GASTROSTOMY CARE GUIDE GASTROSTOMY CARE GUIDE

Universal INDICATIONS FOR Adapter TUBE FEEDING Medication PATIENT INFORMATION Complete nutrition supports Port development, growth, and heal- ing. If the ability to eat or Replaceable Date of tube insertion swallow is lost, or the patient is unable to tolerate food, enteral Feeding feeding can sustain life, nour- Patient name Phone ish, and even increase body Adapter weight. Tube feeding is also Physician Phone used to supplement a deficient food and fluid intake. The feed- Type 0100 0110 0150 0160 (circle one) Fr Size ing procedure can be managed safely and economically at Manufacturer's lot number (printed on package) home, away from the hospital setting. A surgical gastrostomy Mark above the SECUR-LOK¨ Ring in cm provides access to the stomach if long term nutritional support (this means the mark after the initial placement) is necessary. Balloon volume if 0100, or 0110 type G Tube Pure medical grade silicone (the volume should be between 7 and 10 cc) construction makes MIC Feeding Tubes durable, yet soft and comfortable to wear. They SECUR-LOK® Formula are also translucent, allowing Ring visualization of the inside of Brand name the tube above the skin line. All MIC Enteral Feeding Tubes Method of delivery are latex free.

Volume, rate and time the feeding should take MIC PEG Total amount of daily water PEG stands for Percutan- eous (through the skin) Additional ingredients Endoscopic (use of a flexible lighted tube to visualize tube Irrigate the tube with water before and after feeding and medication placement) Gastrostomy administration. (surgical opening into the stomach). PEG Tubes (0150 Internal and 0160 series) and Retention Checking Residual Gastrostomy Tubes (0100 and 0110 series) are the same in Fig.1 Dome Check residual before feeding. Notify physician if residual is more than cc function. PEGs have internal retention domes; G Tubes have retention balloons. PEGs have MIC PEG TUBE replaceable feed ports; G Tubes Series 0150 & 0160 do not because the feed port houses the balloon inflation valve. internal retention dome pre- vents accidental removal of the As the physician inserts the PEG assuring that the tract PEG Tube, a dilator tip on the forms correctly. The PEG Tube tube itself helps to create a must be removed by a physi- stoma the size of the PEG cian once the tract is healed. A Tube. Gradually, the stoma balloon G-Tube that can be heals around the tube forming safely and easily changed at a sealed tract. The home may replace it.

18 3 GASTROSTOMY CARE GUIDE GASTROSTOMY CARE GUIDE

CAUTION DO NOT ATTEMPT TO REMOVE A PEG. NOTES: SERIOUS COMPLICATIONS CAN RESULT. PEG TUBES MUST BE REMOVED BY A PHYSICIAN OR CLINICAL SPECIALIST.

If the PEG SECUR-LOK® Ring is sutured to the skin, care for the stoma is as follows: (Fig. 2) 1. Wash hands thoroughly with soap and water. 2. Saturate a cotton-tipped applicator with a 1/2 strength solution of hydrogen peroxide and sterile water. 3. Gently soften and remove any crusts Cleansing from around and a new underneath the disc. gastrostomy site 4. Finish with a clean, dry applicator. Do not touch the area with your hands. After the sutures are removed, follow the routine tube Fig. 2 care instructions on page 6 of this booklet.

PEG FEEDING ADAPTERS To replace an adapter, remove existing adapter from the PEG Tube. Trim stretched or torn tubing with scissors, then reconnect the new adapter. ADAPTER SIZES Universal (Universal) Feeding 0135-14 fits 14 Fr PEG Adapter 0135-20 fits 20 Fr PEG 0135-24 fits 24 Fr PEG (Bolus) 0136-14 fits 14 Fr PEG 0136-20 fits 20 Fr PEG 0136-24 fits 24 Fr PEG Bolus Bolus adapters are useful for Adapter drainage and/or stomach decompression because they do not have universal connectors inside the feed ports. 4 17 GASTROSTOMY CARE GUIDE GASTROSTOMY CARE GUIDE

MIC GASTROSTOMY TUBE GLOSSARY OF TERMS Feed Port FEEDING PORT MIC series 0100 tubes have a ASPIRATION: Accidently inhaling liquid into the windpipe and/or lungs. "universal connector" inside Balloon Port the feed port to prevent the BOLUS FEEDING: Large amounts of formula delivered through the tube. port from leaking after repeat- Medication ed use. (Fig. 3) If your formula Port CONSTIPATION: Bowel movements (stools) sometimes painful, and difficult to pass. delivery set does not fit the connector, use a MIC 0105-6 CONTINUOUS FEEDING: Formula delivered at a constant rate throughout the day (or night) extension set to connect the without interruption. tubes. MIC Bolus Gastrostomy Tubes, series 0110, have no Universal DIARRHEA: Frequent, loose, or watery bowel movements. universal connectors or med- Connector ication ports. To drain or ESOPHAGUS: The passage in the throat through which food passes from the mouth into decompress the stomach, use a the stomach. Bolus Gastrostomy Tube. The Bolus Port accepts most con- FEEDING PUMP: A small machine, plug-in or battery powered, that automatically controls nectors. If additional tubing length is needed, MIC 0105 the amount of formula being delivered through the feeding tube. extension sets may be pur- FEEDING SET: Tubing that connects the feeding container to the feeding tube. chased from your medical sup- Centimeter plier or from Ballard Medical Products Customer Service. Markings FEEDING TUBE: Tube through which formula flows into the stomach or intestine. (gastrostomy or jejunostomy tube) MEDICATION PORT The medication port accepts G TUBE: Gastrostomy tube. A tube that passes through the skin into the stomach. Also the Luer connectors on most syringes. The port joins the ® called feeding tube. main tube lumen, there is no SECUR-LOK separate channel. Before and Ring GASTROESOPHAGEAL REFLUX: Backing up of formula or gastric fluid from the stomach after giving medication, stop into the esophagus. the formula and flush water through the medication port to GASTRIC DECOMPRESSION: The removal of gas or fluid from the stomach. clear the tube. If your feeding (Also called "venting") set connector fits into the med- ication port, you may also use Internal GASTROSTOMY: A surgical opening (stoma) through the skin into the stomach. the port to give formula. Retention SECUR-LOK® RING Balloon GRANULATION TISSUE: Fleshy projections on the surface of the stoma that form If both the tube and the ring fibrous scar tissue. are dry, friction holds them together preventing the tube GRAVITY DRIP: Formula flows into the feeding set by gravity. from sliding inside the stom- ach. Position the ring 3 mm Tip INTERMITTENT FEEDING: Small amount of formula given frequently. (the thickness of a dime) above Fig. 3 the skin.(Fig. 4) IF THE NUTRIENTS: Food or any substance that nourishes the body-protein, carbohydrate, fat, RING POSITION IS TOO vitamins, minerals, and water. CLOSE FOR VERY LONG, A PRESSURE INJURY MIC SERIES 0100 G TUBE STOMA: Surgical opening into the body. COULD RESULT. BALLOON PORT STOMACH RESIDUAL: Stomach contents 4 hours after feeding. This port houses the balloon valve. DO NOT INADVER- SYMMETRICAL: Correspondence in shape, size, and relative position of parts on opposite sides. TENTLY GIVE MEDICA- TION OR FORMULA INTO THE PORT. If this happens, the valve may clog and the gas- Fig. 4 trostomy tube will be more dif- ficult to remove from the stom- ach. Position the ring this far above the skin 16 5 GASTROSTOMY CARE GUIDE GASTROSTOMY CARE GUIDE

Feed Port RETENTION BALLOON CONSTIPATION Besides anchoring the tube GASTROINTESTINAL Inactivity, a change in formula, inside the stomach, the balloon DISTRESS helps to keep the stoma from medication, or feeding routine can cause constipation. A leaking. The 20 cc label on the DIARRHEA balloon port is the balloon Balloon Port physician or dietitian can CAPACITY, not the recom- The most common complication advise the addition of fiber and mended volume. Fill the bal- of enteral feeding is diarrhea. liquid to the diet to correct the loon with 7-10 cc distilled water Possible Causes include the for- problem. or saline. DO NOT USE AIR mula composition, a new med- TO INFLATE THE BAL- ication, or a change in feeding TRACKING PROGRESS LOON. Air will migrate over routine. Other causes may be several hours causing the bal- When tube feedings are first loon to deflate just as a regular rapid formula administration, started, your daily record of balloon gradually deflates. The contaminated formula, or ill- intake and output may help recommended volume for the ness. Try diluting the formula your clinician evaluate the Low Volume Balloon is 2-3 cc. with water and giving it at room nutritional adequacy of the pre- (Fig. 5) temperature. scribed formula and water. For Temporarily decrease the flow SECUR-LOK® the first week or two, and in ill- rate. If diarrhea is severe and CARE AND USE Ring ness, keep a running total of persistent, a physician should daily feeding, water and gastric STOMA AND TUBE CARE direct the care. residual measurement. A To ensure a healthy gastrosto- NOTE: CHECK THE TUBE weekly body weight may be my site (stoma), keep the skin helpful. The cause of poor clean and dry. Wash the area POSITION. IF THE TUBE with soap and water, including SLIPS FORWARD INTO THE growth is an insufficient calorie the tube and the bottom of the INTESTINE, FORMULA WILL intake. SECUR-LOK® Ring. ENTER THE INTESTINE ROTATE THE TUBE 360 DEGREES (A FULL CIR- DIRECTLY, NOT THE STOM- CLE) EVERY DAY TO PRE- ACH, CAUSING VENT THE TUBE FROM DIARRHEA AND OTHER ADHERING TO THE PROBLEMS. STOMA TRACT. Dry the skin surface well after tube care. VOMITING Tape restricts air flow and may Internal This may allow gastric contents break the skin down resulting Retention in infection. If possible, avoid to escape into the lungs increas- Balloon dressings. ing the risk of pneumonia. If Fig. 5 MIC 0110 Bolus G TUBE the patient becomes nauseated, CAUTION: vomits, chokes, or has feeding or REPORT PROLONGED REDNESS, breathing difficulty during a ORAL CARE IRRITATION, SORENESS OR UNUSUAL tube feeding, stop the feeding at DRAINAGE TO THE PHYSICIAN Tube feedings deprive the mouth of the stimulation pro- once. Disconnect the delivery vided by normal eating. Dental set and evacuate the stomach ACTIVITY using a catheter tip syringe. After the gastrostomy heals, plaque accumulates faster than Wait 1-2 hours before feeding. most people resume normal usual. Plaque harbors bacteria activity. Before bathing or that causes tooth decay and Always check the position of the swimming, close the feeding gum infection. To reduce bacte- tube. Children who vomit fre- and medication ports tightly. A rial growth and increase circu- quently may outgrow it as their physician or clinical specialist lation to the gums, brush teeth anatomy matures. should direct your activity and gums twice daily. level. 6 15 GASTROSTOMY CARE GUIDE GASTROSTOMY CARE GUIDE

8. Cleanse and dry the GASTRIC DECOMPRESSION stoma. Gastric leakage (VENTING) and/or slight local bleed- To passively decompress the ing is normal. stomach, open the feed port. Position the tube to empty into 9. Carefully position the Fig. 6 Aspirating stomach ® a drainage receptacle using an SECUR- LOK Ring contents with an without putting tension extension set such as the MIC on the tube: 3 mm above 0105. If the patient is nauseat- irrigation syringe. the skin level (the thick ed or vomiting, use a ness of a dime). *Monoject® catheter tip syringe to suction the gas or liquid from 10.To ensure correct tube the stomach. Turning the placement: a. Listen for air. Place patient to the right side may your ear or a stethoscope allow the gas to rise and escape against the abdominal through the tube. Do not use wall halfway between force to suction stomach con- the navel and the left tents. If you do not get results, nipple. Inject 10-20 cc air try repositioning the patient, or into the feed port and consider that the stomach may listen for the sound of air be empty. entering the stomach. (Fig. 6) b. Use the catheter tip syringe to withdraw stomach contents back ENTERAL FEEDING into the syringe. It may PROCEDURES help to position the patient on the left side so stomach contents gravi- ENTERAL FEEDING tate toward the tube tip. SUPPLIES 11.Record the cm number on •Formula the tube above the top of • 60 cc catheter tip the SECUR-LOK® Ring in Monoject® syringe the Patient Information • Pump stand or IV pole Section of this booklet. • Pump controller 12.Inspect the stoma site for •Formula bag moisture. If the stoma •Water leaks, re-check the balloon • At least one 12 cc Luer position (step 6) and ® syringe (for medication) the SECUR-LOK Ring • Extension tube (optional) position. Adjust if neces- sary. •Y Connector (optional) Handwashing is the single PREPARING TO FEED USE UP TO 5 cc IN THE 5 cc most important defense BALLOON (LOW VOLUME). THE 1. Wash hands with soap and against infection. CORRECT VOLUME IS 2-3 cc's. water. (Fig. 7) 2. Pour formula into a clean Fig. 7 USE UP TO 10 cc IN THE 20 cc bag or use a prefilled bag. BALLOON (STANDARD BAL- 3. Purge the delivery set tub- LOON). THE CORRECT ing with formula to push VOLUME IS 7-10 cc's. the air out, then clamp the tubing. 4. Flush the gastrostomy NOTE: NEVER FEED THROUGH A tube with 20 cc water. G TUBE IF THERE IS ANY 5. Elevate the patient's head QUESTION THAT THE TIP MAY and torso 30-45 degrees. NOT BE INSIDE THE STOMACH 6. Set the pump flow rate or adjust the delivery set clamp. 14 7 GASTROSTOMY CARE GUIDE GASTROSTOMY CARE GUIDE

PREPARING TO FEED REPLACING THE (cont'd) TUBE 7. To verify that the tip of the tube is inside the stomach: This procedure can be safe and easy. Ask your nurse or clinical a. Insert a catheter tip specialist to teach you the pro- syringe filled with 10-15cc cedure before trying it at home. air into the feed port. Change the gastrostomy tube Slide the ring if: The tube is obstructed and up the tube b. Place your ear or a cannot be cleared, the tube acci- stethoscope over the left dentally falls out, is pulled out, Fig. 13 side of the stomach just or a clinical specialist or physi- above the waist. cian orders the change. Note: You may need a second person c. Depress the syringe to restrain a child while chang- plunger to inject air into ing the tube. the tube and the stom- ach. Listen for bubbling 1. Wash your hands as the air enters the 2. Test the new tube for: stomach. a. Ring function. It should FEED ONLY AFTER be difficult to move up d. If you do not hear and down the tube. bubbling sounds, try CONFIRMING THAT THE TIP (Fig.13) again, or aspirate for b. Balloon integrity. Fill a Apply counter gastric residual. OF THE TUBE IS INSIDE THE Luer syringe with 5 cc pressure with saline or distilled water one hand Aspirating for gastric STOMACH and inflate the balloon. If residual: the balloon sticks to the Fig. 14 tubing, squeeze and bend a. Turn the patient to the it to "unstick" the balloon left side allowing stom- and to check for leaks. ach contents to flow Deflate the balloon with toward the tube tip. the syringe. b. Insert a catheter tip 3. To remove the used tube syringe into the feed from the stomach: port. a.Withdraw the water from the balloon with a c. Withdraw stomach syringe. contents into the BECAUSE FREQUENTLY b. Place a flat hand firm- syringe. ly against the abdomen, DELAYED OR SLOW FORMULA and gently but firmly, d. Record the date, time, RATES MAY DEPRIVE THE pull the tube out.(Fig.14) and the amount with- To insert a new tube: drawn. Also record the PATIENT OF ESSENTIAL 1. Wait 10-15 minutes before time the previous feed- NUTRIENTS, DISCUSS THE inserting the new tube. ing was given and the The stoma will constrict Inserting a amount. PLAN OF CARE WITH THE enough to tightly fit the gastrostomy tube PHYSICIAN OR CLINICAL new tube. Fig. 15 e. If the amount you with- 2. Wash and dry the stoma draw from the stomach SPECIALIST. MANY PATIENTS and skin. is more than 1/2 the NEED EVERY CALORIE THAT IS amount of the previous 3. Lubricate the tip of the new feeding, feed the patient PRESCRIBED TO MAINTAIN OR tube with a water soluble 5. If you meet resistance, cautiously. You may GAIN WEIGHT agent. DO NOT CONSIS- completely remove the tube wait to feed, or decrease TENTLY USE PETROLE- and try again. the flow rate. UM PRODUCTS. 6. Inflate the balloon with dis- 4. Hold the tube at a 90 tilled water or saline while f. If little or no stomach degree angle to the abdo- fluid is withdrawn, the men. Gently but firmly holding the tube in place. stomach might be insert it 2-3 inches into 7. Snug the balloon against empty. the gastric stoma. (Fig.15) the inside stomach wall by gently pulling the tube out . 8 13 until it stops. GASTROSTOMY CARE GUIDE GASTROSTOMY CARE GUIDE

TUBE PROBLEMS METHODS OF DELIVERY TUBE MIGRATION PUMP CONTROLLED If the balloon slips away from METHOD the inside stomach wall, it Pump controllers deliver for- could cause an intestinal Fig. 12 mula accurately and reduce obstruction. Pressure may stomach distention and esophageal reflux by decreas- build inside the stomach, caus- ing the amount of air that ing leaking from the stoma, enters the stomach. This bene- nausea and/or vomiting. Before fits infants because there is every feeding, know the length usually no need to burp them of the tube that is outside the after feeding. Formula is given body. The tube number above over 8-24 hours on an inter- the SECUR-LOK® Ring must mittent or continuous sched- be the same as the number ule. Continuous formula written in the information sec- administration decreases feed- ing intolerance problems and tion. If they are different, the promotes weight gain. tube must be adjusted. Wash Formula given during sleep and rinse the tube and both hours adds calories to supple- sides of the ring. Remove any ment daytime feedings. Flush oil on the tube with alcohol if decreased, fill the syringe the G Tube with water every with the correct amount of six hours. (Fig. 8) necessary. Pull the tube out of Fig. 8 the stoma until the correct water, and inject it into the GRAVITY METHOD number is visible. Adjust the balloon port. Bags with manual flow regula- ring 3 mm above the skin. The tors are used for gravity feed- matching number must be TUBE OBSTRUCTIONS ing. The only other necessary above the ring. If the above pro- Adherence of residue to the equipment is an IV pole. The cedure is confusing, measure inside the tube causes obstruc- formula may clog the tube or Pump Controller run poorly at flow rates slower the visible tube length with a tions. The residue consists of ruler. Write the length down, than 100 cc per hour, and the hardened stomach contents, amount given is often inaccu- and always check it before medication, and / or formula. rate. Hang the bag about 2 feet starting a feeding. (Fig. 12) Avoid this by flushing the tube above the tube. Count the flow If the tube looks longer, check with water before and after rate at the beginning of the feeding. Recheck the rate after Adjusting a the number above the ring. The each feeding. Separate med- a few minutes. It will probably balloon may have a slow leak, ication from the formula. To de- have slowed and need to be flow regulator allowing it to slide out of the clog an obstructed tube, fill a adjusted. To prevent clogs, stomach. Push the tube in 2-3 catheter tip syringe with warm flush the G Tube with water inches. Check the balloon vol- water and inject the water gen- every six hours. (Fig. 9) ume. Return the tube and the BOLUS METHOD ring to their original positions, tly into the tube. Repeat until the blockage clears. If the Bolus feedings are a conve- then recheck the balloon vol- nient and natural way to feed if ume in 2-3 hours. A skin level obstruction is visible inside the tolerated by the patient. A feeding tube such as the MIC- tube above the skin line, mas- measured amount of formula is KEY® prevents this from hap- sage the tube and flush it with given 3 or 4 times daily like a pening. warm water to clear. meal. The procedure takes 5- 10 minutes, or the rate can be BALLOON CHECK lowered if it is more comfort- Measure the amount of water CAUTION able for the patient. Use a 60 Fig. 9 cc catheter tip syringe. Push inside the balloon once every DO NOT USE FORCE TO thick formula or pureed table week. To do this, insert a FLUSH ANY SILICONE food into the G Tube with the syringe into the balloon TUBE. THE TUBE MAY syringe plunger. To refill the RUPTURE. IF THE syringe, remove it from the G valve and withdraw the water. OBSTRUCTION WILL NOT If the amount has Tube and close the tube's feed CLEAR, REPLACE THE port. To give regular Gravity TUBE. formula bag 12 9 GASTROSTOMY CARE GUIDE GASTROSTOMY CARE GUIDE

BOLUS METHOD (cont'd) TUBE REPLACEMENT skills. Prevent accidental formula, hold the syringe or With daily stoma and tube removal of the gastrostomy hang it above the G Tube (with- hygiene, the G Tube can remain tube without discouraging out the plunger). As the formu- in the stomach until it eventual- physical activity. Tuck the tube la runs in, more formula is ly falls out. However, the physi- inside clothing or tape it to the poured into the syringe. If cian or clinical specialist may abdomen if necessary. Overalls hanging the syringe, use an want to change it at regular and shirts that snap between extension tube to connect the intervals. the legs will protect the tube syringe to the gastrostomy better than two piece clothing. tube. Increase or decrease the Keep an extra G Tube the same Consider trying a skin level flow rate by raising or lowering Fr size or one Fr size smaller. feeding tube such as the MIC- the syringe. Without a tube in place, the KEY® to decrease the inci- (Fig. 10) stoma may begin to constrict dence of accidental tube within 30 minutes. If you are removal. not comfortable inserting a G AFTER FEEDING Tube, cover the stoma with a Pour a pre-measured amount of gauze dressing and tape it in DEHYDRATION water into the syringe or for- place. Take the patient to the Abnormal conditions such as mula bag before the last of the hospital or clinic. prolonged vomiting, diarrhea, formula runs down the tube. sweating, or fever may cause This keeps air from entering the body to lose a large amount the stomach. Disconnect the PEDIATRICS of fluid. The caregiver should syringe or delivery set and close know the early signs of dehy- the feed port. dration. Warnings include dry Bolus Infant tube feedings begin with lips and mouth, fewer wet dia- gastrostomy pers, fewer urinating times or To reuse a formula bag, wash it frequent tiny amounts of formu- feeding la. With weight gain, the stom- dark concentrated urine. with warm soapy water, rinse ach capacity gradually increases Look for crying that does not and dry it before using it again. and the amount of formula produce tears. Other early Wash the bag and tubing every given can be increased. If the signs are weakness, dizziness, 24 hours. If formula residue stomach gets too full, formula headache, and irritability. adheres to the inside of the tub- may leak from the stoma, or the Consult your physician or ing, soak the bag and tubing in Fig. 10 infant may vomit or burp up for- dietitian for the maximum daily a solution of equal parts of mula. If this happens, return to water allowance you can give by white vinegar and water. smaller more frequent feedings, tube. or slow the formula flow rate. To ensure nutritional requirements MEDICATION are met, a physician or clinical STOMA AND SKIN Fill two Luer tip syringes with specialist should direct the care. CARE water to flush the tube before and after giving the medica- Giving medication BABY'S MOUTH BLEEDING STOMA tion. If a pump feeding is in To associate oral gratification progress, "PAUSE" the infusion Occasional slight bleeding from with a full stomach, encourage the stoma is normal and should pump (clamp the delivery tub- the tube-fed infant to suck a ing if using a gravity system). be expected during a tube pacifier or thumb as the feeding change. If the bleeding increas- Open the medication port and is administered. The sucking es or continues, or if stom- flush the tube with 10-20 cc stimulus is present despite the ach contents contain blood, noti- water. Give the medication, absence of oral intake. Holding fy a physician. and follow it with 10-20 cc the infant upright, cuddling, and water. Close the medication gently touching during feeding DO NOT provide a sense of security. GRANULATION TISSUE port and restart the feeding. Granulation tissue forms as the Use liquid medication whenev- •MIX TWO OR MORE MEDICA- Affection should be a priority, TIONS TOGETHER. too much is not possible. body tries to heal the stoma. er possible. Crush tablets or The tissue may proliferate and pills, then dissolve them in • MIX MEDICATION WITH require treatment. If continu- warm water. Give medication FORMULA. NORMAL ACTIVITY ous bleeding occurs or a large 1-2 hours between feedings •MIX OTHER MEDICATION As active toddlers roll, scoot, and amount of tissue builds up, call when possible. (Fig. 11) Fig. 11 WITH ANTACIDS, MAGNE- learn to walk, they develop and a physician. A large amount of SIUM, CALCIUM OR IRON SUP- refine important motor granulation may allow gastric PLEMENTS. contents to leak. • CRUSH ENTERIC COATED OR TIME RELEASE CAPSULES. 10 11 GASTROSTOMY CARE GUIDE GASTROSTOMY CARE GUIDE

CONTENTS

A. INDICATIONS FOR TUBE FEEDING 3 B. MIC PEG 3-4 C. MIC GASTROSTOMY TUBE 5 - The Feeding Port 5 - The Medication Port 5 - The SECUR LOK® Ring 5 - The Balloon Port 5 - The Retention Balloon 6

D. CARE AND USE 6 -Stoma and Tube Care 6 - Activity 6 - Oral Care 6 - Gastric Decompression (Venting) 7

E. ENTERAL FEEDING PROCEDURES 7 -Feeding Supplies 7 - Preparing To Feed 7-8

F. METHODS OF DELIVERY 9 - Pump Controlled Method 9 - Gravity Method 9 - Bolus Method 9-10 - After Feeding 10 - Medication 10 - Tube Replacement 11

G. PEDIATRICS 11 H. STOMA AND SKIN CARE 11 I. TUBE PROBLEMS 12 J. REPLACING THE MIC GASTROSTOMY TUBE 13 K. GASTROINTESTINAL DISTRESS 15 L. GLOSSARY OF TERMS 16

2 19 MICª GASTROSTOMY FEEDING TUBES PEGS INCLUDED

MICª MEDICAL INNOVATIONS CORPORATION

Division of Ballard Medical Products

Authorized Representative in the E.U.: MediMark¨ Europe S.a.r.l. BP 2332, 38033 Grenoble YYOUROUR GUIDEGUIDE TTOO PRPROPEROPER CARECARE 0344 CEDEX 2 France

Ballard Medical Products 12050 Lone Peak Parkway Draper, Utah (801) 572-6800 Printed in U.S.A. Made in U.S.A. Z0214C 6/98 MICª MEDICAL INNOVATIONS CORPORATION

MICª, MIC-KEY¨, SECUR-LOK¨ and MIC-KEY¨ Gª U.S. Patents Nos. 4789592 4685901 Division of Ballard Medical Products * Monoject is a registered are trademarks of Ballard Medical Products. 4666433 4701163 5234417 Other U.S. trademark of Sherwood Medical www.bmed.com and foreign patents pending. © 1998 Ballard Medical Products