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Introduction ⬇

An enteral tube allows direct administration of medication into the GI system of patients who can’t ingest the drug orally. Before administration, check the patency and positioning of the tube and assess the patient’s GI status, because the procedure is contraindicated if the tube is obstructed or positioned improperly, the patient is vomiting around the tube, or the patient’s bowel sounds are absent because of such conditions as mesenteric ischemia, small-bowel obstruction, and paralytic ileus.1,2

Administering medications via the enteral route poses risks, because most medications given via this route weren’t originally formulated for direct GI tract administration.3 Medications administered enterally must be given in liquid form to avoid enteral tube obstruction. They must be administered separately through an enteral tube because of the risk of physical and chemical incompatibilities, tube obstruction, and altered therapeutic response. They shouldn’t be added directly to an enteral feeding formula.2,4,5

Equipment ⬆ ⬇

Equipment

Prescribed medication • fluid-impermeable pad or towel • clean enteral syringe (20 mL or larger)2 • purified water (distilled, ultrafiltrated, ultraviolet-light treated, or sterile)2 • medicine cup(s) • gloves • cleaning supplies for syringe and container for flushing • Optional: mortar and pestle or other pill-crushing device, pH testing supplies, measuring tape, gown, mask with face shield or mask and goggles, labels.

Preparation of Equipment ⬆ ⬇

Preparation of Equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility. Consult the pharmacist if the patient receives a continuous tube feeding. You may need to withhold the feeding for at least 30 minutes before administering the medication if separation is required to avoid altered drug bioavailability.2,5

Implementation ⬆ ⬇

Implementation
  • Avoid distractions and interruptions when preparing and administering the medication to prevent medication errors.6,7
  • Verify the practitioner’s order, including the drug, dose, dosage form, route, and access device.2,8,9,10,11
  • Reconcile the patient’s medications when the practitioner prescribes a new medication to reduce the risk of medication errors, including omissions, duplications, dosing errors, and drug interactions.12
  • Review the patient’s medical record to verify the location of the distal tube tip before administering the medication, to ensure adequate administration and absorption of the drug.2,13,14
  • Gather and prepare the necessary equipment, supplies, and prescribed medication.
  • Compare the medication label to the order in the patient’s medical record.8,9,10,11
  • Check the patient’s medical record for an allergy or contraindication to the prescribed medication. If an allergy or contraindications exist, don’t administer the medication, and notify the practitioner.8,9,10,11
  • Check the expiration date on the medication. If the medication is expired, return it to the pharmacy and obtain new medication.8,9,10,11
  • Visually inspect the solution for particles or discoloration, or other loss of integrity; don’t administer the medication if integrity is compromised.8,9,10,11
  • Discuss any unresolved concerns about the medication with the patient’s practitioner.8,9,10,11
  • Consult the pharmacist to determine the safest dosage form of the drug before administration, if needed. Use medications prepared by the pharmacy under controlled conditions whenever possible.2 If needed and permitted by your facility, you may prepare nonhazardous and nonallergenic medications in a clean area of a medication room.2
  • Use the available liquid dosage form if it’s appropriate for enteral administration. Further dilute the drug before administration, as directed by the pharmacist; the volume of diluent required to further dilute liquid medication depends on the desired viscosity, osmolality, or both.2
  • If the liquid form of a medication isn’t appropriate or available, substitute only immediate-release dosage forms, and prepare them according to the pharmacist’s instructions. This may include crushing simple compressed tablets to a fine powder using a mortar and pestle or other pill-crushing device and mixing the powder with purified water,2 or opening hard gelatin capsules and mixing the powder containing the immediate-release medication with purified water in a medicine cup.2
  • Perform hand hygiene.15,16,17,18,19,20
  • Confirm the patient’s identity using at least two patient identifiers.21
  • Provide privacy.22,23,24,25
  • If the patient is receiving the medication for the first time, teach the patient and family (if appropriate) about potential adverse reactions or other concerns related to the medication.8,9,10,11
  • Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.26
  • Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route to reduce the risk of medication errors.8,9,10,11
  • If your facility uses bar-code technology, use it as directed by your facility.
  • Raise the bed to waist level before providing care to prevent caregiver back strain.27
  • Place a fluid-impermeable pad or towel across the patient’s chest to avoid soiling the linens during the procedure.
  • Elevate the head of the bed to at least 30 degrees. If contraindications exist, consider the reverse Trendelenburg position to reduce the risk for aspiration.2
  • Perform hand hygiene.15,16,17,18,19,20
  • Put on gloves and other personal protective equipment, as needed, to comply with standard precautions.28,29,30
  • Trace the tubing from the patient to its point of origin to make sure that you’re accessing the correct tube before beginning medication administration.2,31,32
  • Unclamp the enteral tube if not in continuous use, or (if not already done) stop the continuous enteral feeding, clamp the enteral administration set, and cap the distal end of the tubing.
  • Verify enteral tube placement using at least two of the following.2 Observe for a change in the external tube length or the incremental marking at the exit site.2,14 Review chest and abdominal X-ray reports.2,14 Aspirate tube contents and inspect the visual characteristics of the tube aspirate; fasting gastric secretions often appear grassy-green, brown, or clear and colorless. Aspirate from a tube that has perforated the pleural space typically has a pale yellow serous appearance.2,14 Measure the pH of aspirate from the tube if your facility uses pH measurement. Fasting gastric pH is usually 5 or less, even in patients receiving gastric acid inhibitors. Fluid aspirated from a tube in the pleural space typically has a pH of 7 or higher.2
  • Notify the practitioner if tube placement is in doubt. Arrange for an X-ray, if ordered.2,14
  • After verifying proper tube placement, flush the tube with at least 15 mL of purified water.2
  • Monitor the patient closely throughout instillation. Stop the procedure immediately and notify the practitioner if the patient shows signs of distress.

NURSING ALERT Don’t mix different medications intended for administration through the enteral tube together because of the risks of physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses.2

  • Administer the medication using a clean enteral syringe (as shown below).2

  • Flush the enteral tube again with at least 15 mL of purified water, taking into consideration the patient’s fluid volume status.2
  • Repeat the procedure with the next medication, if prescribed.2
  • Flush the enteral tube one final time with at least 15 mL of purified water.2
  • Clamp the enteral tube and detach the syringe.
  • Replace the cap at the tip of the enteral tube. Alternatively, attach the enteral administration set tubing to the end of the enteral tube, unclamp the tube, and restart the enteral feeding, if ordered, to avoid compromising the patient’s nutrition status. Withhold the enteral feeding for 30 minutes or more after medication administration only if separation is indicated to avoid altered drug bioavailability. Consult a pharmacist, as needed.
  • Route the tubing toward the patient’s feet and place the enteral feeding pump (if used) toward the foot of the bed, because a standardized approach of keeping IV lines routed toward the head and enteric lines routed toward the feet prevents dangerous misconnections.31 If different access sites are used, label each tubing at the distal end (near the patient connection) and proximal end (near the source container) to distinguish different tubing and prevent misconnections.32
  • Remove and discard the fluid-impermeable pad or towel.30
  • Keep the head of the bed elevated to at least 30 degrees, or have the patient sit upright in a chair. If these positions are contraindicated, consider the reverse Trendelenburg position, as ordered, to reduce the risk of aspiration.2
  • Return the bed to the lowest position to prevent falls and maintain patient safety.33
  • Clean and dry reusable equipment, including enteral syringes and containers for flushing and medication administration.2
  • Discard used supplies in appropriate receptacles.30
  • Remove and discard your gloves and, if worn, other personal protective equipment.28,30
  • Perform hand hygiene.15,16,17,18,19,20
  • Store the equipment away from potential sources of contamination.2
  • Perform hand hygiene.15,16,17,18,19,20
  • Document the procedure.34,35,36,37

Special Considerations ⬆ ⬇

Special considerations
  • If the patient’s gastrostomy tube becomes clogged, flush the tube with water. Notify the practitioner if flushing with water is unsuccessful. A pancreatic enzyme solution, an enzymatic declogging kit, or a mechanical declogging device may be considered before exchanging the tube for a new one.2
  • The Joint Commission issued a sentinel event alert related to managing risk during the transition to the new International Organization for Standardization tubing standards that were designed to prevent dangerous tubing misconnections, which can lead to serious patient injury and death. During the transition, make sure to trace the tubing and catheter from the patient to the point of origin before connecting or reconnecting any device or infusion, at any care transition (such as a new setting or service), and as part of the hand-off process; route tubes and catheters with different purposes in different standardized directions; when there are different access sites or several bags hanging, label the tubing at the distal and proximal ends; use tubing and equipment only as intended; and store medications for different delivery routes in separate locations.32

Patient Teaching ⬆ ⬇

Patient teaching

If the patient will require an enteral tube after discharge, give the patient and family (as appropriate) oral and written instructions for instilling medication through the tube. Remain with the patient when the patient or family performs the procedure the first few times so that you can provide assistance and answer any questions. Encourage the patient and correct errors in technique, as needed.

Complications ⬆ ⬇

Complications

Potential complications of enteral drug administration include aspiration, drug–drug or drug–nutrient interactions, a clogged feeding tube, reduced drug effect, and increased drug toxicity. The risk of complications increases with inappropriate preparation or administration technique.2 Some medications in liquid form contain a large amount of sorbitol, which may cause abdominal cramps and diarrhea.4

Documentation ⬆ ⬇

Documentation

Document the medication strength, dose, administration route, and date and time of administration. Record any adverse reactions to the prescribed medication, the date and time that you notified the practitioner, prescribed interventions, and the patient’s response to those interventions.38 On the intake and output record, note the amount of fluid instilled. Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching. Document whether the patient or family gave a return demonstration.

References ⬆

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