Chapter 32: Enteral Nutrition
The nurse is caring for a patient with an enteral feeding tube in place. The nurse assesses for pulmonary aspiration as the main complication related to feeding tubes. Other complications include which of the following? (Select all that apply.)
a. Infection b. Diarrhea c. Tube clogging d. Tube dislodgment The main complication related to feeding tubes is pulmonary aspiration with possible lung compromise. Other complications include misplaced tubes, infection, diarrhea, tube clogging, and tube dislodgment.
The nurse, physician, and dietitian collaborate to select an enteral feeding formula for the patient. Their decision should be based on which of the following? (Select all that apply.)
a. Protein requirements of the patient b. Digestive ability of the patient The nurse, dietitian, and physician collaborate to select an enteral feeding formula based on the patient's protein and calorie requirements and digestive ability. Formulas in the United States are sterile and lactose free. Disease-specific formulas are available, but research has not always supported their efficacy.
Conditions that increase the risk for spontaneous tube dislocation include which of the following? (Select all that apply.)
a. Retching/vomiting b. Nasotracheal suction c. Coughing Conditions that increase the risk for spontaneous tube dislocation include retching/vomiting, nasotracheal suction, and severe bouts of coughing. Cyanosis may be an indicator of displacement but is not a cause.
The nurse is checking gastric residual on a patient who has a continuously running tube feeding and finds that the patient has a 600-mL gastric residual volume (GRV). How should the nurse respond?
a. Stop the tube feeding. Tube feedings are stopped if the patient has a gastric residual volume (GRV) greater than 500 mL.
The nurse is caring for a patient who is receiving continuous tube feedings. What must the nurse do to care for this patient?
a. Verify tube position every 4 to 6 hours. After initial radiographic verification that a tube is positioned in the desired site (either the stomach or the small-intestine), the nurse is responsible for ensuring that the tube has remained in the intended position before administering formula or medications through the tube. Therefore, the nurse must verify tube position every 4 to 6 hours and as needed. Because it is not practical to do radiographic checks at this frequency, other methods of determining placement have been investigated. Insufflation of air into the tube while the abdomen is auscultated is not a reliable means of determining the position of the feeding tube tip. It is possible for the tip of a feeding tube to move into a different location (from the stomach to the intestine, or from the intestine into the stomach) without any external evidence that the tube has moved. The risk for aspiration of regurgitated gastric contents into the respiratory tract increases when the tip of the tube accidentally dislocates upward into the esophagus.
What is an appropriate amount of nasogastric irrigant for an adult patient?
b. 30 mL Draw up 30 mL of normal saline or tap water in a syringe. This amount of solution will flush the length of the tube. Irrigation of a tube requires a smaller volume of solution in children: 1 to 2 mL for small tubes to 5 to 15 mL or more for large ones.
Before insertion of a nasogastric (NG) tube, of which finding should the physician be notified?
b. Absent bowel sounds Absent bowel sounds may indicate decreased or absent peristalsis and increased risk for aspiration. A finding of patent nares rules out obstruction or irritated nares, septal defect, or facial fracture and does not need to be reported to the physician because it is a "normal" finding. The nurse should assess the patient for a gag reflex to determine the patient's ability to swallow and to discern whether a greater risk for aspiration exists. An evident gag reflex is a normal finding and does not need to be reported to the physician. Impaired swallowing is the probable reason for insertion of the nasogastric (NG) tube.
The nurse is initiating a continuous tube feeding for a patient who has a gastrostomy tube. Which of the following procedures indicates proper practice?
b. Change the bag every 24 hours. Rinse the bag and tubing with warm water whenever feedings are interrupted. Use a new administration set every 24 hours. Allowing the container to empty over 30 to 45 minutes is the method used for intermittent administration of tube feedings. Administer water via a feeding tube as ordered or between feedings. This provides the patient with a source of water to help maintain fluid and electrolyte balance and clears the tubing of formula. Gradually advancing the rate of concentration of the tube feeding helps to prevent diarrhea and gastric intolerance to formula.
Which technique is appropriate for the nurse to implement during nasogastric (NG) tube insertion?
b. Have the patient mouth-breathe. Emphasize the need to mouth-breathe and swallow during the procedure. This facilitates passage of the tube and alleviates the patient's fears during the procedure. Put on clean gloves. Do not force the tube. If resistance is met, or if the patient starts to cough or choke, or becomes cyanotic, stop advancing the tube, pull the tube back, and start over. Have the patient flex his head toward his chest after the tube has passed through the nasopharynx. This closes off the glottis and reduces the risk that the tube may enter the trachea.
Which technique is appropriate for providing intermittent tube feeding once placement of the tube has been checked?
c. Allowing the bag to empty gradually over 30 to 45 minutes Allow the bag to empty gradually over 30 to 45 minutes. Gradual emptying of tube feeding by gravity from the feeding bag reduces the risk for abdominal discomfort, vomiting, or diarrhea induced by bolus or too-rapid infusion of tube feedings. Cold formula causes gastric cramping. Place the patient in high-Fowler's position, or elevate the head of the bed at least 30 degrees to prevent aspiration. Do not add food coloring or dye to formula to assist in detecting aspiration, presumably by staining tracheobronchial secretions. This is associated with increased risk for contamination and may cause patient deaths.
Of the patients listed below, which would be a candidate for nasoenteric feeding tube placement?
c. Elderly patient with a diagnosis of failure to thrive and an inability to chew Enteral nutrition, commonly called tube feeding, is the administration of nutrients through the gastrointestinal tract when a patient cannot ingest, chew, or swallow, but can digest and absorb nutrients. Nasoenteric tubes are contraindicated in patients with facial trauma, prolonged bleeding, and upper gastrointestinal (GI) blockage (as is seen in cases of solid cancer).
The nurse is caring for a patient with a nasogastric tube in place. What interventions would the nurse perform to reduce the risk of clogging the feeding tube? (Select all that apply.)
c. Flush the tube liberally with water before, between, and after each medication instillation. d. Use the largest barrel syringe possible to reduce the pressure in the tube. e. Crush solid medications thoroughly and mix them in water before administration. Flushing the tube liberally with water before, between, and after each medication instillation will reduce the risk of clogging, as will crushing solid medications thoroughly and mixing them in water before administration. The largest barrel, not the smallest barrel, syringe exerts less pressure and reduces the risk of clogging. Mixing medications with formula is contraindicated because it increases the risk of clogging.
Which evaluation indicates that placement of a nasogastric or enteric tube is correct?
c. Gastric aspirate with a pH of 5 or less after patient fasting Gastric fluid from a patient who has fasted for at least 4 hours usually has a pH of 5 or less. Fluid from an enteric tube of a fasting patient usually has a pH greater than 6. The pH of pleural fluid from the tracheobronchial tree is generally greater than 6. Patients with continuous tube feeding may have a pH of 5 or greater.
The nurse is checking the residual volume on a patient who is getting intermittent tube feedings via his NG tube. Which of the following may indicate that the patient has started to bleed again?
c. The nurse obtains red aspirate. Red or brown coloring (coffee-grounds appearance) of fluid aspirated from a feeding tube indicates new blood or old blood, respectively, in the gastrointestinal tract. If the color is not related to medications recently administered, notify the physician. Abdominal distention usually indicates that the tube feeding is not progressing through the GI tract. This could be a sign of paralytic ileus. Stop the tube feeding and notify the physician. If the patient develops severe respiratory distress (e.g., dyspnea, decreased oxygen saturation, increased pulse rate), this may be a result of aspiration or tube displacement into the lung. Stop any enteral feedings. Notify the physician. Obtain chest radiographs as ordered.
An appropriate technique for nasogastric (NG) tube insertion is for the nurse to:
c. advance the tube while the patient swallows. Encourage the patient to swallow by giving small sips of water or ice chips. Advance the tube as the patient swallows. Rotate the tube 180 degrees while inserting. Swallowing facilitates passage of the tube past the oropharynx. Position the patient sitting with the head of the bed elevated at least 30 degrees. If the patient is comatose, place him in semi-Fowler's position with the head propped forward using a pillow. If the patient is forced to lie supine, place him in reverse Trendelenburg's position. This reduces the risk for pulmonary aspiration in the event that the patient should vomit. Apply water-soluble lubricant. The tip of the tube must reach the stomach. Measure the distance from the tip of the nose to the earlobe to the xiphoid process of the sternum. Add 20 to 30 cm (8 to 12 inches) for a nasoenteric tube.
The home health nurse evaluates the provision of intermittent tube feedings by the patient's family member. The nurse notes that additional teaching is required when she notices that the family member:
c. begins the feeding before checking tube placement. For intermittent tube-fed patients, test placement immediately before each feeding and before each administration of medication. Each administration of feeding/medication can lead to aspiration if the tube is displaced. For intermittent feeding, have a syringe ready and be sure that the formula is at room temperature. When tube feedings are not being administered, cap or clamp the proximal end of the feeding tube. Draw up in the syringe 30 mL of normal saline or tap water. This amount of solution will flush the length of the tube
The nurse is preparing to administer an enteral feeding for the patient. The patient has been on enteral feedings for 2 days. The nurse knows that the most appropriate technique for implementing enteral feeding is:
c. changing the formula every 12 hours in an open system. Maximum hang time for formula is 12 hours in an open system, and 24 to 48 hours in a closed, ready-to-hang system (if it remains closed). Weigh the patient daily until the maximum administration rate is reached and maintained for 24 hours, and then weigh the patient 3 times per week. Check the gastric residual volume. Residual volume should be assessed before each feeding for intermittent feedings.
The nurse has inserted a nasogastric (NG) feeding tube. The feeding tube has a stylet in place to aid insertion. What should the nurse do once the tube is in place?
d. Leave the stylet in place and obtain a chest/abdomen radiograph. Leave the stylet in place (if used) until correct position has been verified by x-ray film. Never attempt to reinsert a partially or fully removed stylet while the feeding tube is in place. This can cause perforation of the tube and can injure the patient. Do not use safety pins to pin the tube to the patient's gown. Safety pins become unfastened and can cause injury to the patient.
The nurse has just inserted a nasogastric (NG) feeding tube into a patient. What should the nurse do to definitely ascertain that the tube is in the stomach or in the intestine?
d. Obtain an order for a chest radiograph. The most reliable method of feeding tube verification is a chest radiograph (chest x-ray). Gastric and intestinal pH measurements have been shown to differentiate tube placement, with the stomach having a lower pH than the intestines. This helps to ensure that the tube is beyond the pylorus, theoretically reducing the risk for aspiration. This method is helpful before and after radiological confirmation. Carbon dioxide sensors are helpful in determining tube placement between the stomach and the lung. A small plastic piece with an embedded yellow sensor is attached to the end of the feeding tube; the sensor changes color when carbon dioxide is present. Investigators have shown that this reduces the incidence of inadvertent pulmonary placement. This method is helpful before and after radiological confirmation. Elevation of the head of the bed to a minimum of 30 degrees is a simple method used to keep the risk for aspiration at a minimum. The nurse is instrumental in achieving this goal. This method does not ascertain placement but may be useful in preventing aspiration.
The nurse would anticipate the need for an enteral access device in which of the following patients?
d. Patient who suffers from severe acute dysphagia A patient who is unable to swallow because of severe acute dysphagia will require an enteral access device to provide adequate nutrition. The patient recently diagnosed with a CVA may require an enteral access device if the ability to swallow is affected, but more information would be needed before this option is chosen. A patient whose bowel sounds have not yet returned will remain NPO and may have no need for an enteral access device. Less invasive strategies can be used for the patient who does not like the taste of food provided by the agency
The nurse determines that a nasogastric (NG) tube needs irrigation when she:
d. obtains an unusually thick secretions. Thick secretions indicate the need to irrigate the tube. Note the ease with which tube feeding infuses through the tubing. Excess volume of secretions (more than 200 mL) indicates delayed gastric emptying. Irrigating the NG tube will not help. Failure of the formula to infuse as desired may indicate a developing obstruction.
The nurse is caring for a patient in a chronic vegetative state with inadequate gastric emptying. The nurse would anticipate finding in a ________ tube placed to assist with this patient's nutritional needs.
jejunostomy A jejunostomy tube would be appropriate for this patient. A nasally inserted tube would be inappropriate for long-term use; this fact rules out nasogastric and nasoenteric tubes. A tube placed into the stomach would be inappropriate for a patient with inadequate gastric emptying; this fact rules out gastrostomy and nasogastric tubes.
A tube passed through the nose or mouth with the end terminating in the stomach or the small bowel, and used in feeding the patient for short periods is known as a ____________
nasogastric (NG) feeding tube A nurse passes a nasogastric (NG) tube through the nose or mouth with the end terminating in the stomach or the small bowel for use in delivering supplemental nutrition or facilitating gastric decompression.
