600 Sixth St, Suite 400, Lincoln CA 95648
Ph: (916) 645-4078 Fax: (916) 645-9267
Health Services
GASTROSTOMY TUBE FEEDING PROCEDURE BOLUS
STUDENTS NAME:__________________________________________ TEACHER:____________________
SCHOOL:________________________________________________________________________________
A.
State the name and purpose of procedure:_______________________________________________________________
B.
Identify potential problems and appropriate actions:________________________________________________________
C.
Preparation:
1. Time(s) to be administered:_____________________________Time(s) on Minimum/Short Day:__________________
D.
E.
2.
Name of formula______________________________(formula may change per parent request. No MD order required)
3.
Amount of formula to be given______________cc
4.
Flush with___________cc water before and ____________cc water after feeding
5.
May give____________cc additional water during school day
6.
Feeding to be completed in ___________minutes
7.
Position for feeding_________________________
Gather Supplies:
1. 60cc syringe, administration set tubing
2. Gloves (non-latex)
3. Prescribed medication (if ordered)
4. Prescribed diet at room temperature
5. Water in cup for flush
Procedure: ALWAYS STANDARD PRECAUTIONS
1. Clean surface and area to be used with an approved sanitizer. Lay barrier down on preparation surface (paper towel, white
wipes, chux)
2. Bring MD orders to procedure area
3. Wash hands thoroughly with soap and water. (If water is not available, use approved hand sanitizer)
4. Gather and assemble equipment. Shake formula and wash top of can with soap and water and clean paper towels before
opening.
5. Explain procedure and position student. Unless otherwise specified, a semi-sitting position is preferred to facilitate digestion.
6. Wash hands thoroughly with soap and water. APPLY GLOVES (non-latex)
7. Attach the administration set (tubing) to the 60cc syringe. Clamp tubing of administration set.
8. Check patency by gentle flushing with 10-20cc water using syringe OR pour into 60cc syringe and prime tubing for flush
9. Pour feeding into 60cc syringe to half full. Open clamp and prime tubing- allow feeding to fill tubing, reclamp
10. Open G-tube port and insert tip of tubing into port matching black lines, turn to lock in place and secure. Unclamp
administration tubing
11. Adjust feeding delivery rate by raising and lowering syringe as needed
12. When the formula finishes to 5cc mark, add water to flush through syringe and tubing
13. Clamp tubing. Disconnect administration set from port
14. Make sure port is capped or tubing is secured and tucked inside clothing
15. Keep student in upright position for about 30 minutes after feeding.
16. Clean syringe and administration set with hot, soapy water, blot with paper towel, air dry, and store
17. Document feeding time, start and finish in Procedure/Feeding Log.
18. Report any problems to school nurse (she will notify parents)
Note: If child vomits or has a seizure during feeding, stop feeding immediately. Notify parent by phone, and document in daily log.
If gastrostomy tube becomes dislodged:
A.________ Reinsert per protocol.
_____ with balloon inflation
(Licensed Nurse only- physician’s authorization must be on file)
B. _______ Cover with gauze and notify parent
_____ without balloon inflation
*Prompt reinsertion of Gastrostomy Tube is recommended so the ostomy remains patent (open and flowing). Delay of reinsertion may
cause the ostomy to constrict (close), a condition which may require painful reinsertion or surgical intervention.
I understand this information will be shared with educational staff as deemed necessary to provide quality care. I hereby give my consent
for information on this form to be released to school staff, transportation staff and emergency personnel as needed to provide quality care.
This authorization is valid until________________, and maybe revoked at any time.
Parent/Guardian Signature:_____________________________________
Date:____________________________