Enteral Nutrition - Nursing Skills Notes

Unexpected Outcome: Displacement of feeding tube to another site (e.g., from duodenum to stomach) possibly occurs when patient coughs or vomits.

-Aspirate GI contents and measure pH. -Remove displaced tube and insert and verify placement of new tube. -If there is question of aspiration, obtain chest x-ray film.

Enteral tube feeding is preferred over parenteral nutrition because:

-It improves the utilization of nutrients. -It is generally safer for patients because of a reduced risk of infection since it is inserted via the gastrointestinal tract as opposed to a central venous line. -It maintains the structure and function of the gut. -It is less expensive.

Unexpected Outcome: Aspiration of stomach contents into respiratory tract (delayed response or small-volume aspiration), evidenced by auscultation of crackles or wheezes, dyspnea, or fever.

-Report change in patient condition to health care provider; if there has not been a recent chest x-ray film, suggest ordering one. -Position patient on side to protect airway. -Suction nasotracheally and orotracheally. -Prepare for possible initiation of antibiotics

The nurse is going to irrigate a nasogastric feeding tube. The nurse would be correct to draw up how much water into the ENFit syringe?

30ml

A patient has been receiving ranitidine hydrochloride, an H2 receptor antagonist, for treatment of a duodenal ulcer. How may this affect pH testing?

H2 receptor antagonists, such as ranitidine hydrochloride, reduce the volume of gastric acid secretion and the acid concentration of secretions, thus increasing gastric pH.

Unexpected outcomes: Red or brown coloring (coffee grounds appearance) of fluid aspirated from feeding tube indicates new or old blood, respectively, in GI tract.

If color is not related to medications recently administered, notify the health care provider.

As you are inserting the feeding tube, resistance is felt and the patient begins to cough. What action should you take?

If resistance is met or the patient starts to cough, choke, or become cyanotic, pull the tube back into the posterior nasopharynx until normal breathing resumes.

A nurse is telling a coworker that she is unable to flush a feeding tube. Which suggestion offered by the coworker would be accurate, useful information?

If unable to instill fluid, the nurse should reposition the patient in a left side-lying position and try again. The tip of the tube may have been against the wall of the stomach. Changing the patient's position may move the tip of the tube away from the stomach wall. Cola or fruit juices should not be used to flush tubing. The nurse should first reposition the patient and reattempt flushing the tube before calling the health care provider. The health care provider should be notified if the tube remains obstructed.

You are flushing the patient's feeding tube with a bolus of water (administered by gravity) when the patient complains of abdominal cramping. What can you do to slow the rate of infusion?

Lowering the syringe will decrease the rate of flow. The syringe should be less than 18 inches above the insertion site to allow it to empty gradually over several minutes, which reduces the risk of abdominal discomfort.

AACN (2012) recommends several expected practices to minimize the risk of aspiration in tube-fed patients:

Maintain head-of-bed elevation at an angle of 30 to 45 degrees unless contraindicated. Use sedatives as sparingly as possible. For tube-fed patients, assess placement of the feeding tube at 4-hour intervals. Maximum hang time for formula is 12 hours in an open system, 24 to 48 hours in a closed, ready-to-hang system (if it remains closed). Refer to manufacturer's guidelines.

Nasal tubes are associated with

sinusitis, otitis, vocal cord paralysis, and pressure injuries to the nose and sinuses.

Enteral nutrition

refers to nutrients given via the GI tract

Clinical conditions that interfere with normal ingestion or absorption of nutrients or create hypermetabolic states:

surgical resection of oropharynx, proximal intestinal obstruction or fistula, pancreatitis, burns, and severe pressure ulcers.

Jejunostomy tubes are indicated when:

the risk of regurgitation and aspiration is especially high, as in cases of severely delayed gastric emptying or conditions such as pancreatitis that limit the use of the stomach for feeding.

percutaneous endoscopic jejunostomy (PEJ)

tube is passed through the PEG and advanced into the jejunum.

After initial x-ray verification of correct feeding tube position:

you must monitor the tube to ensure that the tube tip remains in the intended site. Based on a patient's clinical condition and agency policies, you check feeding tube position at regular intervals (often every 4 to 6 hours) and before administering formula or medications through the tube. Radiographic verification is impractical every 4 to 6 hours, but the reports of routine chest and abdominal films should be monitored for reference to the feeding tube location

Identify the patients who might benefit from enteral nutrition.

A patient who experienced a stroke and has difficulty swallowing-Patients may require enteral feeding because of ineffective swallowing or a weakened gag reflex that causes aspiration. A patient with muscular dystrophy-Patients with neuromuscular diseases who have a high incidence of aspiration, such as those with amyotrophic lateral sclerosis (ALS) and muscular dystrophy (MD), may benefit from long-term enteral therapy. A patient with cancer of the head and neck-Patients with a functional GI tract who are unable or unwilling to ingest oral nutrients may benefit from enteral tube feedings.

Unexpected Outcome: Patient develops nausea and vomiting.

Administer antiemetic as ordered. Use agents (ordered by health care provider) to increase gastric motility. Withhold tube feeding and notify health care provider. Be sure that tube is patent; aspirate for residual.

The nurse observes a confused patient pulling at her NG feeding tube. As the nurse retapes the tube to the bridge of the patient's nose, the nurse notices that the mark on the tube has moved away from the naris. What action should the nurse take?

Advance the tube until the mark is even with the naris and verify correct tube placement. An increased external length of tube may indicate that the distal tip is incorrectly positioned. Using the tube in its current location could place the patient at greater risk for aspiration. The nurse needs to advance the tube until the mark reaches the patient's naris and then verify correct tube placement. It is unnecessary to remove the tube unless the nurse is unable to advance the tube the desired length. Pulling back on the tube will only increase the external length of the tube, thus preventing the tube from being inserted the desired depth.

Identify conditions that increase risk for spontaneous tube migration or dislocation:

Altered level of consciousness, agitation Retching, vomiting Nasotracheal suction Feeding tubes may become dislocated by increases in intraabdominal pressure or coughing, but most frequently they are displaced when patient moves or pulls on tube.

Tube feedings may be administered in several ways:

As an intermittent gravity drip, administered for 30 to 45 minutes several times per day with a pouch to hang the feeding As a continuous drip per infusion pump administered over 24 hours or as a cyclic feeding administered intermittently

Unexpected Outcomes: Feeding tube is clogged

Attempt to flush tube with water. Special products are available for unclogging feeding tubes; do not use carbonated beverages and juices. Hold feeding and notify health care provider. Maintain patient in semi-Fowler's position. Contact pharmacist to change medications to liquid form and flush before and after intermittent feedings and medications (Kozeniecki et al., 2015).

The nurse has inserted an NG feeding tube. Which of the following actions should be included in the nurse's evaluation of the procedure? (Select all that apply.)

Auscultation of lung sounds Confirming x-ray results with health care provider Observing patient for persistent gagging or coughing

A patient has a medical history of cerebrovascular accident with impaired swallowing, stomach cancer with gastric resection, anemia, and hypertension. What route of feeding would you expect the patient to have?

Because a gastric resection contraindicates NG feeding, the expected route would be NI.

Expected outcomes after completion of procedure:

Color, pH, and appearance of aspirate are consistent with the initial tube placement. Gastric fluid aspirated from patient who has fasted for at least 4 hours usually has pH range of 5.0 or less. Fluid from tube in small intestine of fasting patient usually has pH greater than 6.0 (Bourgault et al., 2015).

Which of the following, if exhibited by the patient, may increase the risk for spontaneous enteral tube dislocation?

Conditions that increase the risk of spontaneous tube dislocation from the intended position include vomiting or retching, nasotracheal suctioning, altered level of consciousness, and agitation. Nausea, ambulation, and H2 antagonists are not risk factors for spontaneous dislocation of an enteral feeding tube.

Assess patient's clinical status to determine need for tube feedings:

Decreased level of consciousness Nutritional deficits Head or neck surgery Facial trauma Impaired swallowing

The health care provider has ordered an enteral feeding tube for an elderly patient. Which statement, if made by the patient's family member, indicates further instruction is needed?

Enteral feedings will not improve digestion. Enteral feedings are used with patients who have adequate digestion and absorption but cannot ingest, chew, or swallow food safely or in adequate amounts. Advantages of enteral feedings over parenteral feedings are that they are less expensive, maintain functioning of the gut, and are less likely to cause infection.

You determine the patient's residual volume is 300 mL. The patient denies any abdominal discomfort or nausea. What should you do?

GRVs in range of 200 to 500 mL should raise concern and lead to implementation of measures to reduce risk of aspiration. Automatic cessation of feeding shouldn't occur for GRV less than 500 mL in the absence of other signs of intolerance.

Evaluation:

Measure gastric residual volume (GRV) per policy, usually every 4 to 6 hours, and ask if nausea or abdominal cramping is present. Monitor intake and output at least every 8 hours and calculate daily totals every 24 hours. Weigh patient daily until maximum administration rate is reached and maintained for 24 hours; then weigh patient 3 times per week. Monitor laboratory values as ordered by health care provider. Observe patient's respiratory status. Examine abdomen and auscultate bowel sounds. For gastrostomy tubes, inspect site for signs of impaired skin integrity and symptoms of infection, injury, or tightness of tube. Observe nasoenteral tube insertion site at least daily (see agency policy). Note skin integrity and look for edema under device, excoriation, or presence of injury.

Unexpected Outcomes: Fluid and electrolyte imbalances occur. Insufficient irrigation can cause water deficiency; excessive irrigations can cause fluid volume excess.

Notify health care provider of abnormal electrolyte levels or imbalanced intake and output.

Unexpected Outcomes: Patient develops large amount of diarrhea (more than three loose stools in 24 hours).

Notify health care provider. Consult dietitian about need to change formula to prevent malabsorption. Identify and treat underlying medical/surgical issues and infections (Kozeniecki et al., 2015). Provide perianal skin care after each stool. Determine other causes of diarrhea (e.g., Clostridium difficile infection, contaminated tube feeding, medication containing sorbitol).

You have received an order to insert an NG feeding tube and to begin tube feedings once placement has been verified. Which of the following may contraindicate NG tube insertion and feeding at this time?

On anticoagulant therapy with recent nosebleed Absence of bowel sounds in all four quadrants

Expected outcomes after completion of procedure:

Patient achieves established target for body weight over time. Patient has no sign of respiratory distress. Patient remains or returns to fluid/electrolyte balance. Patient is free of abdominal cramping.

Which of the following patients may benefit from enteral nutrition?

Patients with brain injury or an altered or reduced level of consciousness and patients with neuromuscular diseases who have a high incidence of aspiration may benefit from long-term enteral therapy. Patients with head or neck cancer may be candidates for enteral nutrition. A patient with paralytic ileus has a nonfunctional GI tract, and enteral nutrition is inappropriate. Some patients have an increased metabolism as a result of sepsis or burns and are unable to ingest enough calories to meet their bodies' metabolic needs. These patients may also benefit from enteral nutrition.

Observe patient for respiratory distress:

Persistent gagging Paroxysms of coughing Drop in oxygen (O2) saturation Respiratory patterns (e.g., rate and depth) that are inconsistent with baseline measures

For intestinal placement of a feeding tube, in what position should the nurse place the patient while waiting for radiological confirmation of correct placement?

Placing the patient on the right side promotes passage of the tube into the small intestine (duodenum or jejunum).

Unexpected Outcomes: Tube cannot be irrigated after testing.

Reattempt to irrigate tube. Do not force fluid. If unsuccessful, notify health care provider.

Place patient in high Fowler's position (if tolerated) or semi-Fowler's position.

Reduces reflux and risk for pulmonary aspiration during irrigation.

The radiologist calls stating that the end of the patient's feeding tube is in the esophagus and the tube should be advanced approximately 7.5 cm to reach the stomach. You return to the patient's room and find that the stylet has already been removed. What action should you take next?

Remove the tape, advance the tube the desired amount, and have another x-ray image. correct answer

Unexpected Outcomes: Tube cannot be irrigated and remains obstructed

Repeat irrigation; if unsuccessful, notify health care provider. Tube may need to be removed and a new tube placed.

Unexpected Outcome: Patient aspirates formula (auscultation of crackles or wheezes, dyspnea, or fever).

Report change in condition to health care provider. Position patient on side. Suction nasotracheally or orotracheally.

Unexpected Outcomes:Patient develops severe respiratory distress (e.g., dyspnea, decreased oxygen saturation, increased pulse rate) as a result of aspiration or tube displacement into lung.

Stop any enteral feedings. Notify health care provider. Obtain chest x-ray film as ordered.

The patient is recovering from a motor vehicle accident. He has been too weak and his appetite too poor to consume enough calories to aid his healing. Because the patient has a functioning GI tract, the health care provider has ordered an NG feeding tube be inserted. Select the appropriate expected outcomes for this procedure. (Select all that apply.)

The nasal mucosa remains pink without irritation. The tube is placed in the stomach.

The nurse is irrigating a nasogastric feeding tube after having verified tube placement by pH testing. The nurse draws up 30 mL of tap water into an ENFit syringe, removes the plug at the end of the tube, attaches the ENFit syringe, and slowly instills the irrigation solution. The nurse removes the syringe and plugs the end of the tube. What error occurred in the performance of this skill?

The nurse failed to kink the feeding tube while removing plug at end of tube, allowing leakage of gastric secretions.

What French tube should the nurse select for patient comfort?

The nurse should select the smallest diameter possible to enhance patient comfort. An 8-French tube has a smaller diameter than a 12-French tube.

A patient is receiving a continuous enteral feeding by infusion pump. The nurse enters the patient's room to verify tube placement and measure residual. The nurse notices the patient's respirations are shallow and rapid and that the patient's color is ashen. The nurse notes crackles on auscultation, and the patient appears to be coughing up sputum of a color similar to the formula feeding. What action(s) should the nurse take?

The patient has aspirated formula. The nurse should turn off the tube feeding immediately, position the patient in in a side-lying position, suction, and notify the health care provider. It is unnecessary to ask the patient about feeling short of breath because it is apparent. Having the patient deep breathe and cough will fail to help at this time.

You are preparing to administer an intermittent tube feeding. For effective time management, you enlist the help of NAP. What instructions should you give the NAP to complete this task?

To place the patient in an upright position Correct answer Show Feedback Allow the feeding to infuse per ordered rate Correct answer Show Feedback Report any difficulty with the feeding infusion Correct answer Show Feedback To report any distress experienced by the patient immediately

The nurse is irrigating a patient's feeding tube and is unable to instill the fluid. What is an appropriate nursing action?

Turn the patient onto left side and reattempt irrigation. correct answer

You notice that the infusion pump was accidentally turned off for a few hours. Knowing this, what consideration should be made?

You should make sure that the tube feeding does not hang for more than 12 hours. correct answer

Placement of a feeding tube requires:

a health care provider's order. All candidates for NG or NI tube placement require an assessment of their coagulation status. Anticoagulation and bleeding disorders pose a risk for epistaxis during nasal tube placement; the health care provider may order platelet transfusion or other corrective measures before tube insertion.

factors that increase risk for complications related to feeding tube insertion:

altered level of consciousness, abnormal clotting, or impaired gag or cough reflex.

Situations in which normal eating is unsafe because of high risk for aspiration:

altered mental status, swallowing disorders, impaired gag reflex, dependence on mechanical ventilation, esophageal conditions (strictures or dysmotility), and delayed gastric emptying.

intestinal aspirates

are stained by bile to a distinct yellow color

The patient is presently receiving intermittent tube feedings of 120 mL every 6 hours. The health care provider's orders state: Jevity formula feeding 240 mL every 6 hours per feeding tube, increase per patient tolerance. Which of the following assessment data indicate patient intolerance of the tube feeding and therefore inability of the rate to be increased?

f the patient develops diarrhea 3 or more times in 24 hours, this indicates intolerance. Notify the health care provider and confer with the dietitian to determine the need to modify the type of formula, concentration, or rate of infusion. Tolerance is indicated by absence of nausea and diarrhea and by low gastric residuals. Residual volume indicates whether gastric emptying is delayed; 500 mL or more remaining in the patient's stomach may reflect delayed gastric emptying. Abdominal discomfort and distention may indicate intolerance to the tube feeding, possibly from too rapid an infusion. Flatulence and thirst do not indicate an intolerance to tube feeding.

History of these problems may require you to consult with health care provider to change route of nutritional support. Passage of tube intracranially can cause neurological injury:

for basilar skull fracture, nasal problems, nosebleeds, facial trauma, nasal-facial surgery, deviated septum, anticoagulant therapy, coagulopathy

Parenteral nutrition

is a method of delivering nutrition through a catheter placed in a large central vein

combination tube

is clearly labeled to distinguish between the gastric and the jejunal ports.

short-term feeding

nasal or oral feeding tubes are used. (usually less than 30 days)