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8%20Sample%20Ent%20Ntr%20Order%20Form

8%20Sample%20Ent%20Ntr%20Order%20Form - SAMPLE Enteral...

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SAMPLE: Enteral Nutrition Order Form ENTERAL NUTRITION SUPPORT ORDER Date:_____________Time:________________________________ DX:___________________________________________________ Reason for TF:__________________________________________ ENTERAL NUTRITION SUPPORT ORDERS: 1. ROUTE: Check tube type ( ) NGT ( ) PEG/G-TUBE ( ) PEG/JTUBE 2. FORMULA: Check the desired formula Formula kcal/cc Formula kcal/cc ( ) general purpose 1.0 ( ) fiber enriched 1.0 ( ) general purpose 1.2-1.4 ( ) monomeric 1.0 Hi Nitrogen 3. METHOD OF FEEDING: Check the Desired schedule ( ) Schedule A: Bolus Feeding Via Syringe/Gravity Bag ( ) Schedule B: Pump ( ) Schedule C: Tube Feeding Protocol Via Gravity Bag 4. ( ) ALTERNATE ORDERS: ENTERAL NUTRITION SUPPORT GUIDELINES: PHYSICIAN: 1. PLACEMENT: Confirm placement of NGT by abdominal x-ray. 2. MEDICATIONS: Identify via enteral feeding tube: A. Consult pharmacist to verify appropriate form of medication. B. 30 cc water flush before and after each medication. C. Administer each medication separately. 3. FLUID BALANCE: Patient fluid needs should be assessed, include IV, water flush and water available from tube feeding (formula is approximately 80% free water). 4. LABORATORY WORK-UP: A. Initial: Na, K, CO 2 , Cl, Bun, Creat, Mg, Ca, Phos B. Thereafter, as needed. 1. 8:00 am 240 cc formula 12:00 pm 240 cc formula 4:00 pm 240 cc formula 8:00 pm 240 cc formula 2. Water can be added to gravity bag pending hydration needs. 3. As tolerated, Registered Dietitian to advance feeding and adjust water to meet goal rates. 4. Formula progression to goal:____________________ _______________________________________________ _______________________________________________ _______________________________________________
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