Staff Name:
Individual’s Name:
Date:
Pass (P), Fail (F), N/A / Comments / Procedure for Continuous Feedings:
1. / Checks Health Care Provider’s orders.
2. / Washes hands.
3. / Gathers equipment and 20 ml (or other amount if specifically prescribed) water for flush.
4. / Informs individual of what is being done.
5. / Positions individual in correct position.
6. / Marks label on bag or bottle with current date and time.
7. / Fills feeding bag with no more than 4 hours worth of formula unless otherwise directed by RN, NP, or Health Care Provider.
8. / Primes tubing before connecting bag to pump.
9. / Clamps feeding bag tubing (of both old and new feeding bags) prior to removing old feeding bag from pump.
10. / Connects new feeding bag tubing to pump and sets desired rate on pump.
11. / Clamps/pinches G/J-tube before unplugging or disconnecting tubing.
12. / Removes plug or disconnects feeding. (If using plug, places plug so that it remain free of contamination.)
13. / Separates barrel from plunger of syringe.
14. / While G/J tube is still clamped or pinched, places tip of syringe into G/J tube and pours 20 ml (or other amount if specifically prescribed) water into barrel of syringe.
15. / Unclamps tube and allows water to slowly enter stomach/intestine by gravity. (For J-tube, may have to replace plunger back into barrel and push water in gently.)
16. / Clamps/pinches tube just prior to syringe being completely emptied.
17. / Connects tube to clean feeding bag tubing and unclamps tube.
18. / Rechecks setting on the pump and turns pump on.
19. / Documents that feeding has been hung, the rate of feeding, and how individual is tolerating procedure.
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Pass (P), Fail (F), N/A / Comments / Procedure for Discontinuous Feeding:1. / Verifies by looking at Health Care Provider’s orders and MAR sheet that it is time to stop the feeding.
2. / Washes hands.
3. / Gathers equipment and 20 ml (or other amount if specifically prescribed) water flush.
4. / Informs individual what is being done.
5. / Turns off pump.
6. / Clamps or pinches G/J tube.
7. / Clamps or pinches feeding bag tube.
8. / Disconnects tube from feeding bag tubing. (If feeding bag is to be used again, ensures tubing does not get contaminated.)
9. / While G/J-tube is still clamped/pinched, places tip of syringe (which has been separated from plunger) into tube.
10. / Pours 20 ml (or other amount if specifically prescribed) of water into syringe; unclamps tube and allows water to flow into stomach/intestine by gravity. (For J-tube, may have to replace plunger back into barrel and push water in gently.)
11. / Clamps/pinches tube just prior to syringe being completely emptied.
12. / Inserts plug.
13. / Unclamps G/J tube.
14. / Checks G/J tube placement by measuring tube.
15. / Documents according to MAP regulations and policies.
Based on this Competency Evaluation Tool, I as RN Trainer have determined that the Certified Staff Person named below is competent to administer continuous feedings via G/J and discontinuous feedings via G/J tube to the individual named below.
Staff Person’s Printed Name / Individual’s Printed Name
Staff Person’s Signature / Date
RN’s Printed Name / RN’s Phone Number
RN’s Signature / Date
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Maintain a copy of this document in training records at the program site.