1. 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

2. 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

3. 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

4. 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

5. 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

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

7. 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

8. NGT…. Nursing care Insertion- Elevate head of bed 30-90 degrees
Checking tube placement
Administration of feeding
Irrigation- usually 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

9. 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

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

11. 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

12. 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

13. 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

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

15. 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

16. 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

17. 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

18. 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

19. Enteral Feeding Methods
Intermittent tube feedings
Bolus feedings
Continuous infusion feedings

20. 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

21. 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

22. 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

23. 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

24. 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 #

25. 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

26. 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

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

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

29. 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

30. 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

31. 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

32. 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