PHYSICIAN’S ORDER FOR GASTRIC TUBE FEEDING Student: _______________________________________ D.O.B: _________________Grade: ____________ Formula: ________________________________________________________________________________ Amount of feeding (#of ounces/feedings):___________ Frequency of feedings or scheduled times: ______________________________________________________ If residual greater than________, do not feed. Recheck in _________min/hrs., then feed if residual is less than _____________________. Gravity: ______________ Pump Rate: _______________ Position:________ Flush: __________cc of _______________________ after feeding. Dressing change instructions: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

ALL EQUIPMENT FOR THE FEEDING AND ANY DRESSING CHANGE WILL BE PROVIDED BY THE PARENT Your attention to this matter will better assist the school nurse in providing the most appropriate care for your patient. NOTE: As per the La Joya Independent School District policy, the nurse will not re-insert the gastrostomy tube should it become dislodged. If the parent cannot be located, EMS will be called. Physician: ______________________________________________________ Date: ____________________

I give the nurse permission to give my child his/her feeding as ordered by the physician. Yo le doy permiso a la enfermera que le dé a mi hijo(a) su alimento según las órdenes del doctor.

___________________________________ Signature/ Frima

______________________ Date/Fecha