ENTERAL PATIENTS ONLY

4. Nutrition Related Information
Feeding Schedule:
I use the following brand of formula: _______________________ (Attach a label from your can)
Method: (check one) ____ Bolus _____ Gravity _____ Pump
Infusion Volume: _________ Rate: _________ Over ___ # hours
I have ______ # of feedings/day
Total Volume fed in 24 hours: ________
I tube feed ____ #days/week
Time: (check one) ____ Overnight _____ Daytime _____ Around the Clock

Additives: (i.e. Iron, Medications...additional list may be attached)
The following substances are added to my HEN:

Additives Amount Frequency

I infuse extra hydration (Attach label from bag): _____ Yes _____ No (check one)
If yes: _____ Volume _____ Rate
by: _____ Tube _____ IV (check one)

Other Pertinent Info:
Recent Lab Values: (See attached Lab Results)
Daily Input/Output:
Usual Weight _________ (may be a range)

5. Access Information/Protocols
Feeding Tube:
Type: (check one) ____ N/G ____ N/J ____ G-Tube

____ G-Button ____ J-Tube ____ G/J- Tube

Brand Name: _____________________ Size ____________
Date Inserted _____/______/______
Inserted at Institution: _______________________
By: ____ Surgeon _____ Interventional Radiologist
____ Gastroenterologist _____ Other __________
Phone #: (_________) _________ - _____________

Flushing Protocol:
Solution: (i.e. water, saline) ________________________
Amount: ____________
Frequency: _________________________________

Dressing Change Protocol:
Frequency: ___________________________________
Dressing Type: ________________________________
Skin Prep Solution: ____________________________
EN Tube Securement Method: (check one)
____ Attachment Device ___ Tape
____ Sutures ___ None
I use gloves when changing my dressing:
____ Yes ____ No (check one)

6. Pump & Supplies
1. Brand: _____________________ Mfg: ______________________
Used for _______ PN _____ EN _____ Pain Meds (check one)
Pump Tubing Brand & Reorder #: ______________________________________________
Attachment Tubing (for EN button) Brand & Reorder #: _____________________________

2. Brand: _____________________ Mfg: ______________________
Used for _______ PN _____ EN _____ Pain Meds (check one)
Pump Tubing Brand & Reorder #: ______________________________________________
Attachment Tubing (for EN button) Brand & Reorder #______________________________

7. Ostomy (Output) Supplies & Protocol
Type of Ostomy: (check one) ______ jejunostomy ______ileostomy _____colostomy
Date Created: ____/____/____
Institution/Surgeon: ___________________________
Phone #: (_________) _________ - _____________

I use the following for my appliance:
Type of Pouch: ____________________
Type of Wafer: ____________________
Type of Skin Prep: ____________________
I change my dressing/pouch every ____________ days.
I use gloves when changing my ostomy dressing: ____ Yes ____ No (check one)