Home Enteral Nutrition

Standards for Patient Education

+-----------------------------------------------------------------------+
| I.  Patient and/or caregiver will receive education and provide a     |
|     return demonstration for the following:                           |
|                                                                       |
|     1.  Feeding product preparation and administration.               |
|                                                                       |
|     2.  Sanitation techniques for preparation, storage, infusion.     |
|                                                                       |
|     3.  Use and maintenance of equipment and infusion methods.        |
|                                                                       |
|     4.  Cleaning techniques for tube handling and site care.          |
|                                                                       |
|     5.  Recognition of and appropriate response to complications.     |
|                                                                       |
| II. Patients and/or caregivers will receive education materials.      |
|                                                                       |
| III. Process will include periodic reassessment and retraining.       |
+-----------------------------------------------------------------------+

[Home Enteral Nutrition Education Checklist]{.underline}

[PURPOSE AND INSTRUCTION:]{.underline} This Checklist will:

1\. Assist in identifying instructional responsibilities.

2\. Aid in teaching patients and caregivers the skills needed to perform
Home Enteral Nutrition.

Clinical staff (nurses, physicians, dietitians) will collaborate to
teach the patient about tube feeding administration and care of tubing
and equipment.

**Date & initial each** section when instruction/demonstration is
completed.\
Document all education on the shared Patient Education template.

**Implementation of Home Enteral Nutrition Education**

The Registered Nurse will educate the patient in the following:

  ------------------------------- --------- ------------- -------------------
                                  Discuss   Demonstrate   Return
                                                          Demonstration by
                                                          Patient/Caregiver

  Give Home Tube Feeding Guide to                         
  patient and/or caregiver                                

  Complete page 1 in Guide                                

  Discuss the purpose of tube                             
  feeding                                                 

  Instruct in how to administer                           
  tube feedings and check                                 
  residuals                                               

  Instruct in how to administer                           
  medications through feeding                             
  tube                                                    

  Instruct in skin care, oral                             
  care, and trouble shooting                              
  tips.                                                   

  Feeding tube care                                       

  Feeding bag care                                        

  Syringe care (if used)                                  

  Feeding pump care (if used)                             
  ------------------------------- --------- ------------- -------------------

**Feeding product & Fluids**

The Registered Dietician will educate the patient in the following:

Inform patient of the type of feeding product to be provided

Discuss purpose, type, amount, feeding product and concentration

Discuss fluid needs

Discuss preparation of feeding product

Discuss administration schedule

Discuss weight exceptions

Discuss possible complications and when to contact the doctor.

+-----------------------------------------------------------------------+
| ![](media/image1.wmf){width="1.0361111111111112in"                    |
| height="1.3194444444444444in"}                                        |
|                                                                       |
| HOME\                                                                 |
| TUBE FEEDING GUIDE                                                    |
|                                                                       |
| Michael E. DeBakey VA Medical Center                                  |
|                                                                       |
| Houston, Texas                                                        |
|                                                                       |
| ![](media/image2.jpeg){width="2.5166666666666666in"                   |
| height="0.9354166666666667in"}                                        |
+-----------------------------------------------------------------------+

  ----------------------------------- -----------------------------------
  Patient Name                        

  Feeding Product Name                

  Type of feeding tube                G-tube PEG PEJ NGT J-tube

  Date tube was placed                

  Description of tube placed          

  Length of tube (from insertion site 
  to end)                             

  Total Amount to be given daily      cans/units

                                      

  Daily nutritional content of        calories
  feeding                             

                                      protein

  Amount/rate of feeding product      

  Feeding times                       

  Total Amount of Water to be Given   
  Daily                               

  Amount of Water for flushing tube   
  ----------------------------------- -----------------------------------

+-----------------------------------------------------------------------+
| **[Directions]{.underline}:**                                         |
|                                                                       |
| Flush feeding tube with 30 ml of warm water before and after each     |
| feeding or medication given through the feeding tube.                 |
|                                                                       |
| ***Flush*** the tube with 25-35ml (1/8 cup) of warm water every       |
| \_\_\_ hours during feeding.                                          |
|                                                                       |
| For PEGs only, check residuals every \_\_\_hours.                     |
|                                                                       |
| Mixing Directions (if any) [\_\_\_\_\_\_]{.underline}                 |
|                                                                       |
| [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}          |
|                                                                       |
| **Doctor:                                                             |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |
|                                                                       |
| **Dietitian:** Dial the main hospital number 713-791-1414, request    |
| extensions:                                                           |
|                                                                       |
| Mary J. Carr, MS, RD, Extension 3976                                  |
|                                                                       |
| Nancy Baker, RD, CDE, Extension 4295                                  |
|                                                                       |
| Alicia Merritt, RD, Extension 6166                                    |
|                                                                       |
| **[TeleCare]{.underline}:** 1-800-639-5137 Extension 2458 to speak to |
| a registered nurse.                                                   |
|                                                                       |
| **Community Support:** The Oley Foundation for Home Parenteral and    |
| Enteral Nutrition                                                     |
|                                                                       |
| \(800\) 776-OLEY [www.oley.org](http://www.oley.org/)                 |
+-----------------------------------------------------------------------+

**[WHAT IS TUBE FEEDING?]{.underline}**

During the normal eating process, food passes through the mouth into the
esophagus and then goes into the stomach. The mouth and esophagus are
bypassed during a TUBE FEEDING. The liquid tube feeding product goes
directly into either the stomach or the jejunum.

Tubes placed in the STOMACH are either gastrostomy tubes or percutaneous
endoscopic gastrostomies (also referred to as PEG). Tubes sometimes must
be placed in the jejunum which is a section of the small intestine.
These tubes are called jejunostomy tubes (also referred to as J-tubes or
PEJ). If tube feeding is needed for a short time period, feeding tubes
placed through the nose are used. These are called nasoenteric tubes and
can be placed in either the stomach or the jejunum.

![](media/image3.png){width="3.3895833333333334in"
height="4.014583333333333in"}![](media/image4.jpeg){width="3.3895833333333334in"
height="4.014583333333333in"}

The feeding tube stays in your\
stomach or jejunum all the\
time. The picture shows\
where a G-tube (or PEG) and J-tube\
(or PEJ) are placed.

![](media/image5.png){width="2.498611111111111in"
height="2.0006944444444446in"}

![](media/image6.png){width="1.625in" height="0.875in"}

![](media/image7.wmf){width="1.3472222222222223in"
height="1.3055555555555556in"}

**[HOW TO PREPARE TUBE FEEDING]{.underline}**

1.  Always wash your hands with soap and warm water.

2.  Gather all the equipment you will need:

+---------------------------------+-----------------------+-----------+
| -   room temperature feeding    | -   wall hook or      |           |
|     product                     |     clothes hanger    |           |
+---------------------------------+-----------------------+-----------+
| -   feeding bag                 | -   clean cloth,      |           |
|                                 |     towel,\           |           |
|                                 |     or paper towel    |           |
+---------------------------------+-----------------------+-----------+
| -   syringe (if needed)         | -   1 cup warm        |           |
|                                 |     (tepid) water     |           |
+---------------------------------+-----------------------+-----------+
|                                 |                       |           |
+---------------------------------+-----------------------+-----------+

3.  Prepare the feeding product as directed by your health care
    provider.

4.  Wash the top of the can with hot water and shake the can well

5.  Cover any unused feeding product, write the date on the container,
    and place it in the refrigerator. Once container is opened, throw
    away refrigerated feeding product after 24 hours.

    **[Common Measurements]{.underline}**

When measuring water and tube feeding product, you can use the following
chart to convert milliliters to cups or ounces.

![](media/image8.wmf){width="1.1493055555555556in" height="1.375in"}

  -------------------------------- ---------------- ---------------------
  milliliters (ml)                 Cups             Ounces

  30                               1/8              1

  60                               1/4              2

  120                              1/2              4

  240                              1                8
  -------------------------------- ---------------- ---------------------

![](media/image9.wmf){width="0.9583333333333334in"
height="0.8194444444444444in"}**[WHERE TO DO THE]{.underline}** **[TUBE
FEEDING]{.underline}**

![](media/image10.wmf){width="1.3888888888888888in"
height="1.0833333333333333in"}Somewhere **comfortable** and **safe:**

-   Sitting in a chair

-   Propped up in bed or on a couch in a

-   Half-sitting position with head raised 30\
    degrees or more (equivalent to 2 pillows)

![](media/image11.wmf){width="1.6229166666666666in"
height="1.6229166666666666in"}

![](media/image12.wmf){width="1.8472222222222223in"
height="1.198611111111111in"}

**[GIVING YOUR TUBE FEEDING]{.underline}**

Most tube feedings given in the home setting are by *gravity* which
means there is no need to have a feeding pump. This is preferred because
it allows people to continue normal daily activities when feeding is
done.

 **Gravity Feedings**

1.  Using a hanger or hook, hang the feeding bag above head level.

2.  Flush the feeding tube with warm water in the amount specified by
    your health care provider. Do this by placing water in the feeding
    bag (or syringe if recommended by the healthcare professional).

3.  Remove the protective cap from the end of the feeding bag.

4.  Insert the tip of the feeding bag tubing into the feeding tube.

5.  Open the clamp on the feeding bag. Allow water to infuse and then
    close the clamp (or gently push in water with syringe).

6.  Add feeding product to bag as instructed by your nurse.

7.  Slowly open the clamp on the feeding bag. Use the clamp to adjust
    the flow rate if needed.

8.  Close the clamp when finished.

9.  Repeat steps 2 and 3 to flush the tube with additional warm water.

10. Disconnect the feeding bag and clamp or plug the feeding tube.

11. Wash bag with liquid soap and warm water, rinse well, & air dry.

12. Store in a clean covered container or wrap in a clean towel until
    next use. Discard bag every 3-4 days and replace with new.

-   **Pump Feeding**

1.  When there is a possibility you will be away from home when you need
    to receive your tube feeding, take your feeding pump and at least a
    24 hour supply of feeding product.

2.  Check the feeding bag to make sure it is attached to the pump
    properly.

3.  Add only enough feeding product for 4-6 hours.

4.  Remove the protective cap from the end of the feeding set.

5.  Insert the tip of the feeding bag into the feeding tube.

6.  If the bag has a clamp, open the clamp.

7.  Turn on the pump and set the rate according to directions.

8.  Start the pump.

9.  Stop the pump once the feeding container is empty.

10. Flush the tube with warm tap water in the feeding container. See
    page 2 for specific instruction about amount and frequency.

11. Turn on the pump and let the water flow into the tube.

12. Stop the pump and disconnect the feeding bag from the feeding tube.

13. [For Intermittent Feedings]{.underline}

-   Use a syringe to flush the tube with 30 ml (1/8 cup) of warm water.

-   Close the feeding tube until the next feeding.

-   Wash bag with liquid soap and warm water, rinse well, & air dry.

-   Store in a clean covered container or wrap in a clean towel until
    next use. Change bag at least 2 times per week.

    [For Continuous Feedings]{.underline}

-   ***Disconnect*** the feeding container from the PEG tube and feeding
    pump.

-   ***Rinse*** the feeding container (bag) and tubing set with warm
    water before adding more feeding product.

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-   ***Place*** new feeding product into the feeding container and
    repeat the feeding procedure.

-   ***Flush*** the tube with warm water several times daily as directed
    by your health care provider.

**[CHECKING RESIDUALS]{.underline}**

The amount of feeding product remaining in your stomach since your last
feeding is commonly called a "**residual**." If your feeding tube is
placed in the stomach (example: PEG, g-tube, NGT), then the residual
should be monitored. ***For feeding tubes placed in the jejunum, this
process is not indicated.*** To properly check residuals, follow the
instructions listed below:

1.  Remove the cap from the end of your feeding tube and insert the tip
    of the syringe into the end.

2.  Remove clamp if there is one.

3.  Pull back slowly on the syringe plunger to withdraw the contents of
    your stomach. ![](media/image13.wmf){width="0.99375in"
    height="0.99375in"}

4.  Place the contents in a large measuring cup to determine\
    the amount of residual.

5.  Repeat steps 1-4 until no more fluid can be withdrawn\
    from the stomach.

6.  Push the fluid back into the stomach if the amount is less than
    100ml or 1/3 cup.

7.  If the stomach residual is more than about 8 ounces (250ml), or you
    feel unusually full, DO NOT administer the feeding.

8.  

9.  Measure residuals again in one (1) hour. If the residual is not
    decreasing in volume (or if you still feel full or nauseated),
    contact your home care nurse or the TeleCare nurse.

10. Flush the feeding tube with 30ml (1/8 cup or 2 ounces) of warm water
    through the tube using the syringe.

> **[CHECKING G-TUBE AND]{.underline}** **[J-TUBE]{.underline}**
> **[PLACEMENT:]{.underline}** **[MEASURING TUBE LENGTH]{.underline}**

Since the feeding tube may move from the original location, you should
check to be sure it remains secure and in place. Problems can occur if
the end of the tube doesn't remain in place. To check this, you should
take the following steps:

-   If the tube has a scale with numbers on it, be sure you record the
    correct number to be sure there is no change before beginning each
    feeding. Check the position of the tube at least daily.

-   ![](media/image14.wmf){width="1.3472222222222223in"
    height="0.9722222222222222in"}If the feeding tube does not have a
    number scale, use a ruler to measure the distance from your skin
    where the tube is inserted to the end of the tube. It is helpful to
    mark the site with a permanent marker.

-   Each day, record this measurement in a journal or notebook. Compare
    this figure with previous measurements. If the distance has changed,
    hold the tube feeding and call your home health nurse or TeleCare.

+-----------------------------------------------------------------------+
| ***[IMPORTANT THINGS TO REMEMBER]{.underline}***                      |
|                                                                       |
| > ![](media/image15.wmf){width="1.0694444444444444in"                 |
| > height="0.98                                                        |
| 61111111111112in"}![](media/image16.png){width="0.3854166666666667in" |
| > height="0.3645833333333333in"}PLAN AHEAD! When you will be away     |
| > from home, take equipment, supplies and tube feeding product IF     |
| > there is a possibility you may not return when it's time to give    |
| > your feeding.                                                       |
| >                                                                     |
| > ![](media/image16.png){width="0.3854166666666667in"                 |
| > height="0.3645833333333333in"} Always wash your hands before        |
| > handling your feeding tube, product or supplies.                    |
| >                                                                     |
| > ![](media/image16.png){width="0.3854166666666667in"                 |
| > height="0.3645833333333333in"} Always verify placement of your      |
| > feeding tube.                                                       |
| >                                                                     |
| > ![](media/image16.png){width="0.3854166666666667in"                 |
| > height="0.3645833333333333in"} DO NOT feed if you are in doubt of   |
| > the tube placement.                                                 |
| >                                                                     |
| > ![](media/image16.png){width="0.3854166666666667in"                 |
| > height="0.3645833333333333in"} Flush your tube with warm water      |
| > before and after feeding.                                           |
| >                                                                     |
| > ![](media/image16.png){width="0.3854166666666667in"                 |
| > height="0.3645833333333333in"} Brush your teeth at least twice      |
| > daily as if you were using them to eat.                             |
| >                                                                     |
| > ![](media/image16.png){width="0.3854166666666667in"                 |
| > height="0.3645833333333333in"} Be sure you are sitting at an        |
| > incline of 30-45 degrees when taking your tube feeding. NEVER give  |
| > tube feeding while lying flat in bed.                               |
+-----------------------------------------------------------------------+

**[GIVING MEDICATIONS THROUGH THE FEEDING
TUBE]{.underline}:**![](media/image17.wmf){width="1.2361111111111112in"
height="1.3194444444444444in"}

***INSTRUCTIONS***

1.  Flush tube with 60ml of water before and after administering
    medications.

2.  Do not crush enteric-coated or time-released medications. Do not
    dilute medications unless specified by your physician or pharmacist.

3.  ![](media/image18.wmf){width="1.3611111111111112in"
    height="0.7222222222222222in"}Do not add medications directly to the
    tube feeding product.

4.  Administer each medication according to directions.

5.  Flush tube with 20 ml of water between each medication and after
    giving all the medications.

6.  Ask your pharmacist about the availability of liquid forms of your
    medications.

7.  ![](media/image19.wmf){width="0.7708333333333334in"
    height="0.7708333333333334in"}You may use a crushing device if
    needed. After crushing, dissolve in up to 20 ml water and push into
    feeding tube.

8.  If you have any questions or concerns about how to give medications,
    contact your physician or pharmacist.

![](media/image20.wmf){width="1.9861111111111112in"
height="0.4444444444444444in"}**If you experience any ADVERSE SIDE
EFFECTS with the medication(s) contact your physician immediately.**

+-----------------------------------------------------------------------+
| ***HELPFUL TIPS REGARDING MEDICINE***                                 |
|                                                                       |
| > ![](media/image16.png){width="0.3854166666666667in"                 |
| > height="0.3645833333333333in"} Proper flushing of the tube will     |
| > prevent residue buildup inside\                                     |
| > the tube.                                                           |
| >                                                                     |
| > ![](media/image16.png){width="0.3854166666666667in"                 |
| > height="0.3645833333333333in"} Gastric irritation may be caused by  |
| > crushing enteric-coated and\                                        |
| > time-released medications. These medications may cause adverse      |
| > effects or become ineffective if crushed.                           |
| >                                                                     |
| > ![](media/image16.png){width="0.3854166666666667in"                 |
| > height="0.3645833333333333in"} Medications that are thick (viscous) |
| > may cause your tube to clog\                                        |
| > or may lead to discomfort. To prevent this, use an adequate amount  |
| > of                                                                  |
| >                                                                     |
| > fluid to dilute and flush your medication down the tube.            |
| >                                                                     |
| > ![](media/image16.png){width="0.3854166666666667in"                 |
| > height="0.3645833333333333in"} Using liquid or alternative forms of |
| > medication will help prevent\                                       |
| > your tube from clogging and minimize discomfort.                    |
| >                                                                     |
| > ![](media/image16.png){width="0.3854166666666667in"                 |
| > height="0.3645833333333333in"} Always **WASH** your hands           |
| > **BEFORE** and **AFTER** handling the\                              |
| > feeding tube.                                                       |
+-----------------------------------------------------------------------+

**[Feeding Tube]{.underline}** **[Maintenance:]{.underline}**

1.  Check placement daily by measuring the length of the tube protruding
    from the abdomen. If no external markings are on the tube, a mark
    can be made on the tube using a permanent marker to check the
    correct tube position.

2.  Rotate the tube 360º daily by gently pushing in tube about ½ to 1
    inch to prevent balloon or internal bumper from adhering to the
    gastric wall.

3.  Flush tubes routinely as instructed.

4.  Maintain good oral hygiene. Even when patients are not eating, their
    teeth should be brushed at least twice a day.

5.  Each day, check the tube site for redness, drainage, swelling, rash
    or any type of skin damage. Initially a small amount of drainage can
    be expected. Foul smelling drainage is a sign of infection and you
    should contact your primary care provider for an evaluation.

6.  If the tube has a balloon, check the water in the balloon at least
    once a week. While ensuring that the tube is held safely in place,
    the water should be withdrawn from the balloon in a sterile syringe
    and any volume deficit should be replaced by sterile water. Check
    manufacturer's directions for further instructions.

7.  Clean the skin around the tube site daily with pH-balanced soap and
    water (or normal saline). Rinse well, pat dry. A cotton-tipped
    applicator (Q-tip) is helpful.

8.  Remove any dry or crusted drainage using a solution of 25% hydrogen
    peroxide mixed with water. Rinse well, pat dry.

9.  Dressings are commonly used for 48 hours after initial placement. A
    Split gauze can be used to absorb excessive drainage, and use
    petrolatum based ointment such as A&D Ointment™) on surrounding skin
    to protect it. (Generally gauze is not needed)

10. Retaining devices, such as external bumpers, should be just above
    skin level and not tight against the skin. This may need to be
    adjusted if you gain or lose weight.

11. Stabilizing a tube can reduce the risk of tube displacement, pain
    and enlargement of the tract. Consult the Enterostomal Therapy
    nurses for recommendations.

12. Unless otherwise instructed by your health care provider, it is
    acceptable to shower with enteral devices, be sure and dry your skin
    beneath the external bumper.

13. Gastrostomy tubes (G-tubes) should be replaced when they show signs
    of degradation, balloon breakage, malfunction, or irreversible
    occlusion.

+--------------+-------------------------------------------------------+
|              | **Trouble Shooting** **Tips**                         |
+--------------+-------------------------------------------------------+
| **Pump       | > 1\. Read screen on the pump. It should tell you     |
| malfunction  | > what is wrong and how to correct the problem. Most  |
| or Alarms**  | > pumps have the manufacturer's toll free number on   |
|              | > the device you can call for assistance or you may   |
|              | > contact your home health care nurse.                |
|              |                                                       |
|              | 2\. If the above measures fail, call the TeleCare     |
|              | nurse.                                                |
+--------------+-------------------------------------------------------+
| **Feeding    | 1.  Withdraw any feeding product remaining in the     |
| tube         |     tube.                                             |
| clogged**    |                                                       |
|              | 2.  Flush with warm water.                            |
|              |                                                       |
|              | > Insert 5-10 ml of warm water into tube using        |
|              | > syringe and clamp for 5 minutes. Flush with water   |
|              | > until clear and flow is restored.                   |
|              |                                                       |
|              | 3.  Mix 1 teaspoon baking soda in 5 ml warm water.    |
|              |     Using a syringe, insert mixture into tube. Clamp  |
|              |     for 5 minutes. Flush with water until clear.      |
|              |                                                       |
|              | 4.  If the above measures fail, call the TeleCare     |
|              |     nurse.                                            |
+--------------+-------------------------------------------------------+
| **Feeding    | > **Stomach:** Get medical care immediately, either   |
| tube Falls   | > your home care nurse or Emergency Room visit. The   |
| out**        | > hole can close very quickly, sometimes within hours |
|              | >                                                     |
|              | > **Nose:** Contact your home health care nurse       |
|              | > immediately for replacement. If you do not have     |
|              | > home care services, go to the emergency room to     |
|              | > have it replaced.                                   |
+--------------+-------------------------------------------------------+
| **Vomiting** | 1.  If patient in bed, position on side lying         |
|              |     position.                                         |
|              |                                                       |
|              | 2.  Stop tube feeding.                                |
|              |                                                       |
|              | 3.  Check the residuals (G-tubes in stomach only).    |
|              |                                                       |
|              | 4.  Verify position of the tube.                      |
|              |                                                       |
|              | 5.                                                    |
|              |                                                       |
|              | 6.                                                    |
|              |                                                       |
|              | 7.  Encourage walking.                                |
|              |                                                       |
|              | 8.  If no further vomiting after 8 hours, check       |
|              |     residual again. If less than 250 ml, resume       |
|              |     feeding.                                          |
|              |                                                       |
|              | 9.  If vomiting continues, contact your home health   |
|              |     care nurse or TeleCare.                           |
+--------------+-------------------------------------------------------+
| **Diarrhea** | 1.  Slow down the rate of feeding as tolerated. Avoid |
|              |     formula hanging for longer than 6-8 hours.        |
|              |                                                       |
|              | 2.  Check for correct placement of tube, if tube has  |
|              |     moved from stomach to jejunum this can cause      |
|              |     diarrhea if bolus feedings are used.              |
|              |                                                       |
|              | 3.  Increase water to prevent dehydration.            |
|              |                                                       |
|              | 4.                                                    |
|              |                                                       |
|              | 5.                                                    |
|              |                                                       |
|              | 6.  Use only feeding product at room temperature.     |
|              |                                                       |
|              | 7.                                                    |
|              |                                                       |
|              | 8.                                                    |
|              |                                                       |
|              | 9.  If diarrhea persists longer than 24 hours, call   |
|              |     home healthcare nurse or TeleCare.                |
+--------------+-------------------------------------------------------+

+------------------+---------------------------------------------------+
|                  | **Trouble Shooting** **Tips - continued**         |
+------------------+---------------------------------------------------+
| **Leakage of     | 1.  Check residual.                               |
| feeding from     |                                                   |
| around opening   | 2.  Check to be sure tube is in correct position  |
| in stomach**     |     and secure in stomach.                        |
|                  |                                                   |
|                  | 3.  Decrease feeding rate                         |
|                  |                                                   |
|                  | 4.  If problem persists, contact TeleCare or your |
|                  |     home health nurse.                            |
+------------------+---------------------------------------------------+
| **Hole in tubing | > Get medical care immediately, either your home  |
| or Internal      | > care nurse or go to the Emergency Room to have  |
| Balloon breaks** | > the tube replaced.                              |
+------------------+---------------------------------------------------+
| > **Skin         | 1.  For minor irritation, apply Vaseline™         |
| > Breakdown**    |     (petrolatum-based product) around site.       |
|                  |                                                   |
|                  | 2.  For severe irritation, apply zinc-based paste |
|                  |     around insertions (ex: zinc oxide or A&D      |
|                  |     Ointment™, CriticAide™)                       |
|                  |                                                   |
|                  | 3.  If no improvement; contact your home health   |
|                  |     care nurse or TeleCare.                       |
+------------------+---------------------------------------------------+

**Approved by the Patient & Family Education Committee on 10/30/2002**

**Revised April** **2007**