Feeding tubes are a critical intervention for seriously ill Pts or for those who cannot eat, whatever the underlying cause. However, they are not without risk, and Pt must be closely monitored for complications. FT may be inserted through nares or through abdominal wall.
| Types of Feeding Tubes | Purpose |
|---|---|
| Nasogastric (NG) feeding tube | Short-term feeding only for Pts with a competent esophageal sphincter, no disorders of stomach, and normal gastric motility. NG feeding tubes are irritating to Pts, and a confused Pt may actively try to remove it. If tube has been pulled on but not removed, it greatly raises risk of aspiration. |
| Nasojejunal (NJ) or nasoduodenal (ND) tube | Short-term feeding. Bypass stomach when Pts cannot tolerate gastric feeding or need to lie flat. |
| Gastric (gastrostomy tube, G-tube, or percutaneous endoscopic gastrostomy [PEG]) | Inserted through abdominal wall into stomach for long-term use. For Pts with a normally functioning GI tract. |
| Gastrojejunal (GJ-tube) | Long-term feeding for Pts who cannot eat such as those with severe gastric motility problems, high risk of aspiration, or oral cancer. |
| Jejunal (jejunostomy, J-tube) | Long-term feeding for Pts who cannot eat, such as those with severe gastric motility problems, high risk of aspiration, or oral cancer. |
Clinical Findings
Resp: Breathing problems, diminished breath sounds (often w/aspiration).
Skin: Fever.
GI/GU: Obstructed FT (e.g., feeding will not flow), obvious displacement of feeding, stomal infection (gastric or jejunal tubes), fluid leaks from stoma (gastric or jejunal tubes).
MS: Fatigue, weakness.
Possible Causes: Varies according to complication; see table below.
Collaborative Management
- Assess for leakage around insertion site.
- Assess for proper placement (is tube too far in tract, too far out, or completely out?).
- If tube is occluded, elevate head of bed (HOB) to minimize risk of aspiration and attempt to dislodge occlusion using method described in following table.
- Assess for S/S of aspiration (elevated temperature, increased respiratory rate diminished breath sounds).
- Assess LOC/mental status, if Pt is pulling at tubing.
- Assess for S/S of infection (elevated temperature, pain, redness, warmth, purulent discharge).
- Monitor hydration and nutritional status; obtain nutrition consult if indicated.
- Provide stomal care.
- Obtain replacement tube and assist with bedside reinsertion.
- Obtain portable CXR for placement if nasogastric/nasoenteric tube is inserted.
- Resume tube feedings.
Preventing and Managing Gastric and Jejunal Feeding Tube Complications
| Complications | Interventions |
|---|---|
| Leakage of gastric secretions: Improper positioning of Pt, tube migration, stomal erosion or widening | Position Pt upright for feeding. Stabilize tube with gauze pads; adjust crosspiece. Keep skin around stoma clean and dry; use protective ointments and gauze. |
| Tube migration: Internal balloon deflates, or external tube suture, bumper, or disk falls out | Reposition tube. Note length of tube outside of body, using either external marks on tube or a tape measure. Document length in nursing record and measure each shift. Check that disk, suture, or attachment device is secure. |
| Extubation: Internal balloon deflates, or suture, bumper, or disk falls out | Tract can close within a few hours. Feeding tubes must be replaced within a few hours. |
| Stomal infection: Leakage around tube, inadequate stomal care, allergic reaction to soap | Correct cause of leakage. Carefully clean and protect stoma per facility protocol. If stoma site is irritated, use plain water or change type of soap used. |
| Gastroesophageal reflux/large residuals: Delayed gastric emptying | Elevate Pt’s head 30°–45° during feeding and for 1 hr after meal. Check residuals before feeding. Hold feeding if greater than 100 mL, and call HCP. Use gastric stimulant, if ordered, to promote gastric emptying. Consider continuous feeds or smaller, more frequent boluses. |
| Nausea, vomiting, cramps, bloating: Too rapid administration of feeding, lactose intolerance, fat malabsorption, contamination of food or feeding bag | Change to a low-fat formula. Administer feeding at room temperature. Reduce rate of administration. Check residuals before bolus feeding or every 4 hr for continuous feeding. Hold feeding if greater than 125 mL; call HCP. Refrigerate open cans of formula and keep only as long as manufacturer suggests. Clean tops of formula cans before opening. Hang only 4-hr amount of formula at a time. Clean feeding sets well and replace per facility policy. |
| Diarrhea: Too rapid increase in amount of feeding, too rapid administration, feeding too cold, lactose intolerance, tube migration from stomach to small intestine | Add fiber or use a formula with fiber. Reduce rate of administration. Administer feeding at room temperature. Do not add medication to formula. Retract tube to reposition against stomach wall. |
Managing Feeding Tube Occlusions
Prevention
- Flush with 30 mL of water every 4 to 6 hr and before and after administering tube feedings, checking for residuals, and administering medications.
- Use a feeding pump with an automatic water flush feature.
- Dilute liquid medications with 20 to 30 mL of water.
- Obtain all medications in liquid form. If liquid form is not available, check with pharmacist to see if medication can be crushed.
- Administer each medication separately, and flush with 5 to 10 mL of water between each medication.
- Do not mix medications with feeding formula.
Management
- Check feeding tube for kinks.
- Inject a small amount of air into tube.
- Change Pt’s position.
- If no obvious kink is found, place flushing syringe (30 mL) into tube end, and gently pull back on plunger to dislodge occluding plug.
- If tube still blocked, instill warm water into tube. Gently depress and withdraw syringe plunger to remove obstruction. If unsuccessful, leave instilled warm water in tube, clamp tube for 10 to 15 min, and try again.
- Milk tube with fingers from insertion site out.
- Do not instill meat tenderizer—can cause metabolic complications and allergic reactions.
- Commercial products that use thin plastic devices for clearing feeding tubes or products that use a catheter and chemical declogging powder are available; however, an HCP usually must perform procedure.
- To prevent tube damage, do not use force to unclog, or use a syringe smaller than 30 mL.
Checking Feeding Tube Residuals
High residuals may indicate gastroparesis and intolerance to advancement to higher volume of feeding.
Check before each feeding, bolus, administration of medication, and every 4 hr for continuous feeding.
- Using 60-mL syringe, aspirate from gastric feeding tube any residual formula remaining in stomach.
- Volume of <50 mL is normal.
- Volumes of 50 to 100 mL: recheck in 1 hr; if still >50 mL, rate should be decreased.
- Volume >100 mL: stop feeding or do not administer bolus feed. Check residual every 2 hr until <50 mL, then resume continuous feedings at a lower rate or bolus feedings of smaller volumes.