Enteral Feedings Fundamentals of Nursing Care, Burton & Ludwig, 2nd ed., Ch 24 & accompanying workbook. Objectives 1. Identify the indications for use of enteral & parenteral nutrition. 2. Compare various NG & nasointestinal tubes & their use. 3. Explain what is meant by gastric decompression. 4. Describe potential complications associated with tube feedings. 5. Review nursing responsibilities in the management of pts receiving enteral nutrition. 1

In the laboratory setting, the student will be able to: check for tube placement aspirate for stomach contents- residual administer a tube feeding by intermittent bolus flush a tube before & after administering feeding Document findings 2

Terms Dysphagia: Difficulty swallowing Gastric decompression: The process of reducing the pressure within the stomach by emptying it of its contents, including ingested food & liquids, gastric juices, & gas Enteral nutrition: Delivers nutrition via the GI tract

Enteral nutrition (tube feeding) Refers to the delivery of liquid nutrition into the upper intestinal tract via a tube Tube feeding may be used in addition to or instead of oral intake Is the preferred method over parenteral (IV), because it reduces the incidence of sepsis 4

Purposes of Enteral Tubes Decompress the stomach postoperatively, following abdominal injury Treat intestinal obstruction Provide nutritional support or medication administration Collect a specimen of stomach contents for diagnostic assessment of the GI tract

Types of Enteral Tubes Double lumen Single lumen Salem sump tube Levine tube

Types of Enteral Tubes: Nasogastric tube(NGT) -through nose into the stomach Nasoenteric tube (NE) -through the nose into the small intestine (duodenum, jejunum) Gastrostomy tube (GT)-through the abdomen into the stomach Jejunostomy tube (JT)- through the abdomen into the jejunum

NGT…. Nursing care Insertion- Elevate head of bed 30-90 degrees Checking tube placement Administration of feeding Irrigation- usually 30-60 mL NS (in I&O) Removal Tube placement should always be checked prior or feeding. Serious respiratory complications will occur if placed into the lungs 8

NGT…. Nursing care cont’d Tube placement should always be checked prior or feeding. Serious respiratory complications will occur if placed into the lungs 9

A danger with all enteral tubes is that they might move out of the stomach or intestine & end up in the respiratory tract 10

How do you know if the tube is in the right place? NG & NE tubes are placed without direct visualization, therefore…. You need to check the location of the tip of the feeding tube before infusing an enteral feeding Important to confirm that tube has not migrated into respiratory tract 11

Checking placement Most reliable method for checking placement is an x-ray, however this is usually only done after the initial placement of the tube An X-ray is the only way to POSITIVELY confirm any tube placement 12

Checking placement cont’d Aspirate contents- Pull back on plunger until you feel resistance. The presence of aspirant (fluid) indicates that tube is probably in the stomach. The aspirant should be greenish-brown(stomach), or the same color as the formula. Check pH. Note the amount of aspirant (residual) & replace if normal. 13

Checking placement cont’d Remember….. You should not attempt to aspirate from a Jejunostomy-tube or Keofeed tube Why??? 14

Nursing Responsibilities for NG Tube to Suction Assess tube every 2 to 4 hrs for patency Irrigate clogged tube according to physician’s instructions Monitor vacuum source setting Assess tubing connections & color, amount, & consistency of gastric drainage Assess positioning of tubing Auscultate bowel sounds every 4 hours

Nursing Responsibilities for NG Tube to Suction (cont.) Assess abdomen for distention Assess patient for adverse effects every 2 hours Assess for passage of rectal flatus Provide mouth care every 2 hours & provide ice chips if not contraindicated Monitor I/O to prevent fluid deficit or overload Monitor serum K+ level for hypokalemia

Check residual volume before feedings Residual is the amount of formula found in the stomach while a pt is receiving a tube feeding ideal residual amount is zero=0 17

The residual volume tells you: if GI motility is adequate if pt is tolerating feeding &/or formula if rate or volume of feeding is too great for pt if there is a blockage in GI tract A high residual volume is dangerous - can cause reflux, vomiting, & aspiration 18

Enteral Feeding Methods Intermittent tube feedings Bolus feedings Continuous infusion feedings

Feeding Tube Schedules Continuous feedings are a constant flow of formula & an even distribution of nutrition throughout the day or night Usually pts who can’t tolerate large amts at a time Instilled via a controlled pump infusion, drop by drop similar to an IV set up ie. Isocal 100cc/hr The amount is ordered by the MD 20

Residual Rule for Continuous tube feedings: Check gastric residual volume every 4-6 hrs. If the residual volume is more than formula rate per hour hold the feeding for 1 hour & recheck. Replace residual volumes unless residual volume is high (100cc or facility amt) check with MD to find out if residual should be replaced 21

Feeding Tube Schedules Intermittent feedings are given usually to supplement oral intake or for patients who desire greater mobility (bolus) Are given on a regular or periodic basis several times a day ie. 240ml Isocal q4h Formula should administered by gravity, but should not be pushed. 22

Residual Rule for Intermittent tube feeding Check gastric residual volume prior to each feeding. If gastric residual is greater than ½ the volume given in the last intermittent feeding……..hold the feeding for 1 hr & recheck in 1 hr. Replace residual volumes unless residual volume is high (150cc or facility) check with MD to find out if residual should be replaced. 23

Residuals Residuals for both continuous & intermittent feedings should be returned to the pt or replaced! (unless very large then the MD should be consulted) ****Hospital policy may vary these #

Nursing considerations: Bolus Intermittent Tube Feeding Allow 5-10 mins for feeding to flow into stomach & before & after feeding flush with 30 mL water to prevent clogging Continuous Tube Feeding Feeding may be stopped for med administration or patient care, such as... 25

Equipment & Formulas All equipment is clean Prefilled (closed system)-disposable & discarded after use. Can safely hang for 24 hrs if sterile technique is used Cans of formula (open system)-are opened & instilled via a syringe or poured into a reusable bag. Feedings should not hang for more than 6 hrs Administer feedings at room temperature Check expiration date of any feeding prior to administration 26

Complications of Enteral Tube Feedings Aspiration Electrolyte imbalance Hyperglycemia Severe diarrhea Infection at site of insertion

How will you know if your pt is not tolerating a formula? Abdominal distention, abdominal discomfort Nausea, vomiting, diarrhea Large residuals 28

Complications of Enteral Tube Feedings cont’d Clogged tubes Common causes Thick formulas Low rate of delivery (< 50 mL/hr) Instilling crushed meds thru tube Inadequate flushing of tube 29

Prevention of Clogged tubes Flush tube frequently w/water (NS if ordered): Immediately before & after Bolus intermittent feeding Every 4 hrs for continuous feeding After residual check Before & after instilling meds 30

Nursing Responsibilities HOB up at least 30° Monitor wts Assess bowel sounds & BM’s (diarrhea/constipation) Monitor I&O Perform oral care at least q 2-4 hrs Monitor skin breakdown & infection (nose for NGT & insertion site for GT/JT) 31

Nursing Responsibilities cont’d Check tube placement before each feeding Check residual volume before each feeding Lab values (blood glucose, BUN, & electrolytes) Feeding residual Gastrointestinal status