Skill 11-3

Administering a Tube Feeding (Open System)

Skill Variation: Administering a Tube Feeding Using a Prefilled Tube-Feeding Set (Closed System)

Depending on the patient's physical, health, and nutritional requirements and status, feeding through the NG tube or other GI tube might be ordered. The steps for administering feedings are similar regardless of the tube used. Feeding can be provided by bolus, intermittent continuous or continuous infusion (Anderson, 2018b; Bischoff et al., 2020). Bolus formula administration involves administering a 200 to 400 mL volume over a 15- to 60-minute period, depending on patient tolerance, using a 50-mL syringe (no feeding pump) (Bischoff et al., 2020). The total feed volume is divided into four to six feedings throughout the day (Bischoff et al., 2020). Intermittent continuous feeding is the administration of nutritional formula and fluids by giving a volume of formula over a period of time at regular intervals using a feeding pump (Anderson, 2018b; Bischoff et al., 2020). Continuous feeding is the administration of a small volume of formula over a longer period of time, for as much as 12, 18, or 24 hours. Use of a feeding pump delivers nutritional formula and fluid at a set rate over a specified period of time (Anderson, 2018b). Volume-based feeding protocols are another approach to deliver enteral nutrition. Refer to the discussion in the Special Considerations below. Box 11-3 provides criteria to evaluate enteral feeding tolerance.

The procedure below describes using open systems and a feeding pump; the skill variation at the end of the skill describes using a closed system.

Delegation Considerations

The administration of a tube feeding is not usually delegated to assistive personnel (AP) in the acute care setting. The administration of a tube feeding in some settings may be delegated to assistive personnel (AP) who have received appropriate training, after assessment of tube placement and patency by the registered nurse. Depending on the state's nurse practice act and the organization's policies and procedures, the administration of a tube feeding may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Prescribed tube-feeding formula at room temperature
Feeding bag or prefilled tube-feeding set
Stethoscope
Nonsterile gloves
Additional PPE, as indicated
Alcohol preps
Disposable pad or towel
Large syringe (20 to 50 mL)
Enteral feeding pump (if ordered)
Rubber band
Clamp (Hoffman or butterfly)
IV pole
Water for irrigation and hydration, as needed
pH test strip (calibrated in units of 0.5 and approved for use with human secretions)
Tape measure, or other measuring device

Assessment

Assess for signs of respiratory distress; coughing, choking, dyspnea may occur when a tube is inadvertently positioned in the airway (AACN, 2020). Assess the abdomen by inspecting for presence of distention, auscultate for bowel sounds, and palpate the abdomen for firmness or tenderness. If the abdomen is distended, consider measuring the abdominal girth at the umbilicus. If the patient reports any tenderness or nausea, exhibits any rigidity or firmness of the abdomen, and if bowel sounds are absent, confer with health care provider before administering the tube feeding. Assess for patient and/or family/caregiver understanding, if appropriate, for the rationale for the tube feeding and address any questions or concerns expressed by the patient and family members/caregivers.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Aspiration risk
Knowledge deficiency
Effective Response to Enteral Nutrition

Outcome Identification and Planning

The expected outcome to achieve when administering an enteral feeding is that the patient achieves target goal nutrition administration without nausea, vomiting, gastric distention, diarrhea, constipation, or pain. Additional expected outcomes may include that the patient does not exhibit signs and symptoms of aspiration, the patient demonstrates an increase in weight, and the patient verbalizes knowledge related to tube feeding.

Implementation

Action	Rationale
1. Gather equipment. Check amount, concentration, type, and frequency of tube feeding in the patient's health record. Check the formula expiration date.	This provides for an organized approach to the task. Checking ensures that correct feeding will be administered. Outdated formula may be contaminated.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Explain the procedure to the patient. Answer any questions, as needed.	Explanation facilitates patient engagement.
5. Assemble equipment on the overbed table or other surface within reach.	Organization facilitates performance of the task.
6. Close the patient's bedside curtain or door. Raise the bed to a comfortable working position, usually elbow height of the caregiver (VHACEOSH, 2016). Perform respiratory and abdominal assessments as described above.	Closing curtains or the door provides for patient privacy. Having the bed at the proper height prevents back and muscle strain. Assessment is vital to detect changes in the patient's condition before initiating the intervention.
7. Position the patient as upright as possible with the head of the bed elevated at least 30 to 45 degrees or as near-normal position for eating as possible. Patient should remain in this position during feeding and for 1 hour afterward. Patients for whom the semi-recumbent position is contraindicated or who cannot tolerate a semi-Fowler position should be placed in a reverse- or anti-Trendelenburg position (Boullata et al., 2017; Roveron et al., 2018).	These positions minimize possibility of reflux, aspiration, and pneumonia (McClave, Taylor, et al., 2016; Roveron et al., 2018).
8. Put on gloves. Confirm placement of the nasogastric tube in the patient's stomach using at least two methods (refer to Skill 11-2).	Gloves prevent contact with blood and body fluids. With the exception of radiographic examination, which is usually done immediately after insertion to verify initial tube placement, the use of two or more of these techniques in conjunction with each other increases the likelihood of correct tube placement (AACN, 2020; Anderson, 2019; Anderson, 2018a; Dias et al., 2019; Rahimi et al., 2015).
9. If assessments to check placement are inconclusive, the exposed tube length has changed, or there are any other indications that the tube may not be in place, check placement by radiograph (x-ray) of placement of tube, based on facility policy.	Radiographic confirmation is considered the most reliable method for identifying the position of the NG tube (AACN, 2020; Boullata et al., 2017).
10. If gastric residual volume (GRV) checks are part of facility policy and procedure, check GRV: After multiple steps have been taken to ensure that the feeding tube is located in the stomach or small intestine, aspirate all gastric contents with the syringe and measure to check for gastric residual—the amount of feeding remaining in the stomach. Return the residual based on facility policy. Proceed with feeding if the amount of residual does not exceed facility policy or the limit indicated in the health record. Refer to additional information in the Special Considerations below.	GRV has been used to monitor for tolerance of enteral nutrition; however, there is little support for this intervention as routine measurement for most patients, and it is not considered best practice and should not be used as part of routine care to monitor enteral nutrition (McClave, Taylor, et al., 2016; Ozen et al., 2018; Parker et al., 2019; Pars & Çavuşoğlu, 2019; Rysavy et al., 2020). GRV is not a suitable parameter to determine feeding intolerance (McClave, Taylor, et al., 2016; Pars & Çavuşoğlu, 2019). GRV has been shown to be a poor marker of true gastric volume; gastric emptying; and risk of aspiration, pneumonia, and poor outcomes (Hartwell et al., 2018; McClave, DiBaise, et al., 2016). The use of GRVs as a monitor for tolerance increases the risk of tube clogging and decreases attainment of nutritional goals as a result of disruption of delivery of enteral nutrition (McClave, DiBaise, et al., 2016).
11. Flush tube with 30 to 50 mL of water for irrigation. Disconnect syringe from tubing and cap end of tubing while preparing the formula feeding equipment. Remove gloves. Perform hand hygiene.	Flushing the tube prevents occlusion (Bischoff et al., 2020; Boullata et al., 2017; Drummond Hayes, 2018). Capping the tube deters the entry of microorganisms and prevents leakage onto the bed linens. Hand hygiene prevents transmission of microorganisms.
12. Put on gloves before preparing, assembling, and handling any part of the feeding system.	Gloves prevent contact with blood and body fluids and deter transmission of contaminants to feeding equipment and/or formula.
13. Administer feeding.
When Using a Feeding Bag Administration System and Gravity (Bolus; Open System)
a. Label the bag and/or tubing with date and time. Hang the bag on the IV pole and adjust to about 12 inches above the stomach. Clamp tubing.	Labeling date and time of first use allows for disposal of bag and tubing within 24 hours, to deter growth of microorganisms. Proper feeding bag height reduces risk of formula being introduced too quickly.
b. Check the expiration date of the formula. Cleanse top of feeding container with a disinfectant before opening it (Figure 1). Pour formula into the feeding bag and allow solution to run through tubing. Close the clamp.	Cleansing the container top with alcohol minimizes risk for contaminants entering feeding bag. Formula displaces air in the tubing.
c. Attach feeding administration set to the feeding tube (Figure 2), open clamp, and regulate drip according to the prescribed rate or allow feeding to run in over 30 minutes.	Introducing formula at an appropriate rate allows the stomach to accommodate to the feeding and decreases GI distress.
d. Add 30 to 60 mL (1 to 2 oz) of water for irrigation to feeding bag when feeding is almost completed (Figure 3) and allow it to run through the tube.	Water rinses the feeding from the tube and helps to keep it patent as well as provides hydration for the patient. Feeding tubes should be flushed with at least 30 mL of water before starting and after completion of bolus feedings and every 4 to 8 hours during continuous feeding (Bischoff et al., 2020; Boullata et al., 2017; Roveron et al., 2018), based on the patient's fluid needs and restrictions (Boullata et al., 2017).
e. Clamp the tubing immediately after water has been instilled. Disconnect the feeding administration set from the feeding tube. Clamp the tube and cover the end with cap (Figure 4).	Clamping the tube prevents air from entering the stomach. Capping the tube deters entry of microorganisms and covering end of tube protects patient and linens from fluid leakage from tube.
When Using a Large Syringe (Bolus; Open System)
a. Remove the plunger from the 30- or 60-mL syringe (Figure 5).	Introducing the formula at a slow, regular rate allows the stomach to accommodate to the feeding and decreases GI distress. The higher the syringe is held, the faster the formula flows.
b. Attach the syringe to the feeding tube and pour a premeasured amount of tube-feeding formula into the syringe (Figure 6). Open the clamp on the feeding tube and allow the formula to enter the tube. Regulate the rate, fast or slow, by the height of the syringe. Do not push the formula with the syringe plunger.
c. When feeding is almost completed, add 30 to 60 mL (1 to 2 oz) of water for irrigation to the syringe (Figure 7) and allow it to run through the tube.	Water rinses the feeding from the tube and helps to keep it patent as well as provides hydration for the patient. Feeding tubes should be flushed with at least 30 mL of water before starting and after completion of bolus feedings (Bischoff et al., 2020; Boullata et al., 2017; Roveron et al., 2018), based on the patient's fluid needs and restrictions (Boullata et al., 2017).
d. When the syringe has emptied, hold it high, clamp the tube, and disconnect it from the tube. Cover the end of the tube with the cap.	By holding syringe high, the formula will not backflow out of tube and onto patient. Clamping the tube prevents air from entering the stomach. Capping end of tube deters entry of microorganisms and prevents fluid leakage from tube.
When Using an Enteral Feeding Pump (Open System)
a. Close the flow-regulator clamp on tubing and fill the feeding bag with prescribed formula, as described in Steps 13a and 13b. Place a label on the bag with patient's name, date, and time the feeding was hung.	Closing the clamp prevents the formula from moving through the tubing until the nurse is ready. Labeling date and time of first use allows for disposal of the bag and tubing within 24 hours, to deter growth of microorganisms.
b. Hang the feeding container on the IV pole. Open the clamp on tubing and allow the solution to flow through the tubing.	This primes the tubing, removing air in the tubing and preventing air from being forced into the stomach or intestines.
c. Connect the administration setup to the feeding pump, following the manufacturer's directions. Set the prescribed rate (Figure 8).	Feeding pumps vary. Some of the newer pumps have built-in safeguards that protect the patient from complications. Safety features include cassettes that prevent free flow of formula, automatic tube flush, safety tips that prevent accidental attachment to an IV setup, and various audible and visible alarms. The rate of infusion begins at the recommended rate, based on guidelines from the dietician or nutrition nurse specialist, and the rate is advanced in increments until the desired rate is achieved (Anderson, 2018b); feeding should be advanced to goal within 48 to 72 hours of initiation (McClave, DiBaise, et al., 2016).
d. Flush the tube with at least 30 mL of water at least every 4 to 8 hours during continuous feeding. Verify placement (refer to Skill 11-2) before administering flush.	Feeding tubes should be flushed with at least 30 mL of water before starting and after completion of bolus feedings; every 4 to 8 hours during continuous feeding (Bischoff et al., 2020; Boullata et al., 2017; Roveron et al., 2018); and before and after medication administration (Drummond Hayes, 2018) to prevent blockage, based on the patient's fluid needs and restrictions (Boullata et al., 2017).
14. Remove equipment and return the patient to a position of comfort. Remove gloves. Perform hand hygiene. Raise the side rail and lower the bed.	This promotes patient comfort and safety. Removing gloves properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.
15. Put on gloves. Wash and clean equipment or replace according to facility policy. Remove gloves. Perform hand hygiene.	Gloves prevent contamination and deter spread of microorganisms. Reusable systems are cleansed with soap and water with each use and replaced every 24 hours. Refer to facility policy and manufacturer's guidelines for specifics on equipment care.
16. Monitor patient tolerance of enteral nutrition. Observe the patient's response during and after tube feeding and signs of tolerance at least daily. Refer to Box 11-3 for criteria to evaluate tolerance of enteral feeding.	Patient tolerance of the volume and type of formula must be monitored daily (Boullata et al., 2017; McClave, Taylor, et al., 2016).
17. Have the patient remain in an upright position for at least 1 hour after feeding. Refer to Step 7.	This minimizes possibility of reflux, aspiration, and pneumonia and should be implemented unless contraindicated (McClave, Taylor, et al., 2016; Roveron et al., 2018).
18. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.

Evaluation

The expected outcomes have been met when the patient has achieved target goal nutrition administration without nausea, vomiting, gastric distention, diarrhea, constipation, or pain; the patient did not exhibit signs and symptoms of aspiration; the patient has demonstrated an increase in weight; and the patient has verbalized knowledge related to tube feeding.

Documentation

Guidelines

Document the type of NG tube or gastrostomy/jejunostomy tube that is present. Record the criteria that were used to confirm tube placement before feeding was initiated and during administration, as indicated. Record respiratory and abdominal assessments. If GRVs are part of facility policy and procedure, record the amount of gastric residual volume that was obtained. Document the position of the patient, the type of feeding, and the method and the amount of feeding. Include any relevant patient teaching. Document results of evaluation of tolerance of enteral feeding.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Nasogastric tube is identified not to be in stomach or intestine: Tube must be in the stomach before feeding. If the tube is in misplaced, the patient is at increased risk for aspiration. Anticipate replacement of feeding tube. Refer to Skill 13-8.
Patient reports nausea after tube feeding: Ensure that the head of the bed remains elevated and that suction equipment is at the bedside. Assess for other signs and symptoms of changes in tolerance to enteral feeding. Check the medication record to see if any antiemetics have been ordered for the patient. Consider collaborating with the health care team to review administration rate, volume, and type of nutritional formula. Monitor for pattern of nausea related to enteral feeding.
When attempting to aspirate contents, the nurse notes that tube is clogged: Feeding tubes are prone to blockage, due to protein-rich formula solutions, the viscosity of the feeding formulas and relatively small diameter of the feeding tube lumens, the use of the tubes for medication administration, and inadequate water flushes (Bischoff et al., 2020; Drummond Hayes, 2018). Try to remove the clog: use air bolus or attach a 30- or 60-mL piston syringe to the feeding tube and pull back the plunger to help dislodge the clog. Fill the syringe with warm water and attempt to flush. If met with resistance, use gentle back and forth motion of the plunger to help loosen the clog. If necessary, clamp the tube to allow the warm water to penetrate the clog for up to 20 minutes and then attempt to flush (Boullata et al., 2017). The tube may have to be replaced. To prevent clogs, ensure that adequate flushing is completed after each feeding and before and after medication administration (Bischoff et al., 2020; Drummond Hayes, 2018).

Special Considerations

There is no benefit from stopping feedings during short periods of lowering of the head of the bed (such as turning the patient) (Boullata et al., 2017). If a prolonged procedure will require lowering of the head of the bed, feedings should be stopped during this period; feedings should be promptly restarted when the procedure is ended or as feasible.
If GRV checks are part of facility policy and procedure, automatic cessation of enteral nutrition should be avoided for GRVs ; 500 mL in the absence of other signs of intolerance (Boullata et al., 2017; McClave, Taylor, et al., 2016; Roveron et al., 2018).
Volume-based feeding protocols in which 24-hour or daily volumes are targeted instead of hourly rates have been shown to increase volume of nutrition delivered (Heyland et al., 2013, as cited in McClave, Taylor, et al., 2016). This type of method empowers nurses to increase feeding rates to make up for volume lost for scheduled and unscheduled interruptions or while enteral nutrition is held and increase attainment of nutritional goals, supporting optimal nutritional intake (Kinikin et al., 2020; McClave, Taylor, et al., 2016).
Feedings into the intestine are always continuous and include initiation at a lower rate with a gradual increase in the rate until the target rate identified to meet nutritional goals is met (Bischoff et al., 2020).
A combination of methods, such as overnight continuous feeding and bolus feeding during the day, may be used for some patients to best meet their needs and allow for autonomy and lifestyle preferences (Bischoff et al., 2020). For other patients, cyclic feeding, administering continuous feeding for a portion of the 24-hour period, may be implemented. The usual routine is to feed the patient for 12 to 16 hours, most often overnight. Cyclic feeding allows the patient to attempt eating regular meals during the day, if this is possible, making ambulation and activity easier.
Tolerance to gastric feeding can be improved through use of a prokinetic agent, continuous infusion, and elevation of the head of the bed (McClave, DiBaise, et al., 2016).
Sterile water should be used for tube flushes in immunocompromised or critically ill patients (Allen, 2015; Boullata et al., 2017).
If GRV checks are part of facility policy and procedure, evaluate the significance of a single high gastric residual volume in relation to other indicators of GI intolerance, including abdominal distention, abdominal discomfort, nausea, and vomiting (AACN, 2018).
Immediately refrigerate formulas reconstituted in advance. Discard unused reconstituted and refrigerated formulas within 24 hours of preparation (Boullata et al., 2017).
Discard unused reconstituted formulas exposed to room temperature after 4 hours (Boullata et al., 2017).
Some feeding equipment allows for the addition of water for flushes to a second feeding container, which enters the system through a second set of tubing. The feeding pump will automatically administer the preset volume of flush at the preset frequency.

Administering a Tube Feeding Using a Prefilled Tube-Feeding Set (Closed System)

Prefilled tube-feeding sets, which are considered closed systems, are frequently used to provide patient nourishment. Closed systems contain sterile feeding solutions in ready-to-hang containers (Figure A). This method reduces the opportunity for bacterial contamination of the feeding formula. In general, these prefilled feedings are administered via an enteral pump.

Check amount, concentration, type, and frequency of tube feeding in the patient's health record.
Gather all equipment, checking the feeding solution and container for correct solution and expiration date. Label formula container with patient's name, type of solution, and prescribed rate. Label administration tubing/set with date and time.
Perform hand hygiene. Put on PPE, as indicated.
Identify the patient and explain the procedure.
Put on gloves.
Verify feeding tube placement of the feeding tube; refer to Skill 11-2.
If GRVs are part of facility policy and procedure, check and record the amount of gastric residual volume. Return residual to the stomach, as indicated by facility policy.
Flush the tube with 30 mL of water.
Put on nonsterile gloves; remove the screw-on cap and attach the administration setup with the drip chamber and tubing.
Hang the feeding container on the IV pole and connect it to the feeding pump, allowing solution to flow through the tubing, following the manufacturer's directions.
Attach the feeding setup to the patient's feeding tube.
Open the clamp of the patient's feeding tube.
Turn on the pump.
Set the pump at the prescribed rate of flow and remove gloves. Perform hand hygiene.
Observe the patient's response during the tube feeding.
Continue to assess the patient for signs and symptoms of GI distress, such as nausea, abdominal distention, or absence of bowel sounds.
Have the patient remain in the upright position throughout the feeding and for at least 1 hour after feeding.
After the prescribed amount of feeding has been administrated (or according to facility policy), turn off the pump, put on nonsterile gloves, clamp the feeding tube, and disconnect it from the feeding set tube, capping the end of the feeding set.
Flush the feeding tube with 30 to 60 mL of water.
Clamp the feeding tube. Cover the end of the tube with the cap.
Continue as directed in Skill 11-3, Steps 14-18.

EVIDENCE FOR PRACTICE

ASPEN Safe Practices for Enteral Nutrition Therapy

Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii-Wolfe, C., Sullivan, J., Wood, A., Malone, A., Guenter, P., & ASPEN Safe Practices for Enteral Nutrition Therapy, American Society for Parenteral and Enteral Nutrition. (2017). ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15-103. https://doi.org/10.1177/0148607116673053.

The American Society for Parenteral and Enteral Nutrition (ASPEN) Safe Practices for Enteral Nutrition Therapy guideline provides recommendations based on the available evidence and expert consensus for safe practices for patients receiving enteral nutrition.

Refer to details in Skill 11-2, Evidence for Practice.

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Skill 11-3

EVIDENCE FOR PRACTICE