Nursing Procedure 7.20
- Managing Enteral Tube Feeding
Provides nutrition supplementation to clients who cannot ingest adequate amounts of nutrients orally
Nursing Procedure 7.20
Provides nutrition supplementation to clients who cannot ingest adequate amounts of nutrients orally
Assessment should focus on the following:
Nursing diagnoses may include the following:
Outcome Identification and Planning
Sample desired outcomes include the following:
Special Considerations in Planning and Implementation
If the client has an endotracheal or tracheostomy tube and is receiving enteral feedings, ensure that the tracheostomy cuff is inflated during and 30 min after feeding to prevent aspiration. Increase the volume and concentration of formula slowly. Many tube feeding formulas cause diarrhea. If diarrhea persists, report to doctor and administer antidiarrheal medications, if ordered. Be careful with gastrostomy tube irrigations. Depending on the surgery, irrigation may be contraindicated. Verify this with the doctor. Closely monitor residual feeding amounts to prevent aspiration because some medications (e.g., sedatives, narcotics) and some physiologic conditions (e.g., electrolyte imbalances, gastroparesis, pharmacologic vasoconstriction) can contribute to slowed GI motility. Do not discontinue or change tube feeding in clients experiencing diarrhea until other possible causes are examined. Diarrhea may be associated with infections (Clostridium difficile, Giardia), formula contamination, or medications (e.g., magnesium-based antacids, antibiotics, hyperosmolar elixirs). Determining the cause of the diarrhea is important to prevent unnecessary disruption of nutritional support. Administer antidiarrheal medication as ordered. Anticipate the need for regular flushing of small-bore feeding tubes with water to maintain patency; these tubes have an increased incidence of clogging. Always administer a tube feeding at room temperature.
Provide care based on the child's developmental level. Demonstrate the procedure using a doll or stuffed toy. Allow the child to express concerns and understanding through play. Feeding time is normally a time for interaction with an infant or child, so the nurse or family member administering the tube feeding should hold, cuddle, and establish eye contact with the child during feeding (Fig. 7.25). Expect to use intermittent feedings for infants; continuous feedings have the potential to cause irritation of mucous membranes and perforation of the stomach. A decrease in the volume of feedings and an increase in the frequency of feedings are needed due to the decreased capacity of the stomach and intestines of an infant/small child. The immature muscle tone of the lower esophageal sphincter causes the small child/infant to be prone to regurgitation after feeding. Use a pediatric volume-control device or pediatric enteral infusion set to control the volume of feeding in addition to setting the infusion device for infusion of small doses of feeding, then reset for the next volume of feeding.
Physiologic changes associated with aging result in a decrease in GI motility. Monitor for intolerance to enteral formulas, which also may occur in the elderly.
Respect the client's wishes regarding the use of enteral tube feedings. Living wills help to clarify the client's preferences when personal communication is no longer possible.
Instruct client or caregiver how to administer feeding via an enteral tube. Ensure understanding and correct technique by return demonstration.
Unlicensed personnel may be delegated to perform tube feeding if they are properly trained and agency policy permits. However, the licensed professional is responsible for monitoring client response and residual feeding levels.
| Action | Rationale | |
|---|---|---|
| Managing Continuous Feeding | ||
| 1 | Perform hand hygiene and organize equipment. Confirm orders for formula frequency, route, and rate of feedings: | Reduces microorganism transfer; promotes efficiency |
| Prevents introduction of pathogens from contaminated equipment | |
| Promotes proper functioning of equipment | |
| Minimizes risk of fluid overload | |
| 2 | Explain procedure to client; provide for privacy. | Reduces anxiety and embarrassment; promotes cooperation |
| 3 | Adjust bed to comfortable working height. | Prevents back and muscle strain in nurse |
| 4 | Place or assist client into appropriate position. The head of the bed should be elevated in high Fowler’s position during and for at least 30 min after the feeding. | Prevents aspiration |
| 5 | Don gloves. | Prevents contamination of hands; reduces risk of infection transmission |
| 6 | Assess abdomen, noting the presence of bowel sounds. Assess skin at site as enteral tube enters body (naris or abdomen). Provide site care as per doctor’s orders or agency policy, if appropriate. | Verifies GI functioning; prevents skin breakdown |
| 7 | Verify tube placement. | Prevents infusion of formula into pharynx or pulmonary tree |
| 8 | To administer a continuous tube feeding: | |
| Prevent muscle cramps from infusion of cold solution | |
| Checks for leaks in bag or tubing | |
| Closing roller clamp allows for adding of additional formula; adding only a 4-hr volume prevents leakage from excessive volume and spoilage of formula hanging too long without refrigeration | |
| Replaces air with formula | |
| 9 | Attach feeding bag tubing to enteral tube attached to client. | Establishes closed system for tube feeding |
| 10 | Set pump to deliver appropriate volume and check infusion every 1–2 hr. | Reduces microorganism transfer Ensures infusion of proper volume per hour |
| 11 | Every 4 hr: | |
| Determines degree of absorption of feeding; prevents distention of abdomen, possible aspiration, and electrolyte loss | |
| º If residual is greater than specified amount as per orders (commonly, 100 mL), discard aspirated volume from stomach, cease feedings, and notify doctor. | ||
| º If residual feeding is within acceptable level, return to stomach. | ||
| Determines presence of peristalsis | |
| Provides client comfort and prevents accumulation of microorganisms | |
| 12 | Irrigate tube every 2–3 hr and before and after medication administration with 30–60 mL of water or as per doctor’s orders or agency policy. | Maintains patency of tube. |
| 13 | Once each shift, while irrigating enteral tube after completing a dose of formula, rinse bag and gavage tubing with water. | Clears accumulated feeding from bag and tubing |
| 14 | Restore or discard all equipment appropriately. | Reduces transfer of microorganisms among clients; prepares equipment for future use |
| 15 | Remove and discard gloves and perform hand hygiene. | Reduces microorganism transfer |
| Managing Intermittent Feeding | ||
| 1 | Follow Steps 1–7 above. | |
| 2 | Check for residual. | Determines degree of absorption of feeding; prevents distention of abdomen, possible aspiration, and electrolyte loss |
| 3 | Crimp tube and connect syringe to enteral tube and aspirate small amount of contents to fill tube and lower portion of syringe. | Prevents infusion of air into stomach |
| 4 | Fill syringe with formula and allow to flow slowly into enteral tube. Infuse formula, holding syringe 6 in. above tube insertion site (nose or abdomen). Follow with water. | Assists flow of feeding by gravity; maintains tube patency |
| 5 | Do NOT allow syringe to empty until formula and water have completely infused. | Prevents air from entering stomach |
| 6 | Clamp enteral tube, remove syringe, and remind client to stay in semi-Fowler’s or high Fowler’s position for at least 30 min after the feeding. | Decreases reflux of feeding and possible aspiration |
| 7 | Check enteral tube placement and residual feeding before each tube feeding. | Prevents aspiration of formula |
| 8 | Restore or discard all equipment appropriately. | Reduces transfer of microorganisms among clients; prepares equipment for future use |
| 9 | Remove and discard gloves and perform hand hygiene. | Reduces microorganism transfer |
Were desired outcomes achieved? Examples of evaluation include:
The following should be noted on the client's record:
