supplements are commenced.
6.3.2 Patients needing ongoing oral nutritional supplements will have them written on the drug
chart by the Dietitian
6.3.3 Patients should be offered a choice of flavours of oral nutritional supplements
6.3.4 Patients should take oral nutritional supplements in addition to their normal meals and not
as a meal replacement
6.3.5 Oral nutritional supplements should be offered at suitable times for the patient, i.e. in
between meals or after meals. They should not be offered prior to serving a meal.
6.3.6 Nursing staff should document the type and amount of oral nutritional supplement
consumed on the food record and fluid charts.
6.3.7 Nursing staff should inform the Dietitian if the patient is not taking their oral nutritional
supplements
.

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6.4 ONS on Discharge from Hospital
6.4.1 On discharge the efficacy of hospital based nutrition interventions should be reassessed
and ongoing goals for the patient negotiated. The need for ONS should be reviewed as part
of this process.
6.4.2 If a patient has been referred to the Dietetic Service for oral nutritional support during their
hospital stay, the supervising Dietitian will decide if the patient needs ONS on discharge
and will write to the patient’s GP giving a summary of Dietetic care and to request ongoing
supplies if necessary. The patient will also be referred to the Community Support Team for
ongoing follow-up.
6.4.3 If a patient is discharged to a care home, the Dietitian will liaise with the care home staff to
discuss treatment goals. The patient will also be referred to the Community Support Team
for ongoing follow-up.
6.4.4 A 5 day supply of ONS for discharge will be supplied to the patient by the Dietetic
Department.
6.4.5 If the patient has been taking ONS and has not been referred to the Dietitians prior to
discharge, supplies will not be provided and the GP will not be contacted. Ward supplies
should not be used on discharge in this instance.
6.4.6 The Indications for prescription of supplements in the community are:

• Disease related malnutrition
• Short bowel syndrome
• Intractable mal-absorption
• Preoperative preparation of malnourished patients
• Inflammatory bowel disease
• Dysphagia
• Bowel fistula
Action Rationale
Inform the ward Dietitian as early as To enable the GP to be contacted for the
possible of the discharge date of ongoing prescription of ONS. To enable
Dietetically referred patients taking ONS. supplies for discharge to be delivered to the
ward.
6.5 First Line ONS Used Within East Kent Hospitals University NHS Foundation Trust
6.5.1 The first line ONS to be used is milk or juice based and comes in a wide range of sweet
flavours. Please refer to Ward Resource Folder for information on appropriate
supplements. Wards will also have posters of suitable supplements.
6.5.2 If a patient does not tolerate this, the patient needs to be referred to the Dietitian as a
matter of urgency.

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7. ENTERAL FEEDING
7.1 Enteral nutrition is the process whereby nutrition is administered via the gastrointestinal tract.
For the purposes of this policy, this includes nasogastric, gastrostomy, jejunal and
nasojejunal feeding.
7.2 Patients requiring nutritional support, who have a functioning gastrointestinal tract, should be
fed enterally as this maintains gut integrity. Enteral feeding is superior to parenteral nutrition
in terms of physiology, immunology and cost, and has numerous clinical advantages such as
helping to maintain normal intestinal function and structure (McClave et al 1999).
7.3 Indications
7.3.1 When the gut is functional and accessible, the enteral route of support is preferred. If oral or
dietary intake remains compromised for more than 5-7 days artificial nutritional support in
the form of enteral tube feeding may be required. The decision will normally be made in the
secondary care setting and the required intervention undertaken (CREST 2004). Enteral
feeding may be initiated earlier if the patient is already considered malnourished.
7.4 Contraindications
• Mechanical obstruction
• Prolonged ileus (>72 hours)
• Proximal GI Tract Fistula
7.5 Decision making for Alternative Feeding
7.5.1 The decision to commence Enteral Nutrition must be made in consultation with the
Consultant, Dietitian, Nursing Staff, Speech and Language Therapist, patient and their
carers.
7.5.2 The route of access is dependent on the patient’s diagnosis and prognosis; see following
chart:

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7.5.3 Decision making for Alternative Feeding (Cont.)
Unable to meet nutritional requirements via oral route –

Gut functioning: Consider Enteral feeding
Stomach functioning and accessible Stomach

inaccessible:
Consider
Nasojejunal or
Jejunostomy
Immediate or Short Long term (> 4 weeks) or

Term Support NG not tolerated:
needed: Consider Consider PEG, RIG,
Nasogastric (NG) Balloon Gastrostomy
A wide bore tube may be used

when tube is in place primarily for
gastric aspiration or decompression.
Fine Bore (10f) Nasogastric tube
When the tube is purely for feeding, it
should be used whenever possible
should be changed to a fine bore NG
for NG feeding. It can be left in
tube as soon as possible to minimise
place for 30 days
irritation to nasal and oesophageal
BAPEN 1999 tissues and improve patient comfort
If NG feeding Consider Nasal Bridle if

continues for 14 days NG is pulled out on 3
or more, consider an occasions in 48 hours.
alternative route to
support long term
feeding

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7.6 Commencing Enteral Nutrition
7.6.1 Patients must always be referred to and assessed by a dietitian prior to commencing
Enteral Nutrition. If a patient does commence Enteral Nutrition out of hours the standard
emergency regimens must be used. Please refer to Appendix 5.
7.6.2 The regimen used is dependent on the route of feeding. Feeding patients with clostridium
difficile is beneficial and the feed should not exacerbate diarrhoea. Enteral feeding must
not be stopped in this group without consultation of the ward dietitian or the Nutrition Team.
7.6.3 Prior to commencing enteral nutrition, baseline biochemistry must be obtained e.g. U & E’s,
Glucose, Creatinine, Calcium, Phosphate, Magnesium LFT's (Incl. CRP, Albumin), Folate,
B12, Iron, Ferritin, These results should be reviewed by the medical team and corrected
accordingly.
7.6.4 Zinc and Copper levels should be obtained, however feeding can commence prior to
receiving the results, and treatment modified accordingly.
7.7 Nasogastric Feeding (NG)

7.7.1 This is a method of administering enteral nutrition via a tube placed through the nose into
the stomach. This route of feeding is generally used for short term feeding. If feeding is
expected to be longer than 4 weeks, consider long term options. Some individual clinical
situations may indicate longer use of this feeding method. It should be considered for
patients who have full use of their stomach without complications such as vomiting or
aspiration.
7.7.2 Disadvantages of this route of feeding include: the need for frequent tube re-insertion; risk
of aspiration; discomfort to the naso-pharynx; psychological problems due to visibility of
tube.
7.7.3 Nasogastric tubes can become displaced more easily than most other enteral feeding
tubes. For this reason nasogastric feeding is only undertaken where absolutely necessary
in the community setting in East Kent.
7.7.4 Medicina 10fr 85cm nasogastric tubes are used across all acute sites. The tube can remain
in situ for a maximum of 30 days and should then be changed. The date of tube insertion
and any subsequent tube changes should be documented in the patient’s medical notes
and performed by a competent clinician.
7.7.5 Nasal bridle devices provide a means of securing a nasogastric tube to prevent intentional
or accidental removal of the tube by the patient. They should be considered for patients
who have pulled out three or more NG tubes in 48 hours.
7.7.6 If the patient lacks the capacity to make a decision regarding nasal bridle at that time, a
best interest decision should be made. Please refer to Section 3.0
7.7.7 Only appropriately trained health care professionals can insert nasal bridles.
7.7.8 Contraindications for the use of nasal bridles include:

• Basal skull fractures
• Deviated nasal septum
• Structural deformity of the nose or nasopharynx
7.7.9 Once in place, the nasal bridle device should be treated as an NG tube (See section 7.8).
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7.8 Key Points for Nursing Care Of NG Feeding Tubes
Check the position of the tube using Merck pH indicator strips (Code 090120602)
at least once every shift..
• Check the position of the tube using Merck pH indicator strips (Code
090120602) at least once every shift.
• Use freshly opened sterile water.

• Flush before and after feeding and drug administration.
• Always use a 60ml female luer lock ‘purple’ single use syringe as per
NPSA 19 (2007)
• Record all feed and fluid administered on a fluid balance chart.
• Giving sets, packs of feed and reservoirs are for single use only and
should be discarded after 24 hours. All of the above should be labelled
with patient name, date and time.
f
Please refer to Appendix 4 for flow chart detailing how to confirm the correct position of nasogastric
feeding tubes in adults.
7.9 Tube Placement and Care of Patient with NG Tube
Action Rationale
Prior to starting a feeding regimen To identify and correct any biochemical
baseline biochemistry should be abnormalities
obtained.
The nurse / doctor should counsel and Patients not able to meet their nutritional
support patients before and during needs by oral intake alone may find tube
placement and continue while tube insertion stressful.
remains in situ Easy to position and least invasive tube but it
is easily displaced by patient, accidentally or
deliberately.
Ensure the patient is comfortable and To minimise patient discomfort and monitor
observe the patient whenever performing the patient
any tube related procedures
Can be positioned by trained nurse or To reduce patient trauma and reduce risk of
clinician. placement in lungs.

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7.9 Tube Placement and Care of Patient with NG Tube (continued)
Action Rationale
Tube position should be confirmed by To prevent administering feed into the lungs
checking that gastric aspirate is less than
pH 5.5, using by pH sticks.
-before each episode of feeding
-if there is any question of tube migration
from the stomach i.e. following vomiting, To reduce exposure to radiation and
coughing retching minimise delays on feeding
- If there is any reflux of feed.
Note: an x-ray is only necessary if tube
position cannot be confirmed by
aspiration.
See NPSA 5 Feb 2005 for the correct
position of NGT. (Appendix 4)
The nurse / doctor should ensure that all To reduce the risk of infection
equipment is clean, accessible and ready
to use before carrying out any procedure.
Decontaminate hands and use non To reduce the risk of infection
sterile gloves before handling the tube
and feed.
Tube should always be flushed with To prevent tube blocking with congealed feed
sterile water before and after feeds and or drugs.
drugs, and each time the feed is stopped.
Tube should be secured from patient’s To ensure minimum disturbance to patient in
nose across their cheek, with an normal activities, including eating and
adhesive tape. 'Elastoplast is the most drinking, and to minimise the risk of
effective (if this is not tolerated use Mefix) accidental removal.
Nurses should also check tube position To prevent administering feed into the lungs
by observing and recording length marks
on tube to ensure they are maintained as
at positioning (NB this does not replace
the need to confirm position with pH
stick).
60ml female luer lock “purple” syringe as Other syringes will increase pressure within
per NPSA 19 2007 only should be used the tube and may damage or rupture it.
for flushing, bolus feeding or
administering drugs through the NG tube
Patient’s nostrils should be cleaned with To promote patient comfort and reduce
a soft cloth at least 3 times daily infection
The outer visible surface of the tube To reduce the risk of infection
should be cleaned daily with water.
All patients with NG tubes should have Mouth infections are a significant risk for
daily mouth care. See section 7.25 enterally fed patients.
All patients with a NG tube should be fed Patients with a NG tube are at a high risk of
when positioned at an angle of 45° or aspiration if fed when lying flat.
more
Before administering Drugs via an NG Drugs administered via feeding tubes can
tube the Pharmacist should be consulted have their bioavailability affected.
The feed should be delivered as per To ensure patient meets their nutritional
Dietitian’s regimen. If feed is started over requirements
a weekend then follow the NG
emergency regimen (see Appendix 5)
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7.10 Discharge of adult patients into the community with a nasogastric tube
7.10.1 Because the discharge of adult patients with a nasogastric tube in situ is rare the discharge
must be arranged on a named patient basis only, in order to provide an opportunity for
nursing staff in the community to update their knowledge and skills with regard to
nasogastric feeding, if necessary. Prior to discharge the patient and/or their carer must be
trained and competent in monitoring the tube’s position, to reduce the risk of feeding via a
displaced tube.
7.11 Gastrostomy Feeding
7.11.1 Gastrostomy tubes are inserted directly through the abdominal wall and into the stomach. A
soft spongy balloon or bumper on the inside and a firm plastic/polyurethane fixation device
on the external abdominal wall secures the tube. Most are inserted by the Percutaneous
Endoscopic Gastrostomy (PEG) technique. They may also be inserted surgically or
radiologically.
7.11.2 They are indicated when feeding is required for > 4-6 weeks.
7.11.3 Indications
• Disease-related malnutrition
• Hypermetabolism – e.g. major surgery, organ transplant
• Neurological disease – e.g. Cerebrovascular Accident (CVA), Motor Neurone Disease
(MND), Multiple Sclerosis (MS)
• Gastrointestinal disease – oesophageal obstruction
• Cancer – head and neck surgery/radiotherapy
• Learning disability – e.g. cerebral palsy
7.11.4 Discharge documentation must include:

• The type of tube – indicating whether it is a PEG or balloon gastrostomy
• The make of tube
• The size of tube
• Balloon volume (if applicable)
• Visible length of tube
• Date of insertion
• Lot and Reference number of tube, found in patient medical notes
• This is the responsibility of both nursing and Dietetic staff.
7.11.5 Key Points

• The decision for gastrostomy placement is a multidisciplinary one taking into account
the wishes of the patient
• The Consultant responsible for the patient’s care should request reports from
appropriate multidisciplinary team members prior to referral for placement of a
gastrostomy.
• The referral form is sent to the appropriate service, e.g. Endoscopy for PEG and
Radiology Department for RIG
• Immediate post-placement care should be provided by trained nursing staff.
• Details of the gastrostomy tube, including type, brand, lot number and size is to be
documented in patient records and accompany the patient at all times

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7.11.5 Key Points (continued)
• A displaced gastrostomy must be replaced within 2 hours. A Foley catheter must never
be used to provide nutrition support, but can be used to maintain stoma integrity until
the correct tube can be inserted.
• Once the stoma has formed (usually 2 weeks post-initial insertion of gastrostomy) a
gastrostomy feeding tube can be removed and replaced with a button by a trained
practitioner where applicable.
7.12 Pre-placement Patient Care of a gastrostomy
7.12.1 On the day of procedure, ensure the patient has been fully prepared for the placement of
a gastrostomy. Refer to the checklists provided by Endoscopy or Radiology Departments.
7.13 Patient Care immediately Post-placement of a gastrostomy
7.13.1 The department placing the gastrostomy will provide individualised care instructions for
the patient. The instructions should include the following:
Action Rationale
Observations to be taken by nurse caring Ensure patient safety
for the patient
Written instruction for when gastrostomy Ensure patient safety
feeding and/or oral intake can commence
is required
The patient and/or family/carers should be Support patient education and information
provided with information on all aspects of for health care team
gastrostomy care
7.14 Care of the Stoma Site
Care of the stoma site should include the following:
Action Rationale
Daily care of the stoma site should be Reduce risk of infection and identify problems
commenced 24 hours after tube early
placement
There should be daily support for care of Reduce risk of infection and identify problems
the stoma site over the first 10-14 days early
post-placement, as it will take at least 10-
14 days for the stoma tract to form and
the skin to heal.
All staff must decontaminate hands and Minimise risk of infection and microbial
wear non-sterile gloves when handling contamination of feeding system
tube and enteral feed
Nurse should ensure patient is Enhance nursing care and ensure patient safety
comfortable and observe him/her
whenever performing tube-related
procedures

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7.14 Care of the Stoma Site (continued)
Nurse should ensure all equipment is Enhance nursing care and ensure patient safety
clean, accessible and ready to use before
carrying out any procedures
When there is no significant discharge Promote wound healing
from stoma, remove post-procedural
dressing. No further dressing will be
necessary unless the stoma site is having
heavy discharge or leakage
If significant discharge from the stoma Reduce the risk of infection and aid wound
site, use sterile non-adherent thin dry healing
dressing
Do not put a dressing under the external Avoid undue pressure on the internal fixation
fixation devise devise or balloon
Observe, record and report any signs of Early detection of problems and initiation of
infection, irritation or excoriation at stoma treatment
site
Using universal precautions clean the Reduce risk of infection and skin irritation
stoma site daily with sterile saline and
non-woven gauze.
Skin should be dried thoroughly after Avoid soreness and infection
washing, without pulling on the
gastrostomy
Note tube length from the stoma. Use Avoid leakage, dislodging tube or widening
tube markings when available stoma tract
The external fixation device on a PEG or Reduce risk of infection
balloon gastrostomy can be loosened for
cleaning of device, tube and skin
An external fixation device should be Correct positioning of the fixation device
repositioned after cleaning. This is done promotes patient comfort and prevents the tube
by applying gentle traction to the tube from slipping out.
until resistance is felt. Reposition the
fixation device 1cm from the stoma.
An external fixation device too tight causes skin
The patient may lose/gain weight once trauma and discomfort. A fixation device too
long-term feeding has been established, loose causes too much movement of the tube in
the fixation device will need to be and out of stoma, leakage of stomach content
repositioned accordingly. and tube migration.
The patient may shower but not bathe or Reduce the risk of infection while wound is
swim until the stoma tract has formed. healing.
Shower head should not be directed at
stoma. The gastrostomy should be
capped prior to showering

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7.15 Care / Replacement of a PEG
7.15.1 If no information is available about the type of gastrostomy placed, contact the hospital’s
Nutrition and Dietetics Department or Home Enteral Nutrition (HEN) Team. See Appendix 6
for contact details.
7.15.2 For planned replacement of a gastrostomy, a referral must be made to the local Endoscopy
Unit. This will be directed by the HEN Team.
7.15.3 The care/replacement of a PEG should include the following:

Action Rationale
All staff must decontaminate hands and Reduce risk of infection
wear non-sterile gloves prior to carrying out
tube-related procedures
Nurse should ensure patient is comfortable Enhance nursing care and ensure patient
and observe him/her whenever performing safety
The gastrostomy must be flushed at least Reduce risk of gastrostomy becoming
once during the day with sterile water. blocked by gastric content
A PEG should be rotated 360° once daily Reduce risk of buried bumper syndrome
by an experienced and competent and peritonitis
practitioner
Flush gastrostomy with a 60ml female luer Prevent incorrect administration of
lock “purple” syringe as per NPSA 19 treatment via gastrostomy
(2007)
A Foley catheter should never be used to Foley catheters are not designed as
provide nutrition support feeding devices. Feeding connectors do
not fit easily, and are prone to excessive
leakage at the stoma site.
A balloon gastrostomy can be placed by a Quick replacement of a removed PEG or
competent practitioner in community or RIG can maintain stoma tract integrity
hospital setting if PEG/RIG displaced
A balloon gastrostomy should be used to A balloon gastrostomy is designed to resist
replace a PEG or RIG if feeding is still stomach acidity, minimise skin irritation and
required and there is an established tract provide good connection to feeding sets
If a balloon gastrostomy is not immediately Maintain stoma tract integrity until the
available, a short-term alternative tube e.g., correct tube can be inserted
Foley catheter, should be inserted until the
correct tube can be inserted
Lifespan of a balloon gastrostomy is 3 Gastric acid erodes the balloon
months. Referral to Endoscopy should be
made to replace the balloon gastrostomy if
enteral nutrition required for >3 months.
Patients should be provided with a spare Allow immediate placement of a
balloon gastrostomy to insert, should their gastrostomy if PEG/RIG is removed
PEG/RIG be displaced
An easily accessible stock of balloon Allow rapid access to a balloon
gastrostomy tubes should be kept e.g., with gastrostomy when needed
Endoscopy or Radiology Department

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7.15.3 Care / Replacement of a PEG (continued)
Action Rationale
BALLOON INTEGRITY MUST BE Ensure the balloon is not punctured and
MONITORED WEEKLY: the balloon is retaining the tube in the
• Check position of external fixation plate stomach.
and note tube length.
• Balloon inflation is tested by drawing
back the contents through the balloon
inflation valve, (the side arm to main
tube with different sized shape and
coloured connector, labelled “inflation
Xcc”)
• Discard and document volume of fluid
withdrawn
• Re-inflate the balloon by inserting the
recommended volume of fresh water or
saline
• Once re-inflated, check that the tube is
held in correct position by gentle
traction on the tube to cause a slight
movement of abdominal wall
7.16 Care / Replacement of a RIG
7.16.1 If no information is available about the type of gastrostomy placed, contact the hospital’s
Nutrition and Dietetics Department or the HEN team. See Appendix 6 for contact details.
7.16.2 For planned replacement of a RIG, a referral must be made to the local Endoscopy Unit for
placement of a gastrostomy. This will be directed by the HEN Team
7.16.3 The care/replacement of a RIG should include the following:
Action Rationale
All staff must decontaminate hands and wear Reduce risk of infection
non-sterile gloves prior to carrying out tube-
related procedures
The gastrostomy must be flushed at least Reduce risk of gastrostomy becoming
once during the day with sterile water. blocked by gastric content
Flush gastrostomy with a 60ml female luer Prevent wrong administration of treatment
lock “purple” syringe as per NPSA 19 2007 via gastrostomy
guideline No.19.
A balloon gastrostomy can be placed by a Quick replacement of a removed PEG or
competent practitioner in community or RIG can maintain stoma tract integrity
hospital setting if PEG/RIG displaced
A balloon gastrostomy should be used to A balloon gastrostomy is designed to resist
replace a PEG or RIG if feeding is still stomach acidity, minimise skin irritation
required and there is an established tract and provide good connection to feeding
sets
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7.16 Care / Replacement of a RIG (continued)

Action Rationale
If a balloon gastrostomy is not immediately Maintain stoma tract integrity until the
available, an alternative tube e.g., Foley correct tube can be inserted
catheter, should be inserted until the correct
tube can be inserted
A Foley catheter should never be used to Foley catheters are not designed as
provide nutrition support feeding devices. Feeding connectors do
not fit easily, and are prone to excessive
leakage at the stoma site.
Patients should be provided with a spare Allow immediate placement of a
balloon gastrostomy to insert, should their gastrostomy if PEG/RIG is removed
PEG/RIG be displaced
An easily accessible stock of balloon Allow rapid access to a balloon

gastrostomy tubes should be kept e.g., with gastrostomy when needed
Endoscopy or Radiology Department
A RIG will be sutured or fixed with “T” Prevent tube loss or migration
fasteners. These should only be removed
once the stoma tract is formed. NEVER
ROTATE A RIG
A “pig-tail” RIG should not have the retaining Prevent tube loss
wire removed
A displaced gastrostomy tube before the Reduce the risk of peritonitis, which is life-
stoma tract is formed should be treated as an threatening
emergency
Lifespan of a balloon gastrostomy is 3 Gastric acid erodes the balloon
months. Referral to Endoscopy should be
made to replace the balloon gastrostomy if
enteral nutrition required for >3 months.
BALLOON INTEGRITY MUST BE Ensure the balloon is not punctured and
MONITORED WEEKLY: the balloon is retaining the tube in the
• Check position of external fixation plate stomach.
and note tube length.
• Balloon inflation is tested by drawing back
the contents through the balloon inflation
valve, (the side arm to main tube with
different sized shape and coloured
connector, labelled “inflation Xcc”)
• Discard and document volume of fluid
withdrawn
• Re-inflate the balloon by inserting the
recommended volume of fresh water or
saline
• Once re-inflated, check that the tube is
held in correct position by gentle traction
on the tube to cause a slight movement of
abdominal wall

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7.17 Prophylactic Tube Placement
7.17.1 Patients may be fitted with a gastrostomy but do not need to use the device immediately
e.g. head and neck oncology patients prior to commencing chemo-radiation or some MND
patients.
7.17.2 The patient is usually discharged the morning after tube insertion once seen by the
Dietitian. The Dietitian will assess the patient, devise a nutritional care plan and initiate
hospital to home transfer of nutrition support once an electronic referral has been received
from the nursing staff.
7.17.3 It is the responsibility of the Endoscopy Unit or Radiology Department to notify the local
Dietitian of an elective placement.
7.17.4 The ward nurse must ensure the patient has a 14 day supply (1x single use syringe per
day) of 60mls female luer lock purple syringes as per NPSA 5 Feb 2005 for daily flushing of
a gastrostomy.
The ward nurse should also ensure the District nurse will provide care of the gastrostomy
for at least 10 – 14 days post-placement, and that the patient / family / carers have received
adequate training to support care of the patient.

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7.18 Nasojejunal Feeding (NJ)
7.18.1 NJ feeding is used for short term feeding for patients with a functioning GI Tract but in
whom the stomach needs to be by-passed.
7.18.2 NJ feeding refers to a patient being fed beyond the pyloric sphincter into the jejunum. At
EKHUFT NJ tubes can be placed endoscopically or radiologically. The most frequent
method of placement at EKHUFT is endoscopically.
7.18.3 Endoscopically placed Nasal Jejunal feeding tube (Cook) 240cm length, 8fr are used at
EKHUFT. The tube can stay in situ for a maximum of 30 days. Date of tube placement must
be recorded in the patient’s medical notes.
7.18.4 Indications for Nasojejunal Feeding

• Large gastric aspirates
• Gastric Outflow Obstruction
• Risk of aspiration secondary to NG feeding
7.18.5 Key Points
• Check the position of the tube using pH sticks at least once every shift.
• Use freshly opened sterile water.
• Flush before and after feeding and drug administration.
• Always use a 60ml female luer lock ‘purple’ single use syringe as per
NSPA 19 2007
• Record all feed and fluid administered on a fluid balance chart.
• Giving sets, packs of feed and reservoirs are for single use only and
should be discarded after 24 hours. All of the above should be labelled
with patient name, date and time.
• Labels are available from the ward Dietitian.
• Decontaminate hands and use non sterile gloves before handling the tube
and feed.

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7.18.6 Placement and Care of Patient with NJ
Action Rationale
Prior to starting a feeding regimen baseline To identify and correct any biochemical
biochemistry should be obtained. abnormalities
The NJ tube should be x-rayed post insertion To prevent administering feed into the
to ensure it is in the correct position. stomach.
Tube position should be confirmed by To ensure the tube has not retracted into
checking the pH is between 6-8, before the stomach.
every use.
Decontaminate hands and use non sterile To reduce the risk of infection
gloves before handling the tubes and feed.
Tubes should be secured from the patient’s To ensure minimum disturbance to
nose across their cheek with an adhesive patients normal activities and to minimise
tape. Elastoplast is the most effective (if this risk of accidental removal.
is not tolerated use Mefix)
Sterile water should be used to flush the Sterile water is necessary as stomach
tube before and after feed, medications and acid has been bypassed. Flushing is
each time the feed is stopped. necessary to prevent tube blocking with
congealed feed or drugs.
60ml female luer lock “purple” syringe as per Other syringes will increase pressure
NPSA 19 2007 only should be used for within the tube and may damage or
flushing, bolus feeding or administration of rupture it.
drugs though the NJ tube.
The patient’s nostrils should be cleaned with To promote patient comfort and reduce
a soft cloth at least 3 times per day. infection
All patients with an NJ tube should receive Mouth infections are a significant risk for
daily mouth care enterally fed patients.
Before administering Drugs via an NJ tube Drugs administered via feeding tubes can
the Pharmacist should be consulted have their bioavailability affected.
The feed should be delivered as per To ensure patient meets their nutritional
Dietitian’s regimen. If feed is started over a requirements
weekend then follow the NJ emergency
regimen: see Appendix 5

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7.19 Jejunostomy Feeding
7.19.1 Jejunostomy feeding is used for long term feeding for patients with a functioning GI Tract
but in whom the stomach needs to be by-passed.
7.19.2 Jejunostomy feeding tubes are usually placed surgically, directly into the jejunum. However,
jejunostomy tubes can be placed endoscopically or radiologically via a PEG/RIG with an
extension into the jejunum
7.19.3 Key Points

• Jejunostomy feeding is suitable for patients requiring long term post-pyloric feeding.
• Feeding into the small bowel bypasses the protective acidity of the stomach. Universal
precautions must always be taken when providing tube-related care.
7.19.4 Pre-placement Patient Care of the Jejunostomy

On the day of procedure ensure the patient has been fully prepared for the placement of a
jejunostomy. Refer to the checklists provided by Endoscopy or Radiology Departments if a
PEG/RIG is to be inserted with jejunal extension. The checklist should be as per
gastrostomy procedure. If a jejunostomy is to be inserted surgically, follow the pre-operative
instructions provided by the surgeon.
7.19.5 Patient Care Immediately Post-placement

The department placing the jejunostomy, or gastrostomy extension, will provide
individualised care instructions for the patient. The instructions should include the following:
Action Rationale
Details of the type, brand, lot number and Inform health professionals who will need this
size of jejunostomy should be documented in information for teaching the patient/carer,
patient records and accompany the patient at devising the most appropriate feeding regimen
all times and ordering/replacing connectors for tube
Observations taken by nurse caring for the Ensure patient safety
patient
Written instruction when jejunostomy feeding Ensure patient safety
and/or oral intake can commence
The patient and/or family/carers should be Support patient education and information for
provided with information on all aspects of health care team
jejunostomy care

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7.19.6 Care of the Stoma Site
Feeding with a jejunostomy is associated with a high risk of infection. Follow the
instructions provided for care of the gastrostomy stoma site, refer to section 7.14, in
addition to the following:
Action Rationale
Cover the stoma site with a thin keyhole Reduce the risk of infection
dressing around the external fixation plate.
A further dressing should be placed over the
stoma and fixation plate to secure
Do not attempt to rotate a radiologically or Avoid accidental removal and displacement
surgically inserted jejunostomy
Do not attempt to remove suturing from a Avoid accidental removal and displacement
surgically-inserted jejunostomy until final
removal of the tube
Suspect tube migration if patients shows Avoid aspiration pneumonia
signs of feed regurgitation
Ensure Pharmacist is aware feeding is Drugs differ in their site of activation and site
directly into the jejunum of absorption
7.19.7 Care / Replacement of the Jejunostomy
7.19.8 If no information is available about the type of jejunostomy placed, contact the hospital’s
Nutrition and Dietetics Department, or the HEN team for advice. See Appendix 6
7.19.9 For planned replacement of a jejunostomy, a referral must be made to the Department of
Surgery or Endoscopy, depending on the type of jejunostomy
7.19.10 The care/replacement of a jejunostomy should include the following:
Action Rationale
All staff must decontaminate hands and wear Reduce risk of infection
non-sterile gloves prior to carrying out tube-
related procedures
Nursing staff should handle the jejunostomy A jejunostomy tube can be easily dislodged
carefully
Sterile water must be used at all times when Minimise risk of infection due to loss of
flushing the jejunostomy protective gastric acidity
Flush tube at regular intervals e.g., 30mls Maintain tube patency
sterile water every 4-6 hours

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7.20 Discharge of Enterally Fed Patients from Hospital
7.20.1 Patients who are unable to take sufficient food and fluids orally may be taught to manage
enteral tube feeding at home. Their home circumstances and the ability of the patient to
manage the feed must be considered before the patient is discharged.
7.20.2 Adequate time should be allowed in the hospital setting for patients to become fully
accustomed to the techniques of feed administration and care of the feeding tube prior to
discharge home. Support in the form of the GP, Community Nurse and HEN Team should
be established before discharge.
7.20.3 It is uncommon to discharge a patient from hospital if they are fed via an NG tube.
However, it may be possible in some circumstances and should be discussed fully with the
patient, carer, hospital and community staff, nursing residential/nursing home.
7.20.4 Nursing Responsibilities
a) Inform Dietitian of planned discharge at least three working days prior to discharge.
b) Train the patient / carer in how to set up the feed, care for the stoma site etc
c) Give supporting information supplied by the Dietitian to take home.
d) Give seven day supply of feed and equipment to take home.
e) Inform transport that the patient will also have a box of feed, pump, and ancillaries to be
carried.
f) Ensure appropriate medication (e.g. soluble / emulsions) is arranged for discharge and
for long term use in the community.
7.20.5 Dietetic Responsibilities
a) Write to the patient’s G.P. to ask them to prescribe the feed and arrange for its delivery.
b) Provide training and appropriate supporting information for the patient / carer
c) Liaise with Homecare Company for pump and ongoing supplies of plastics and syringes
d) Liaise with Home Enteral Nutrition (HEN) Team to ensure ongoing training and support.
e) Take a seven day supply of feed and pump to the ward.
f) Arrange pump training for care staff if needed by Homeward nurse.

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7.21 Discharge to Patient’s Home and Nursing Homes
7.21.1 Nursing Responsibilities
Action Rationale
Ensure that Dietitian is informed at least This gives the Dietitian time to contact the GP
three working days before discharge to arrange prescription of feed.
Register the patient with the Home To ensure patient’s equipment and feed is
Feeding Delivery System delivered to their home address.
Contact feed company to provide home To ensure patient / carer is trained prior to
based training on the pumps and feeding discharge.
system if necessary
Provide ward based training for the Patients and carers need to be able to
patient and carers regarding administer the feed correctly and set up the
administration of the feed and care of the feeding system and care for the tube in a
tube safe and appropriate way
Ensure that the patient takes a copy of Patients and carers need to be able to
the feeding regimen, Trust information administer the feed correctly and set up the
sheets, contact numbers, and feed feeding system and care for the tube in a
company patient information booklet with safe and appropriate way. They also need to
them on discharge. This information will know what to do if problems arise and who to
be given to the patient by the dietitian. contact for further advice
Only give a patient the tube company’s
information leaflet if the information
within it is not contradictory to the Trust
information sheets.
Ensure that the patient has at least To enable the enteral feed to continue at
seven day supply of plastics and home until ongoing supplies are delivered
syringes and takes then on discharge.
These to come from ward stocks
Ensure that the patient takes at least To enable the enteral feed to continue at
seven day supply of feed with them on home until ongoing supplies are delivered
discharge. The feed will be supplied by
the dietitian.
Ensure Community Nursing Team are To enable Community Nurses to offer support
informed of discharge if patient is to patient / carer at home and be involved in
returning home the discharge if necessary
Check that the patient has a pump for Hospital pumps should not be sent with the
use on discharge (arranged by the patient as contracted feeding company
dietitian). provide a loan pump for patients receiving
home enteral feeding.

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Discharge to Patient’s Home and Nursing Homes
7.21.2 Dietetic Responsibilities
Action Rationale
Organise home based training of patient / Patients and carers need to be able to set up
carers by Homecare Nurse regarding the feeding system and in a safe and
setting up of the feeding system if appropriate way. Most patients/carers will
appropriate require ongoing training and support at
home.
Write to GP to request enteral feed on To enable the enteral feed to continue on
prescription and arrange ongoing discharge
deliveries of feed
Register patient with Homecare To enable the enteral feed to continue on
Company and arrange for loan of pump discharge. Ward pumps should not be given
and drip stand (if necessary) for home to patients to take on discharge.
use and ongoing supplies of plastics and
syringes
Send Enteral Feeding Discharge To enable the Community Home Enteral
Summary to Home Enteral Feeding Feeding Dietitian to follow up the patient on
Team and transfer care of patient to discharge
them on discharge (if patient’s address is
within area and scope covered by
Community Dietitians)
Ensure patient has a copy of their enteral To ensure that patients, carers health
feeding regimen to take with them on professionals are aware of the feeding
discharge regimen. A Community nurse cannot
administer the feed unless there is a copy of
the feeding regimen in the home.
Ensure patient has as least five/ days To enable the enteral feed to continue on
supply of feed to take with them on discharge
discharge
Ensure patient / carer has appropriate Patients and carers need to be able to
literature regarding feeding system, care administer the feed correctly and set up the
of tube and problem solving feeding system and care for the tube in a
safe and appropriate way. They also need to
know what to do if problems arise and who to
contact for further advice
Ensure patient has appropriate contact Patients and carers need to be able to
numbers and Homecare Information administer the feed correctly and set up the
booklet feeding system and care for the tube in a
safe and appropriate way. They also need to
know what to do if problems arise and who to
contact for further advice

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7.22 Enteral Feed Problem Solving
7.22.1 Tube Related
Problem and Action Rationale

Displaced NG Tube may be due to pulling, coughing To avoid feed being
or vomiting. administered into patient’s lungs
1 Stop feed and secure tube or oesophagus.
2 Check position by pH stick if possible.
3 If tube not clearly in place – remove
4 Inform medical team and replace tube if appropriate
Displaced PEG / RIG / Balloon Gastrostomy may If the tube is dislodged before
be due to pulling or damage to internal fixation device. stoma is formed (about 2 weeks)
1 Stop feed and any oral intake this should be treated as an
2 Secure tube emergency as peritonitis can
3 Inform medical team immediately occur.
4 Obtain replacement balloon gastrostomy for If a replacement tube is not
immediate placement if gastrostomy feeding is to be placed within 2hours, the stoma
continued will start to close.
5 If balloon gastrostomy is not immediately available,
a Foley catheter may be placed temporarily.
Blocked NG or Gastrostomy Tube e.g. due to lack Unblocking tubes by the correct
of flushing after feed or drugs procedure avoids damage to
1 Check tube is not kinked or clamped tube that would lead to further
2 Use a 60ml female luer lock “purple” syringe as per disruption to feeding regimens
NPSA 19 2007
3 First try to remove blockage by aspiration.
4 Then with warmed sterile water and gentle
pressure, apply a push / pull technique, discarding
any dislodged feed or drugs pulled back in the water Effective way to unblock tubes,
5 This process may need repeating numerous times. expensive but may be cheaper
6 If the tube remains blocked, an enzymatic than tube replacement
preparation “ClogZapper” is available from the local
pharmacy department.
For further details, discuss with dietitian
7 If the tube remains blocked, cap off the tube and
contact the Dietitian
8 Do not use a smaller syringe size or try to unblock
the tube with other means
9 When unblocked, ensure tube is well flushed to
maintain patency.
Irritation of nasal passages or granuloma of To avoid trauma to local area
stoma
1 Avoid friction / chaffing round tube. Check tube
firmly secured.
2 avoid unnecessary tube traction

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7.22.1 Tube Related Problem Solving (continued)

Infection of Stoma site shown by redness, pus or To identify infection of the stoma
blood leakage, swelling. site or systemic infection.
1 A swab should be sent for microbiological analysis.
2 If the patient becomes clinically unwell with fever, To avoid buried bumper
blood cultures should be taken. syndrome
3 PEGs should be rotated regularly as per
manufacturer’s instructions.
Leakage of stomach contents or feed from the To stop the gastrostomy tube
stoma due to gastrostomy not sealing the stoma. slipping in as this would allow
Check the external fixation device is correctly the internal fixation device to
positioned, up to 1cm from the stoma. move and no longer block the
stoma
7.22.2 Clinical Based Problems

Mouth Discomfort or Infections To prevent pain and infection
Maintain good mouth hygiene particularly if no oral
intake. See section 7.25
Reflux To avoid aspiration pneumonia
1 Check tube position
2 Check patient is being fed in a sitting or semi
recumbent position
3 Check stomach aspirate to confirm gastric emptying.
Abdominal pain, distension, nausea may be due to To avoid discomfort to patient
poor gastric motility or obstruction. and possible vomiting with risk
1 Check bowel function of NG tube displacement
2 Review feed with Dietitian
3 Consider reducing feed rate or halting increments.
Vomiting may be due to poor gastric motility or To avoid discomfort to patient
obstruction and possible vomiting with risk
1 If present prior to feed, start feed slowly and gradually of NG rube displacement.
build up rate
2 Check position of NG tube after any vomit
3 Review medication with Pharmacist + consider pro-
kinetic agent.
Diarrhoea may be due to infection, drugs, rate of It is important to try to maintain
administration nutritional intake and hydration
1 confirm frequency and degree of problem while finding the cause of the
2 review medical history for pre existing bowel diarrhoea.
disorders
3 review drug therapy with Pharmacist
4 Review fibre intake with Dietitian
5 Take stool for culture
6 Review technique for handling equipment and feeds
administration.
7 Maintain feeding rate till cause is investigated.
8 Consider IV fluids

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7.22.2 Clinical Based Problems (continued)

Constipation To avoid reflux and discomfort
1 Check all fluids and feed prescribed are being to patient
administered
2 Review fibre in feed with Dietitian
3 Review medication with Pharmacist, and consider
laxatives
7.23.3 Feeds and Pump Based problems

Pump is not operating or alarming
1 Follow trouble shooting procedure in pump instructions
If pump continues to malfunction, replace with alternative
pump and send the faulty one with details of problem to
the local Dietetic Department.
2 In event of a Power failure, follow instructions for gravity
or bolus feeding
3 If no pump is available contact the Dietetic Department
for a spare pump
Power failure
The standard pump has a battery life of 8 hours at 100ml /
hour. Continue to pump feed under battery power as long
as possible
When there is no battery power left there are two options
Bolus Feeding or Gravity feeding
7.24 Commencing Oral Diet
7.24.1 Patients with swallowing difficulties or at risk of aspiration must be referred to a Speech and
Language Therapist (SLT) for a swallow assessment prior to starting oral diet or fluids.
7.24.2 Once the decision to recommence oral intake has been made the following will occur:
• Risk assessment regarding patients ability to take oral medications
• The Dietitian will liaise with nursing staff and SLT regarding dietary requirements, e.g.
need for altered textured diet, oral supplements.
• Food and fluid record charts must be maintained.
• Enteral feeding regimen will be re-assessed by Dietitian. For example an overnight
enteral feeding plan may be implemented to allow for oral intake during the day.
Tube feeding must not be discontinued until the patient is consuming an adequate
nutritional amount orally – this must be discussed with the Dietitian.
7.24.3 It may take several weeks, or even months, for the patient to meet their nutritional
requirements orally.

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7.25 Oral Hygiene
7.25.1 An individual’s self esteem, motivation and psychological outlook can be improved by good
oral hygiene. Oral hygiene is essential to prevent dental and gum disease and assist in the
prevention of chest infections. A dental review of the individual’s oral health may be
necessary; thereby ensuring any required dental or oral health interventions can be
planned.
7.25.2 Where an individual has all or some of their own teeth it is essential to prevent the build up
of plaque and calculus (tartar) in the increasingly stagnant oral environment. Where the
individual has none of their own teeth the soft tissues of the mouth and any dentures should
be cleaned. A mouth care regime must be established for each patient, taking into account
any risks associated with poor or absent swallowing reflex. Mouth care frequency will be
personal choice but should be a minimum of twice daily.
7.25.3 The best cleaning instrument is a soft toothbrush used with non-abrasive toothpaste; if the
individual is not manually dextrous a large handled or electric toothbrush may be used to
promote independence. If the patient is unable to use a toothbrush please refer to clinical
guidelines for Oral Hygiene.
ype=Attachment
7.26 Mouthwashes
7.26.1 For those individuals receiving radiotherapy or chemotherapy or those with oral infections a
number of products can be used with caution:
• Normal saline – removes loose debris and keeps the mucosa moist. It is non-irritant,
has no unpleasant taste. It should be used four times a day.
• Sodium bicarbonate – removes debris and will release crustiness. It assists in reducing
mouth odour and acidity, but it has an unpleasant taste. It should be used four times a
day.
• Chlorhexidine – can be used to soak dentures if individual is suffering from a Candida
infection.
7.26.2 Over the counter mouthwashes and lemon glycerine swabs should be avoided as they dry
and irritate the oral mucosa.
7.27 Stimulating saliva production
7.27.1 Some medications can affect the normal flora of the mouth: for example, antibiotics,
steroids, antihistamines and antidepressants. Depending on the individual’s swallowing
reflex saliva production can be stimulated by sucking ice cubes, acid drops, boiled sweets
or chewing gum. Synthetic saliva, which can be prescribed, can also be used but it only
moisturises and does not prevent bacteria growth. Pieces of fresh pineapple can be sucked
as they contain an enzyme that cleans the mouth.
7.28 Mouth Care
7.28.1 Discuss with Speech and Language Therapist regarding mouth care in patients with
dysphagia. Also refer to Royal Marsden Hospital Manual of Clinical Nursing Procedures
with regard to mouth hygiene. The Royal Marsden Hospital Manual of Clinical Nursing
Procedures, 7<sup>th</sup> edition - Home Page
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8. PRESCRIBING, PREPARING AND ADMINISTERING MEDICINES FOR USE IN

ENTERAL FEEDING SYSTEMS
8.1 Prescribing
8.1.1 The prescriber's decision to use enteral feeding tubes to administer medication should be
a balance of risk/benefit taking into account that not all medicines can be administered via
the enteral feeding system, that risks may be associated with non-administration, whether
there is experience of administration vie enteral feeding tubes, and whether other routes
are available and their associated risks.
Factors to be taken into consideration include:
- alternative formulations that are available -liquid, suspension, soluble or dispersible
tablets and their appropriateness
- dosage or interval may need to be adjusted
- some formulations should not be crushed
- enteral feed may need to be interrupted for an extended period around administration
- additional monitoring of patient or drug may be required.
- The risks associated with serious sepsis and other adverse complications as a result of
using intravenous routes for solely long term medication administration are often greater
than the risks of using an enteral route
- Need for flushing between preparations
The prescriber should also be aware of possible consequences of altering a drugs

formulation prior to administration via an unlicensed route. Advice should be sought from
ward pharmacist or medicines information, and if multiple medications are involved they will
generally need to be reviewed together. Medical practitioner precribers often have to within
their competency framework use medications out of license or unlicensed preparations.
These issues are covered in the Trust unlicensed medication policy.
8.1.1 No medication is licensed for administration with any enteral feeding system. Some
formulations of licensed medicines may be suitable for administration by this route “ outside
the license” but many medicines will be unlicensed liquid formulations manufactured by
“Pharmaceutical Specials” companies.
8.1.2 Any manipulation of a medicine such as crushing a tablet or opening a capsule for
administration via an enteral feeding system is usually outside the product licence. Such
manipulation may change the properties of a medication or its likelihood of interacting with
another preparation administered by the same route
8.1.3 For both unlicensed medicines and licensed medicines prescribed and used “outside the
licence”, the liability for any adverse effects resulting from administration lies with the
prescriber and administering practitioner. However if the administering practitioner has
clear and appropriate instructions from the prescriber and practises within their trained
competencies and organisational policies this liability is assumed by the organisation.
8.1.4 It is illegal for independent, non medical prescribers to prescribe unlicensed medications.
However, this situation is subject to legal review as of 2009 and indeed in certain well
evidenced use of unlicensed medications (prepared say from compounding two licensed
medications) the authorities have indicated that they would not prosecute, pending
appropriate amendment of medicines legislation.

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8.2 Medication Review
8.2.1 A full medication review should be carried out when it has been decided that the patient is
no longer able to swallow either solid dose or liquid medications. Some medicines are
available in other formulations (e.g. buccal, rectal, transdermal). Alternatively a similar
medicine within the same therapeutic group may be available in a non-oral formulation e.g.
changing from oral isosorbide mononitrate to transdermal glyceryl trinitrate. The drug
monographs in “Handbook of Drug Administration via Enteral Feeding Tubes Rebecca
White and Vicky Bradnam. Pharmaceutical Press 2007” offer alternative licensed
medications for consideration.
8.3 Formulations suitable for use in enteral feeding systems
8.3.1 Some oral formulations are unsuitable for crushing e.g. long acting sustained release
products and enteric coated products. Bioavailability may vary between solid and liquid
forms of the same medicine. It may be necessary to adjust the dose. If possible avoid
changing the brand of product used as formulations of the same drug may vary between
manufacturers. Cytotoxic and hormone preparations should not be crushed due to the risks
to staff from exposure to the powdered drug.
8.3.2 The preferred formulations for administration via a feeding tube are liquids and soluble
tablets. However, some liquid formulations are suspensions of small granules and not
suitable for administration via a feeding tube e.g. lansoprazole suspension.
8.3.3 Interactions between feeds and medications can be significant. Specialist pharmaceutical
advice should be sought. Some information is available in “Handbook of Drug
Administration via Enteral Feeding Tubes: Rebecca White and Vicky Bradnam.
Pharmaceutical Press 2007”
8.3.4 Liquid preparations
• may contain sorbitol which can act as a laxative

• are often low dose paediatric preparations and therefore will require large volumes e.g.
paracetamol suspension.
• are often thick and viscous, can be difficult to dilute with water and therefore can cause
difficulties in administration
• are often unstable or highly irritant when in solution
• the cost of liquid preparations, in particular those made as “Specials” can be
significantly higher than tablet/capsule or other licensed formulations
8.4 Administration
8.4.1 Medicines should be administered only by healthcare staff or patients/carers who

understand the risks involved, have been trained to use safe procedures, and who have
demonstrated their competence for the task.
8.4.2 Before administration, the following should be available: a current prescription, a patient
group direction or other written instructions, essential technical information and a suitable
oral/enteral syringe. The patient’s identity and details should be confirmed.
8.4.3 An appropriate oral/enteral syringe should be used to measure oral liquid medicine if a
medicine spoon or graduate measure cannot be used.
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8.4.4 Only use a well-labelled oral/enteral syringes that do not allow connection to intravenous
catheters or ports.
8.4.5 Enteral feeding systems should not contain ports that allow connection to intravenous
syringes.
8.4.6 Three-way taps and syringe tip adaptors should not be used in enteral feeding systems as
they allow connection design safeguards to be bypassed.
8.4.7 Catheter tip syringes are commonly used in practice to measure and administer large
volumes of medicines and feeds. These syringes are not sufficiently accurate to measure
or administer small volumes of these medicines
8.4.8 Administration may be through the medication port, but only using the following types of
syringe: oral/enteral syringe, catheter tipped and female luer lock syringes (NPSA 19 2007).
8.4.9 The tubing must be flushed with at least 10ml water before and after each medication to be
administered, 10-30ml is advised for the majority of patients. However some patients may
not be able to tolerate this volume. Speak to Dietitian/Pharmacist for further information.
8.4.10 The person administering the medicine should personally make a record of administration
as soon as possible after the event.
8.5 Documentation
8.5.1 Accurate record keeping is essential. Decisions related to administration should be jointly
made including the patient and a pharmacist and recorded appropriately.
8.6 Sources of Information
8.6.1 The Health Professional in charge must ensure that they have as much technical
Information as possible bearing in mind the medicines used will be either “off label” or
unlicensed. The supplying pharmacy will provide any written information available.
8.7 Disposal of pharmaceutical waste
8.7.1 Refer to East Kent Hospitals University NHS Foundation Trust’s policy’s for disposal
of pharmeutical waste.

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9. PARENTERAL NUTRITION (PN)
Parenteral nutrition is required when the intestine is inaccessible or intestinal function is

insufficient to absorb or digest an adequate supply of nutrients on a temporary or
permanent basis. Parenteral Nutrition (PN) should always be a planned initiation. It is not
appropriate to start PN as an emergency at a weekend or out of hours. It is essential that
the patient has been assessed for the risk of refeeding syndrome, that electrolytes are
corrected before PN is started and then monitored closely.
Parenteral Nutrition should only be considered when:

• All other methods and routes of enteral nutrition have been considered and are not
deemed appropriate
• Total nutrient requirements cannot be met using the enteral route due to limited
absorption or very high nutritional requirements
9.1 Indications
• GI Tract Inaccessible
• Short bowel syndrome
• Intestinal Failure
• Prolonged paralytic ileus
• Radiation Enteritis
• High output fistulas
9.2 Contraindications
9.2.1 Patients with functioning GI tract capable of absorption
9.2.2 Where no benefits to the patient can be gained; terminally ill and in last stages of life;
Liverpool Care Pathway (LCP)
9.3 Complications
• Infection
• Pneumothorax
• Haemothorax
• Catheter Embolism (broken tip obstructing blood flow)
• Migration of Catheter
• Myocardial perforation
• Arterial puncture sepsis
• Central vein thrombosis
• Air Embolism
• Dehydration and Fluid Overload
• Hyperglycaemia
• Hyperlipidaemia
• Raised Liver Function Tests
• Fatty Liver
• dysrhythmias

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9.4 Assessment
9.4.1 Selection of patients for parenteral nutrition should be made in consultation with the
multidisciplinary team i.e. Consultant, Anaesthetist, Pharmacist, Dietitian, Nursing Staff and
Patient.
9.4.2 Patients who require parenteral nutrition should be referred to the dietitian for nutritional
assessment.
9.4.3 If there is difference of opinion regarding route of administration of artificial nutrition, the
matter should be referred to the consultant who is the nutrition lead or their deputy on each
site. He or she will be ultimately responsible for the decision.
9.4.4 Patients who may require initiation of Parenteral Nutrition over a weekend must be referred
to the Dietitian by 12 noon on the Friday.
9.4.5 Parenteral Nutrition will not be dispensed by pharmacy unless the patient has been
assessed by a dietitian (except ITU). If a patient is transferred from another hospital on an
existing regimen pharmacy will dispense Parenteral Nutrition. The pharmacist will then
advise the Dietetic Department to ensure that the patient is nutritionally assessed.
9.4.6 When a patient has been assessed as requiring PN the referring team should contact
anaesthetics and request an urgent feeding line.
9.5 Route of Access
9.5.1 Patients should be fed via a dedicated central line or a Peripherally Inserted Central
Catheter (PICC). Feeding lines should be inserted by a full trained practionner (refer to
EKHUFT Vascular Access Guidance). After insertion all patients must have a chest x-ray
to confirm correct placement.
9.5.2 Multiple lumen central lines can be used in Intensive Care with one lumen dedicated to
provision of PN solutions. With meticulous management of all catheter lumens these may
last up to 10 days.
9.5.3 Tunnelling subclavian lines is recommended for long-term use (more than 30 days).
NOTE: Patients must never be fed via a peripheral line
9.6 Management of Catheters
9.6.1 Only healthcare professionals competent in catheter placement should be responsible for
the placement and care of catheters and they should be aware of the importance of
monitoring and managing these safely (refer to East Kent Hospitals University NHS
Foundation Trust Vascular Access Guidance).

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9.7 Commencing PN
9.7.1 Patients must always be assessed by a dietitian before PN can commence.
9.7.2 Parenteral nutrition should be introduced progressively and closely monitored, starting at no
more than 50% of estimated needs for the first 24–48 hours.
9.7.3 Prior to commencing PN baseline biochemistry must be obtained e.g. U & E’s, Creatinine,,
Calcium, Phosphate, Magnesium LFT's (Incl. CRP, Cholesterol, Triglycerides, Albumin),
Folate, B12, Iron, Ferritin, Zinc Copper.
9.7.4 Potassium, calcium, magnesium and phosphate must be corrected prior to feeding.
9.8 Mode of Delivery
9.8.1 Continuous administration of parenteral nutrition should be offered as the preferred method
of infusion in severely ill people
9.8.2 Cyclical delivery of parenteral nutrition should be considered in patients requiring parenteral
nutrition for more than 2 weeks.
9.9 Pumps
9.9.1 All nutrient solutions should be administered through a dedicated feeding line, using a
volumetric pump fitted with occlusion and air-in-line alarms which do not allow free flow.
9.10 Feeding Solutions
9.10.1 Parenteral nutrition is provided by the pharmacy department as an “all-in-one” bag,

containing a mixture of amino acids, glucose, lipids, vitamins and minerals and fluid.
9.10.2 There are a number of bags available within the trust. The type of bag used is dependent
on the patient’s age, weight and clinical condition. The Dietitian will recommend the most
appropriate bag. If pharmacy needs to dispense PN to ITU as an emergency they will
dispense supplemented Kabiven 9g bags.
Unsupplemented PN bags will be available in the Emergency Drug Cupboard at each site,
but are ONLY to be used to replace damaged bags for patients already established on a
regime. They do not have added vitamins and trace elements and so do not conform to
NICE guidance and are only to be used for short term until pharmacy can supply
replacement supplemented PN bags during normal working hours.

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9.11 Administration
9.11.1 Medical teams Prescribe PN as per Dietetic recommendations using a specifically designed
sticker in the complex medication section of the drug chart. This sticker will be provided by
pharmacy.
9.11.2 Dietitians to ensure Pharmacy are advised of the recommended prescription once dietetic
assessment is complete.
9.11.3 Pharmacy will dispense the multi-chamber bag with vitamins and trace elements added. No
additions can be made to a bag of PN outside of pharmacy.
9.11.4 If a patient requires parenteral nutrition at the weekend it is the responsibility of the medical
team to ensure that this is clearly documented on the patients drug chart. The ward
dietitian will advise on an appropriate bag and rate and will liaise with pharmacy.
9.11.5 Parenteral Nutrition should be at room temperature before administration.
9.11.6 If the bag has been refrigerated, it should be removed from the refrigerator for at least 1
hour prior to giving to patient to allow the infusion to reach room temperature. DO NOT
leave un-refrigerated for prolonged periods (>3hours).
9.11.7 PN bags should always be covered by a light protective bag to avoid decomposition of the
solution
9.11.8 When starting PN ensure that
a. Line for administration is appropriate and dedicated solely for PN

b. A label is placed on the giving set recording the details of time and date that PN
commenced. A bag of PN should not be hung for greater than 24hours once it has
reached room temperature
c. Nursing staff time and sign entry on the drug chart as the PN is commenced.
d. PN should remain connected at all times. If it is disconnected it should be discarded
and a new bag supplied and connected.

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9.12 Biochemistry and Monitoring
9.12.1 Monitoring allows the multidisciplinary team to:

• Ensure that the nutritional needs of the patients are being met
• Assess the effectiveness of treatment
• Allow for the early detection of complications
Parameter Frequency / Rationale Interpretation

Duration
Fluid Balance Daily throughout Fluid overload is Interpret with knowledge of
PN administration common urine output and renal
function
Temperature, As per usual Pyrexia and Interpret with knowledge of
Pulse, Blood observation infection is common patients overall clinical
Pressure frequency for the condition
individual patient
Weight Twice weekly Fluid overload is Interpret with knowledge of
common fluid intake and urine
output
Catheter Site Daily Catheter site Interpret with knowledge of
infection is common patients overall clinical
condition
Blood Every 6 hours Glucose intolerance Good glycaemic control is
Glucose until stable and is common essential (particularly in
then daily critical care)
Sodium, Baseline Assessment of Interpret with knowledge of
potassium, Daily until stable renal function, fluid fluid balance and
urea, Then 1 or 2 times status, and Na and medication
Creatinine, a week K status Urinary sodium may be
helpful in complex cases
with gastrointestinal fluid
loss
Calcium, Baseline Hypocalcaemia or Correct measured serum
albumin, Then weekly hypercalcaemia calcium concentration for
magnesium may occur albumin
and Hypocalcaemia may be
phosphate secondary to Mg
deficiency
Low albumin reflects
disease not protein status
C-reactive Baseline Assists To assess the presence of
protein Then 2 or 3 times interpretation of an acute phase reaction
a week until protein, trace (APR). The trend of results
stable element and is important
vitamin results
Triglycerides Baseline Raised levels can Interpret with our liver

and Then weekly occur function tests
Cholesterol

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9.12 Biochemistry and Monitoring (continued)

Parameter Frequency / Rationale Interpretation
Duration
Folate, B12 Baseline Iron deficiency is Serum folate/B12
Then every 2–4 common sufficient, with full blood
weeks count
Zinc, copper Baseline Deficiency People most at risk when
Then every 2–4 common, especially anabolic
weeks, depending when increased APR causes Zn ↓ and
on results losses
Cu ↑
Selenium Long term PN
patients only
(>4 weeks) taken
monthly
Iron, ferritin Baseline Iron deficiency Iron status difficult if APR
Then every 3–6 common in long- (Fe ↓, ferritin ↑)
months term parenteral
nutrition
Full blood Baseline Anaemia due to Effects of sepsis may be
count and 1 or 2 times a iron or folate important
MCV week until stable deficiency is
common
Then weekly
9.13 Stopping PN
9.13.1 Withdrawal should be planned and stepwise with a dietetic daily review of the patient’s
progress. Parenteral nutrition can be withdrawn once adequate oral or enteral nutrition is
tolerated and nutritional status is stable. It should never be stopped suddenly to enable
insulin levels to readjust and to prevent rebound hypoglycaemia.
9.13.2 The ONLY exceptions to this rule are when a patient’s biochemistry deteriorates
significantly or when the line site is suspected of being infected. In these cases PN should
be ceased immediately and if appropriate the line removed.

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10.0 RE-FEEDING SYNDROME
Refeeding syndrome refers to severe electrolyte and fluid shifts associated with metabolic
abnormalities in malnourished patients undergoing refeeding. This syndrome can occur
with oral, enteral and parenteral nutrition.
10.1 Mechanism of Refeeding Syndrome
10.1.1 In starvation: Circulating insulin levels drop and glucagon levels rise. This leads to
glycogen stores being converted to glucose and glucose synthesis occurring from protein
and lipid breakdown.
10.1.2 In Refeeding: There is a switch from metabolism of fat to carbohydrate. With carbohydrate
repletion (from feeding) and subsequent increased insulin production there is an increased
uptake of glucose, phosphate, potassium and water into cells, hence the decrease in serum
levels.
10.2 Consequences of Refeeding Syndrome
10.2.1 Re-feeding can lead to Hypophosphataemia, Hypocalcaemia, Hypokalaemia,

Hypomagnesaemia and altered glucose metabolism. These deficiencies can, in turn, lead
to cardiac, respiratory, renal, hepatic and metabolic complications. For example cardiac
failure, pulmonary oedema and dysarhythmias, acute circulatory fluid overload or depletion
may occur. Complications are most commonly seen 24-48 hours after initiating feeding.
10.3 Degree of Risk of Refeeding Syndrome
10.3.1 Moderate Risk - Patient has one or more of the following:-

• BMI less than 18.5kg/m2
• Unintentional weight loss greater than 10% within the previous 3-6 months
• Very little intake for greater than 5 days
10.3.2 High Risk - Patient has one or more of the following:-

• BMI less than 16kg/m2
• Very little nutritional intake for greater than 10 days
• Low levels of potassium, phosphate or magnesium prior to feeding
10.3.3 Or patient has two or more of the following:-

• BMI less than 18.5kg/m2
• Those with very little intake for greater than 5 days
• A history of alcohol or drugs abuse including insulin, chemotherapy, antacids or
diuretics.

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10.3.4 Severely High Risk – Patients has both of the following:-

• BMI less than 14
• Negligible intake for greater than 15 days
10.4 Standard Pharmaceutical Recommendations for Supplementation
Pharmaceutical treatment of Refeeding Syndrome
Refer to BNF and/or contact local pharmacy for further information or if specified route of
access is not available.
10.4.1 Multivitamin: Multivitamin ONE tablet OD orally (or where available multivitamin capsule
BPC 1-2 capsules OD)
10.4.2 Thiamine: 100mg tablet TWICE or THREE times a day orally (thiamine best given in
divided doses rather than a single daily dose). Ideally continue for the first 10 days of
feeding then review depending upon clinical judgement. Dosage regime can be reduced if
necessary for maintenance therapy. For parenteral administration of thiamine see Pabrinex
IV below.
10.4.3 Vitamin B compound strong: 1 or 2 tablets THREE times a day orally. Ideally continue for
the first 10 days of feeding then review depending upon clinical judgement. Dosing
frequency can be reduced if necessary for maintenance therapy.
10.4.4 Magnesium:
• Oral: Not recommended (due to GI complications) – unlicensed products available.

• IV: Dose depending on level of hypomagnesaemia and clinical judgement consider
whether patient symptomatic, other causes of hypomagnesaemia) 20mmol
Magnesium Sulphate in 100ml sodium chloride 0.9% or dextrose 5% IV over at least 1
hour or
• 40mmol Magnesium Sulphate in 100ml sodium chloride 0.9% or dextrose 5% IV over
at least 2 hours.
Further doses may be required. Magnesium deficiency may need correcting over several
days (up to 160 mmol may be required in divided doses over 4-5 days, allowing for urinary
losses). Caution when interpreting blood results as Magnesium is predominantly an
intracellular cation and whilst blood levels may appear to normalise quickly, intracellular
correction takes longer.
10.4.5 Pabrinex:
• IV:ONE or TWO pairs of Pabrinex IV in 50 - 100ml sodium chloride 0.9% or dextrose

5% IV over at least 30 minutes (in established thiamine deficiency avoid use of
dextrose 5% where possible as dextrose increases thiamine requirements)
Each pair of Pabrinex IV ampoules contains a total of 250mg Thiamine (plus other
vitamins). Further doses of Pabrinex IV may be required depending on clinical judgement
and whether oral thiamine supplementation is appropriate instead (One or two pairs of
ampoules IV up to TWICE or THREE times a day).

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(Note that there is also an Intra-Muscular presentation of Pabrinex available which is a

separate product and must only be given intra-muscularly – the two products are NOT
interchangeable)
10.4.6 Potassium
Dose and route depending on level of hypokalaemia and clinical judgement (consider
whether patient symptomatic, other causes of hypokalaemia, and whether patient can
reliably absorb orally).
Use lower dosage regimes in patients with renal impairment (common in the elderly)
otherwise risk of dangerous hyperkalaemia. Beware drug interactions as a number of drugs
may worsen hypokalaemia and others may increase the risk of hyperkalaemia – seek
pharmacy / medical advice if necessary.
Always monitor potassium response and review accordingly.
• Oral: For prevention of hypokalaemia in at risk patients then Sando-K 2 tablets OD-BD
(effervescent tablets dissolved in water). Sando-K contains 12 mmol K+ per tablet.
• For treatment of established hypokalaemia (K+ < 3.5 mmol/litre) then Sando-K 2 tablets
TDS. For significant, severe hypokalaemia then seek medical review regarding further
treatment and management.
• For patients who cannot take Sando-K for whatever reason then refer to pharmacy for
advice regarding alternative formulations if necessary.
• IV: For severe hypokalaemia (< 2.5 mmol/L or symptomatic) or patients unable to take
K+ supplements orally. Administer 80-100 mmol/day via the intravenous route and
consider:
a. Oliguria – seek medical review first prior to any K+ administration.
b. Use normal saline or dextrose 5% (normal saline preferred - dextrose can cause
blood glucose and insulin levels to fluctuate, creating difficulties with monitoring of
potassium-replacement).
c. Always administer via infusion pump.
d. Use ready-made bags where possible, due to risks associated with addition of
potassium to bags.
e. Care with rate
10 mmol/hour without ECG monitoring.
20 mmol/hour with ECG monitoring.
40 mmol/hour (emergencies only – should already have ECG monitor).
g. Max. conc. that can be administered peripherally is routinely 40 mmol/Litre, (up to
80 mmol/Litre through good peripheral vein but unlicensed) otherwise it must be
given centrally (e.g. 40mmol in 100ml mini-bags).
h. Nb. It normally takes approximately 100 – 200 mmol of potassium to correct a
1mmol/L deficit.

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10.4.7 Phosphate
Dose and route depending on level of hypophosphatemia and clinical judgement (consider
whether patient symptomatic, other causes of hypophosphatemia, and whether patient can
reliably absorb orally)
• Oral: Phosphate Sandoz 1 or 2 tablets TDS depending on level of hypophosphatemia

(effervescent tablets dissolved in water). Phosphate Sandoz contains 16.1 mmol
phosphate, 20.4 mmol sodium and 3.1 mmol potassium per tablet)
• IV: If necessary refer to additional pharmacy guidance on the IV administration of
phosphate in adults.
For symptomatic, severe hypophosphatemia or patients unable to take Phosphate Sandoz

orally.
Caution:
• IV administration of Phosphate, especially when given in high doses or too rapidly, can
cause hypocalcaemia and ectopic calcification (in eyes, heart, kidneys, lungs). Tissue
calcification is more likely in patients with initial hypercalcaemia, and may cause
hypotension, organ failure and acute renal failure. Phosphate administration is generally
contra-indicated in patients with significant hypercalcaemia.
• It is important to monitor serum phosphate, calcium and potassium, renal function and
urine output in patients receiving IV phosphate.
10.5 Standard Dose Regime
10.5.1 9 – 18 mmol phosphate (as Addiphos) diluted in 250 - 500ml 5% Dextrose over 6 – 12
hours via peripheral IV line. Although 5% Dextrose is preferable, normal saline can be used
if necessary. Refer to pharmacy where necessary for advice on minimum volumes and
infusion times if administering through a central line.
10.5.2 In addition, the above dosing regime is recommended initially in the management of
symptomatic, severe hypophosphatemia, where the prescriber is intending to then use oral
replacement therapy.
10.6 High Dose Regime
For severe hypophosphatemia (e.g. serum phosphate < 0.5 mmol/l) for example associated
with re-feeding syndrome, or for persistent hypophosphatemia. 0.5mmol / kg phosphate (as
Addiphos) up to a maximum of 50mmol diluted in 500ml 5% Dextrose over 12 – 24 hours
via peripheral IV line. Although 5% Dextrose is preferable, normal saline can be used if
necessary.
If giving via central IV line then the regime can be given in 250ml 5% dextrose if necessary.
Where the dose to be given is calculated as 50 mmol phosphate then a phosphate

polyfusor (50 mmol phosphate in 500ml) may be used. This may be administered undiluted
via peripheral line over 12 – 24 hours.
The routine use of phosphate polyfusors for doses of less than 50 mmol phosphate is not
recommended due to the high risk of administration error.

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10.7 Feeding Recommendations
All patients at risk of Refeeding Syndrome should commence feeding at a maximum of

10kcal / kg / per day, increasing levels slowly to meet or exceed full nutritional requirements
by 4 – 7 days. In extreme cases it may be necessary to limit intake to 5kcal / kg / day.
(NICE Guidance 32 Nutrition Support in Adults (February 2006)

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11. IMPLEMENTATION INCLUDING TRAINING AND AWARENESS
11.1 All registered nurses must ensure they are competent and confident to deliver any care
they provide for a patient (Nursing Midwifery Council May 2008). The involvement of Health
Care Assistants (HCA) in the delivery of patient care is increasing. Registered nurses must
ensure that before they delegate any aspect of patient care to a HCA, she/he has the
understanding and competency to fulfil the care required.
11.2 The Medical Device Regulations stipulate that the manufacturer of a device is responsible
for establishing that the device is safe and that it is suitable for its intended purpose. To
establish this, manufacturers implement appropriate controls on the device design and
manufacture, and evaluate the safety and performance of the device in its intended
application. This involves an analysis of risks that could arise during use, an assessment of
relevant pre-clinical and clinical data, the preparation of appropriate instructions for use
and, if necessary, specific training schemes. Training on enteral feeding pumps is provided
by the Clinical Advisors from the manufacturers as supported under the contract with
Eastern and Coastal Kent Community Services.
12. STAKEHOLDER, CARER AND USER INVOLVEMENT
12.1 Consultation of key service provides has been undertaken in the formation of this policy
12.2 Consultation in the development of this policy has included Dietitians, Head of Nutrition and
Dietetics plus membership of the Adult Services

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Appendix 1 (page 1 of 6)

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Appendix 2 Trust Food Record Chart PILOT VERSION
Type of diet:-
Normal □
Soft □ PATIENT LABEL East Kent University
Puree □ Hospitals
Normal Fluids □
Thickened Fluids □ Ward
Assistance with eating
□
Date / /200 Date: / / 200
Breakfast Amount offered / Amount offered / Taken

Taken
Cereal / Porridge
Cooked Breakfast
Bread jam/marmalade
Extras
Breakfast drink
Fruit juice
Tea/coffee
Supplements
Mid Morning
Snack
Drink
Lunch
Meat/Fish
Vegetables
Pots/Rice/Pasta
Dessert
Extras
Lunchtime Drinks
Tea/coffee

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Supplements
Mid Afternoon
Snack
Drink
Supper
Soup
Sandwich
Hot meal
Extras
Supper Drinks
Tea/coffee
Supplements/snack

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Appendix 3 Dietary Advice Sheets
Department of Nutrition and Dietetics
This is a guide for discussion with patients. It is not a diet sheet to be given out.
Dietary Advice to Eat More
Introduction
Increasing protein and energy in the diet may be necessary for people who have a poor appetite
and/or weight loss following an operation or illness.
The diet will

• Help to regain weight
• Help wounds or pressure sores to heal
• Help fight infection
• Aid recovery
• Help improve strength and mobility
Protein:
Protein is included for healing and weight gain. Good sources are milk, meat, fish, poultry, pulses,
cheese, eggs and nuts. Aim for 2-3 helpings of any of the foods daily.
Energy:
Energy (Calories) is needed to use protein efficiently. Aim to include some of the following foods at
each meal; bread, potatoes, rice, pasta and breakfast cereal.
Use full fat dairy products and sugary foods. These will increase the energy content of the diet.
Fluid:
Aim for 6-8cups of fluid per day. This can include water, fruit juice, milk, tea and coffee. If easily
feeling full is a problem, try to have drinks after meals.

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Simple steps to improve nutritional intake
1 Eat little and often. Aim to have 3 small meals and 3 snacks each day.
2 Have a high calorie/protein snack between meals e.g.

- Cheese and crackers, toasted crumpets/tea cakes with butter or margarine.
- Sausage roll, meat pie or pasty
- Cakes, scones and biscuits
- Yoghurts or mousse
3 Aim for at least 1 pint of full cream milk daily (rather than skimmed or semi skimmed).
Have milky drinks (Cocoa, hot chocolate, Horlicks, milky coffee, etc) rather than some
of the normal tea or coffee.
4 A small alcoholic drink, sherry, wine, gin and tonic or beer, before a meal may help with
appetite.
5 Fortify foods by:

o Adding 2-4 tablespoons of milk powder to 1 pint of whole cream milk (use enriched
milk in tea, coffee, cereals and in cooking).
o Adding grated cheese, cream or dried milk powder to soup.
o Adding grated cheese, cream, margarine, butter or milk based sauces to potatoes
and vegetables.
o Adding cream, evaporated milk or condensed milk to puddings and custard.
o Use jam, honey, marmalade, syrup
6 Have a pudding at least once or twice a day. Try and have these at different times to
the main course meal.
- Fruit and cream
- Rice pudding (home made or tinned)
- Fruit pie and custard
7 Ideas for snack meals:

o Sandwiches with plenty of butter or margarine filled with cold meat, chicken, canned
fish, cheese or boiled eggs.
o Toast with pilchards, sardines, baked beans, cheese, ravioli or scrambled eggs.
o Jacked potatoes with cheese and/or baked beans. (Add butter or margarine for
extra energy).
o Meat based soups with bread and butter.

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Meal Plan
Breakfast
- Cereal or porridge with full cream enriched milk

- Egg or bacon occasionally
- Toast with butter/margarine and jam/marmalade
- Fruit juice
- Tea or coffee
Mid Morning
- Scone, cake, biscuit

- Tea or coffee
Lunch
- Meat or fish (ready meal if desired)

- Potatoes
- Vegetables (fresh, frozen or canned)
- Pudding – rice, sponge and custard
Mid Afternoon
- Biscuit, cake, sausage roll

- Tea or coffee
Evening Meal
- Macaroni Cheese or
- Sandwich or
- Beans on toast
- Mousse, trifle, yoghurt
Bedtime
- Hot milky drink (Horlicks, Ovaltine)
For further advice please speak to your ward Dietitian.

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Appendix 4
Confirming the Correct Position of Nasogastric Feeding Tubes in Adults
1 Check if on acid inhibiting medication

2 Check for signs of tube displacement and measure
tube length Aspirate obtained (2ml)
3 Reposition or re-pass tube if required
4 Inject 20ml air into the tube using syringe
5 Aspirate using 50ml syringe and gentle suction
Aspirate not obtained
DO NOT FEED
1 If possible, turn adult onto side Aspirate obtained (2ml)

2 Inject 20ml air into the tube using syringe
3 Wait for 15-30 minutes
4 Try aspirating again
Aspirate not obtained
DO NOT FEED
Aspirate obtained (2ml)
1 Advance tube by 10-20cm Test on pH strip or
2 Try aspirating again paper
pH 6 or above pH 5.5 or
Aspirate not obtained below
DO NOT FEED
1 Leave for up to one hour

2 Try aspirating again
pH 6 or pH 5.5 or
above below
DO NOT FEED
1 Call for advice

2 Consider replacement/re-passing of tube and/or
checking position by x-ray Proceed to feed
CAUTION: If there is ANY query about position and/or the clarity of the colour change on the pH strip,
particularly between the ranges of 5 and 6, then feeding should not commence.
In critical care setting staff nurse to consult with team lead re: commencing feed.

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Appendix 5
PATIENT NAME:
DOB:
HOSPITAL NUMBER:
DEPARTMENT OF NUTRITION AND DIETETICS
EMERGENCY NASOGASTRIC STARTER

FEEDING REGIMEN
Please send an electronic referral and the patient will
be assessed on the next working day
IF PATIENT HAS BEEN NBM OR HAD MINIMAL INTAKE FOR > 5 DAYS THEY ARE AT RISK
OF DEVELOPING REFEEDING SYNDROME. THESE PATIENTS MUST BE ASSESSED BY A
DIETITIAN BEFORE COMMENCING NG FEEDING
Route of Administration: via NGT
Before commencing feeding, it is essential that placement of a nasogastric tube is confirmed (see
overleaf for instructions). X-ray should only be used if unable to confirm tube position.
Date/Time Feeding Regimen Volume
DAY 1 Nutrison Multifibre @ 30mls/hour for 10 hours 800mls

Nutrison Multifibre @ 50mls/hour for 10 hours
+ then 4 hour rest period
NOTE: If a patient has been Nil By Mouth for > 3days or is

<40kg do not exceed 50mls/hour

DAY 2 + then 4 hour rest period 1500mls
¾ Flush with 50mls of sterile water before and after feeds and with medication.
¾ All feeds and giving set must be labelled and changed every 24 hours.
¾ Patients must be fed at a 30-45º angle.
¾ Please record all fluid given to the patient (including flushes) on the fluid chart.
Final Regimen Provides

Energy Protein (g) Na+ (mmols) K+ (mmols) PO4 Fluid (ml)
(kcals) (mmols)
1500 60 64.5 57 34.5 1500 +

flushes
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Checking Nasogastric Tube Position

The tube should be checked:
• Following initial insertion
• Before administering each feed
• Before giving medication (medication down NG tubes is not recommended however)
• Following episodes of vomiting, retching or coughing
• Following evidence of tube displacement (e.g. loose tape/ tube appears longer)
The information in this document was originally developed by the National Nurses Nutrition Group
(NNNG) and further developed in collaboration with the Medicines and Healthcare products
Regulatory Agency (MHRA), the National Patient Safety Agency (NPSA), NHS clinicians, risk
managers and other leading experts in the field.
www.NPSA.nhs.uk/advice 2005-02-28

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PATIENT NAME:
DOB:
HOSPITAL NUMBER:
DEPARTMENT OF RENAL DIETETICS
RENAL EMERGENCY NASOGASTRIC FEEDING

REGIMEN
Use if the patient is not on a fluid restriction and
potassium level is within normal range.
Route of Administration: via NGT
Before commencing feeding, it is essential that placement of a nasogastric tube is confirmed X-ray
should only be used if unable to confirm tube position.
Contact Renal Dietetic Department as soon as possible. A message can be left on the
Dietetic Ansaphone on ext. 74795

NOTE: If a patient has been Nil By Mouth for >

3days or is <40kg do not exceed 50mls/hour

DAY 2 + then 4 hour rest period 1000mls
Regimen Provides
Energy Protein (g) Na+ K+ PO4 Fluid (ml)
(kcals) (mmols) (mmols) (mmols)
Day 800 36 34.4 30.4 18.4 680
1
Day 1000 40 43 38 23 840
2

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PATIENT NAME:
DOB:
HOSPITAL NUMBER:
RENAL EMERGENCY NASOGASTRIC FEEDING

REGIMEN
Use if the patient is on a fluid restriction or has a
raised potassium.
Route of Administration: via NASOGASTRIC TUBE
DAY 1 500mls Nepro

• @ 20mls / hour for 10 hours 500mls
• @ 30mls / hour for 10 hours
• 4 hour rest period
DAY 2 2 x 500mls Nepro 700mls

DAY 3 a) if <55kg continue as Day 2 1000mls
b) if >56kg
USE ABBOTT PUMP and GIVING SETS
¾ Patient must be fed at a 30 - 45° angle
Regimen Provides
Energy Protein (g) Na+ K+ (mmols) PO4 Fluid (ml)
(kcals) (mmols) (mmols)
Day 1000 35 17 13 10.5 360
1
Day 1400 49 26 19 16 500
2
Day 2000 70 37 27 22 720
3
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PATIENT NAME:
DOB:
HOSPITAL NUMBER:
EMERGENCY PEG STARTER REGIMEN

Please send an electronic message and the patient
will be assessed on the next working day
DIETITIAN BEFORE COMMENCING PEG FEEDING
Route of Administration: via PEG
DAY 1 Post insertion 4 hour rest

Nutrison Multifibre @ 30mls/hour for 10 hours 800mls



1500 60 64.5 57 34.5 1500 +

flushes

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PATIENT NAME:
DOB:
HOSPITAL NUMBER:
STARTER REGIMEN POST PEG INSERTION

Use if patient is not on fluid restriction and has
potassium within desired range
DIETITIAN BEFORE COMMENCING PEG FEEDING
Route of Administration: via PEG
DAY 1 Post insertion 4 hour rest

Nutrison Multifibre @ 30mls/hour for 10 hours 800mls
NOTE: If a patient has been Nil by Mouth for > 3days or is


Regimen Provides
Day 800 36 34.4 30.4 18.4 680

1
Day 1000 40 43 38 23 840
2

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PATIENT NAME:
DOB:
HOSPITAL NUMBER:
EMERGENCY JEJUNAL STARTER FEEDING REGIMEN

Please send an electronic referral and the patient will be assessed
on the next working day
DIETITIAN BEFORE COMMENCING NJ FEEDING
Route of Administration: jejunal feeding
If a patient is being fed nasojejunally or with a jejunal extension to a gastrostomy, the position must
be checked prior to feeding. Refer to acute Nutrition Policy for further details.
X-ray should only be used if unable to confirm tube position.
DAY 1 Nutrison standard @ 30mls/hour for 12 hours 840mls

Nutrison standard @ 40mls/hour for 12 hours

Nutrison standard @ 50mls/hour for 24 hours
DAY 2 1200mls
Energy Protein (g) Na+ (mmols) K+ (mmols) PO4 (mmols) Fluid (ml)
(kcals)
1200 48 51.6 45.6 27.6 1200 +

flushes

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Appendix 6
Acute Dietetic Teams Contact Details

Kent and Canterbury Hospital Ethelbert Road, Canterbury, Kent CT1
3NG
Tel: 01227 864236
Fax: 01227 864163
Queen Elizabeth Queen Mother Hospital St Peters Road, Margate,
Kent CT9 4AN
Tel: 01843 234310
Fax: 01843 234278
William Harvey Hospital Kennington Road, Willesborough,
Ashford, Kent, TN24 0LZ
Tel: 01233 616624
Fax: 01233 616725
Community Nutrition Support Contact Details

Queen Victoria Memorial Hospital King Edward Avenue, Herne Bay, Kent,
CT6 6EB
Tel: 01227 594739
Fax: 594723
Home Enteral Nutrition (HEN) Team Barnsdale Bungalow, Whitstable and

Whitstable and Tankerton Hospital Tankerton Hospital, Northwood Road,
Whitstable, Kent, CT5 2HN
Tel: 01227 594660
Fax: 01227 594670
Intermediate Care Teams Contact Details

Thanet Intermediate Care Team Westbrook House, 150 Canterbury Road,
Margate, Kent, CT9 5DB
Tel: 01843 254136

Dover and Deal Intermediate Care Team Victoria Hospital, London Road, Deal,
Kent, CT14 9UA
Tel: 01304 865310
Renal Dietetic Team Ethelbert Road, Canterbury, Kent CT1

3NG
Tel: 01227 766877 # 74795
Fax: 01227 783073

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References
Department of Health Guide to consent for examination or treatment (2001) see
below
Nutritional Support for Adults and Children: A Handbook for Hospital Practice
By Tim Bowling, British Association for Parenteral and Enteral Nutrition
Published by Radcliffe Publishing, 2004
ISBN 1857758315, 9781857758313
Red Tray policy: see below
Protected Mealtime policy, see below
McClave SA, Snider HI, Lowen CC et al. Use of residual volume as a marker for
enteral feeding intolerance: prospective blinded comparison with physical
examination and radiographic findings. Journal of Parenteral and Enteral Nutrition
1992; 16: 99-105
http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-199907000-00003.htm
Kirby DF, Teran JC. Enteral feeding in critical care, gastrointestinal diseases, and
cancer. Gastrointestinal Endoscopy Clinics of North America 1998; 8: 623-643
http://www.ncbi.nlm.nih.gov/pubmed/9654573
The Nursing Midwifery Code of professional conduct: standards for conduct,

performance and ethics 2008 http://www.nmc-
uk.org/aFrameDisplay.aspx?DocumentID=3954
Guidelines for placing a Nasogastric Tube in Clinical Procedures Manual

http://www.ekhut.nhs.uk/home-page/for-staff/policies-and-guidance/policy-and-
guidance-search/?assetdet=24500
NPSA 5 Feb 2005 for the correct position of NGT
http://www.NPSA.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=3399
NPSA 19 2007 guidelines for daily flushing of gastrostomy
Liverpool Care Pathway http://www.mcpcil.org.uk/liverpool_care_pathway
EKHUT Vascular Access Guidance http://www.ekhut.nhs.uk/home-page/for-
staff/policies-and-guidance/policy-and-guidance-
search/?ignoreeveryonegroup=0&assetdet=20123&p=2
Royal Marsden Hospital Manual of Clinical Nursing Procedures
Refer to BNF http://www.bnf.org/
Department of Health guidelines; Reference guide to consent for examination or treatment

2001
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuid
ance/DH_4006757
And the Mental Capacity Act 2007 http://www.dca.gov.uk/legal-policy/mental-

capacity/mca-cp.pdf
Red Tray policy:

ype=Attachment

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Protected Mealtime policy:

ype=Attachment
Other useful websites:
www.bnf.org.uk
www.medicines.org.uk
www.cks.library.nhs.uk
www.bapen.org.uk

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Document Reference No: To be allocated by Policy Development Manager when

1st December 2009 Page 1 of 79

1.0 EXECUTIVE SUMMARY

Mental Capacity Act 2007 http://www.dca.gov.uk/legal-policy/mental-capacity/mca-cp.pdf

1st December 2009 Page 2 of 79

Document Tracking Sheet

Multi-Agency Public Protection Arrangements Policy & Procedure

Version Status Date Issued Comments

1st December 2009 Page 3 of 79

3. THE ETHICAL PRINCIPLES OF NUTRITION 8

4. PROVISION OF FOOD FOR ADULT INPATIENTS 15

5. ROLES AND RESPONSIBILITIES 17

6. ORAL NUTRITIONAL SUPPLEMENTS (ONS) 18

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7.15 Care / Replacement of a PEG 28

8. PRESCRIBING, PREPARING AND ADMINISTERING MEDICINES FOR USE IN

9. PARENTERAL NUTRITION (PN) 466

10.0 RE-FEEDING SYNDROME 52

11. IMPLEMENTATION INCLUDING TRAINING AND AWARENESS 57

12. STAKEHOLDER, CARER AND USER INVOLVEMENT 57

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3. THE ETHICAL PRINCIPLES OF NUTRITION

3.1.1 Key Points

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3.2 The Dying / Terminally Ill Patient

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3.3 Nutrition Screening

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3.4 Screening for Malnutrition Risk

3.4.1 Key Points

MUST should aid rather than replace clinical judgement

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3.5 Outcome of MUST

Step 1: BMI Score

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3.6 General Advice for Improving Nutritional Intake

3.6.4 Please refer to the EKHUFT Red Tray Clinical Guidelines

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3.7 Referral to Dietetic Department

3.7.2 Special considerations should be given to the following patient groups:

3.7.2.1 Patients with Clostridium Difficile:

3.7.2.2 Patients with Suspected bowel obstruction:

3.7.2.3 Patient on enhanced recovery programme:

3.7.4 Key Points

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4. PROVISION OF FOOD FOR ADULT INPATIENTS

4.1 Availability of Food

4.1.1 Food will be available for patients 24 hours per day.

4.1.2 Ad hoc meals will be provided for:

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4.3.1 Food is to be presented in an attractive manner.

4.5.1 Patients are to be provided with 7 hot beverages daily.

4.6 Therapeutic Diets

5. ROLES and RESPONSIBILITIES

5.2 Responsibilities of hospital staff – Nursing

5.3 Responsibilities of Hotel Services Staff

• Provision of meals 24 hours a day

5.4 Responsibilities of other Healthcare Professionals (Speech and Language Therapist