Enteral Tube Feeding

size of small-bore nasogastric feeding tubes

5 French Infant < 1,500 grams 6 French Infant > 1,500 grams 8 French Child up to 5 years of age 8 to 10 French Child older than 5 years 8 to 12 French Adult

percutaneous endoscopic gastrostomy (PEG) tube

a hollow cylindrical device, inserted through an endoscopically created opening into the stomach, that functions as a conduit for delivering enteral feedings

nasoduodenal tube

a hollow, flexible, cylindrical device, inserted through the nose and extending to the duodenum, that serves primarily as a conduit for delivering enteral feedings

nasointestinal tube

a hollow, flexible, cylindrical device, inserted through the nose and extending to the intestines, that serves primarily as a conduit for delivering enteral feedings

nasojejunal tube

a hollow, flexible, cylindrical device, inserted through the nose and extending to the jejunum, that serves primarily as a conduit for delivering enteral feedings

nasogastric tube

a hollow, flexible, cylindrical device, inserted through the nose and extending to the stomach, that has multiple functions including serving as a conduit for delivering enteral feedings

pH

a measure of the acidity or alkalinity of a substance, with a low pH indicating acidity and a high pH indicating alkalinity; a measure of the concentration of hydrogen ions

formula

a mixture of nutrients in liquid form, with enteral formulas prepared to be delivered to the stomach or intestines via an enteral tube

carina

a projection of the lowest tracheal cartilage that forms a prominent semilunar ridge running anteroposteriorly between the orifices of the two bronchi

A nurse inserting a nasogastric tube asks the patient to flex her head toward her chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by

closing off the glottis

The most reliable method for verifying initial placeent of a small-bore feeding tube is by

obtaining an abdominal x-ray

naris

one of the two external orifices of the nose; nostril (plural: nares)

When teaching a pt who is about to receive an intermittent nasogastric feeding, what should the nurse instruct the pt to report immediately?

persistent coughing

To prevent aspiration during the administration of an enteral tube feeding, a nurse should

place the pt in Fowler's position

trachea

the cartilaginous and membranous tube that descends from the larynx and branches into the right and left main bronchi

duodenum

the first or proximal portion of the small intestine extending from the pylorus to the jejunum

epiglottis

the lid-like cartilaginous structure overhanging the entrance to the larynx and preventing food from entering the larynx and trachea during swallowing

mucous membrane

the moist inner lining of various tubular structures, including the mouth, esophagus, stomach, and intestines

esophagus

the musculomembranous passage extending from the pharynx to the stomach

nasopharynx

the portion of the pharynx (the passage between the mouth and posterior nares and the larynx and esophagus) that lies above the level of the soft palate

uvula

the small, fleshy mass hanging from the soft palate above the root of the tongue

gastric aspirate

the substance or material obtained by withdrawal or removal, via a syringe and through a nasogastric or gastrostomy tube, from the patient?s stomach

To determine how much of the length of the nasocenteric tube to insert, a nurse should measure the distance from the tip of the patients nose to the earlobe and from the earlobe to the

xiphoid process plus 20 to 30 cm more

For continuous feedings,

1. HANG the feeding bag and tubing on an IV pole. 2. CONNECT the distal end of the tubing to the proximal end of the feeding tube. 3.CONNECT the tubing through the infusion pump and set the rate. 4. make sure the SLIDER CLAMP on the tubing is in the open position.

2 examples of secondary verification methods include:

1. MARKING the feeding tube at the exit site with indelible ink at the time of radiography or immediately following surgical placement. 2. DOCUMENTING the length of the tube at the exit site.

For intermittent tube feedings:

1. REMOVE the syringe's plunger 2. PINCH the proximal end of the feeding tube and attach the barrel of the syringe to the tube 3. FILL the syringe with a measured amount of formula, release the tube, and hold the syringe high enough to allow it to empty gradually by gravity. 4. REFILLand repeat until you have delivered the prescribed amount. Depending on your facility's policy, you can use a feeding bag with or without a feeding pump.

Prior to inserting a feeding tube:

1. VERIFY the provider's orders 2. REVIEW the patient's medical history for nasal problems, such as nosebleeds, nasal polyps, chronic sinus infections, or oral, facial or sinus surgery; a past history of aspiration; or anticoagulant therapy. If you find any of these conditions, discuss the situation with the provider. 3. DISCUSS the procedure with the patient, and verify verbal consent. 4. DEVELOP a method to communicate during the procedure, such as having the patient raise an index finger to indicate discomfort, may help the patient feel more relaxed and can also facilitate the intubation process. 5. Be sure you have all EQUIPMENT readily available at the bedside before starting. 6. HAND HYGENE 7. ASSESSMENT 8.assist patient into a comfortable upright position with a pillow behind her head and shoulders. Place a towel or a disposable pad across the patient's chest. 2. After performing hand hygiene and donning gloves, determine the portion of the tube to be inserted by measuring from the tip of the patient's nose to her earlobe to the xiphoid process of her sternum. Add 20 to 30 cm for duodenal or jejunal placement. Use a piece of tape to mark the length of the tube at the proximal end. 3. Prior to insertion, a medication may be used to anesthetize the mucous membranes, such as lidocaine in a spray, gel, or nebulized form. Be sure to consult your facility's policies before using these medications.

preparing and administering formula

1. WARM it to room temperature, checking its integrity, and making sure it is clean. 2. check the formula's EXPIRATION and SHAKE the container well. 3. ELEVATE the head of the patient's bed to 30 degrees or higher, then don clean gloves. 4. If you are using a READY-TO-HANG container, access the port using sterile procedures. 5. when using a feeding-tube bag, fill the bag with formula from the container. 6. to prevent bacterial contamination, fill the bag with only enough formula to last over a 4-8 hour period. 7. allow the formula to FILL the tubing to the distal tip. 8. be sure to LABEL the formula bag and the tubing.

assessing the patient

1. assess the patency of the patient's nares. (Have her close each naris alternately and breathe. If both are patent, ask the patient which side she prefers for tube placement.) 2. assess the patient?s gag reflex to evaluate her ability to swallow, a function that is important during the insertion process. 3.auscultate the patient's abdomen for bowel sounds a baseline for your

flushing

1. be sure to follow your facility's policies for how often to check residuals (generally every 4 hours), how often to document intake and output and the volume of formula in the bag, and how often to replace the feeding tube bag (generally every 24 hours). 2. general amounts of flush solution used 6 French 1.5 to 5 mL water 8 French 5 to 10 mL water 10 French 10 to 20 mL water >12 French 30 mL water 3. flush the feeding tube intermittently with water (sterile or tap water according to your facility's policies, the provider's orders, the patient's condition, and tap-water quality) to prevent clogging before and after feedings and medication administration and after gastric aspiration. When the tube is not in use, cap or clamp its proximal end. 4. Be sure to document all feeding-administration procedures.

Prior to administering the formula:

1. be sure to follow your facility's procedures for verifying tube placement as well as the provider's orders for the type of formula, rate, route, and frequency 2. obtain laboratory data and bedside assessments, such as finger-stick blood glucose, according to the provider's orders. 3. explain the procedure to the patient and have the equipment at hand. 4. auscultate for bowel sounds. 4. check for gastric residual (if not done previously during verification procedures. (Generally, residual volumes are checked only for patients who have tubes placed in the stomach, because the small intestines continually propel contents forward. With small-bore feeding tubes, use a 50- to 60-mL syringe for this procedure to avoid collapsing the tube)

Directly following tube placement:

1. check the pH of the aspirate, along with the color and consistency of the fluid. 2. evaluate the patient's risk for undetected respiratory placement and verify radiographic confirmation with the provider prior to administering feedings or medications through the tube. (Patients with a decreased level of consciousness, poor cough or gag reflexes, endotracheal intubation, recent extubation, inability to cooperate with the procedure, restlessness, or agitation are at greater risk for improper tube placement and require extra precautions.)

elemental formulas

1. contain PREDIGESTED nutrients, making it easier for a partially dysfunctional gastrointestinal tract to absorb them 2. provide 1 to 3 kcal/mL

modular formulas

1. contain SINGLE macronutrients (protein, glucose, polymers, lipids) and are not nutritionally complete. 2. deliver 3.8 to 4.0 kcal/mL and are used to supplement patients' nutritional needs.

polymeric formulas

1. deliver 1 to 2 kcal/mL and require that patients can absorb WHOLE nutrients. 2. include MILK-based blenderized foods and commercially prepared whole-nutrient formulas

inserting the tube

1. dip the tube into a water-based lubricant and ask the patient to tip her head backward. Insert the tube through the naris to the back of the throat (the posterior nasopharynx). After you have passed the tube through the nasopharynx, have the patient flex her head toward her chest and swallow. If the patient is able to swallow liquids safely, ask her to take a sip of water. Advance the tube each time the patient swallows until you have inserted the predetermined length of tube. 2. check for the position of the tube in the back of the throat with a penlight and a tongue blade. You should be able to visualize the tube taut against the back of the throat. 3. observe for any signs of difficulty breathing, coughing, or gagging. Auscultate lung sounds and assess your patient's comfort level. After temporarily anchoring the feeding tube, verify tube placement according to your facility's policies and procedures. Large-bore tubes do not include a guidewire. 4. Verify placement by obtaining, examining, and testing gastric aspirate for pH. Some facilities use CO2 (subscript) detection during or after the insertion procedure to verify placement, and some require an x-ray for confirmation before using the tube. Small-bore tubes are usually inserted with a guidewire. In this case, use the side port to obtain the gastric or intestinal aspirate. 4. Verify placement by testing the pH of the aspirate, monitoring CO2, or having the contents analyzed in a laboratory. 5. Confirmation of tube placement by abdominal x-ray is typically mandatory. 6. Remove the guidewire after confirmation of the tube and do not reinsert it, as it could potentially damage surrounding tissue during reinsertion. 7. After confirming tube placement, secure the tube at the point of insertion and mark the tube with indelible ink directly where the tube meets the naris or the mouth. Be sure to flush the tube to remove aspirate. Auscultate lung sounds. Secure the tube at the point of insertion and mark the tube with indelible ink directly where the tube meets the naris or the mouth. 8. After verification, secure the tube with a fixation device. Fasten the end of the tube to the patient?s skin or gown. Be sure to follow your facility's policies for securing the tube. 9. Assist the patient to a comfortable position, dispose of all equipment in the appropriate receptacle, apply clean gloves, and administer mouth care. 10. Be sure to document all feeding-tube insertion procedures.

Feeding tubes with a guidewire

1. make sure that it is securely positioned against the weighted tip and that the connection ports are fitted together snugly. 2. be sure to follow your facility's policies for using lidocaine spray, gel, a nebulizer, or other medications used to numb the airway tissues. 3. when inserting a small-bore feeding tube, make certain that the guidewire is securely positioned against the weighted tip and that both the Luer-Lok™ connections are snugly fitted together. 4. if the catheter does not come with the guidewire already in place, inject 10 mL of water from a 30-mL or larger Luer-Lok™ or catheter-tip syringe into the tube to help with the insertion of the guidewire or stylet.

removing a small bore-feeding tube

1. make sure you have followed all of the pre-steps 2. remove the tube's anchoring device. Instruct the patient to take and hold a deep breath. 3. clamp or kink the tubing securely and then pull the tube out steadily and smoothly, end over end, while the patient holds her breath. 4. clean the patient?s nares and provide mouth care. Document the procedure.

What ara the four basic types of enteral formula?

1. polymeric 2. modular 3. elemental 4. specialty.

specialty formulas

1. range from 1 to 2 kcal/mL 2. designed to meet SPECIFIC nutritional needs related to specific illnesses, such as liver failure, pulmonary disease, diabetes, or HIV infection

Before removing a small-bore feeding tube:

1. verify the provider's order to discontinue the tube and explain the procedure to the patient. pH 2. make sure that the feeding tube?s pump is turned off and disconnected from the proximal end of the tube. 3. apply disposable gloves. 4. Flush the tube with 1.5 to 30 mL of air, depending on the age and size of the patient, to clear formula from the tubing. 5. Give the patient some facial tissues and place a clean towel or disposable pad across her chest 6. Remove the tube's anchoring device. Instruct the patient to take and hold a deep breath.

_______, _______, _______, and ________are nursing measures to prevent aspiration include.

1. verifying tube placement 2. checking gastric residuals 3. assessing bowel function to confirm peristalsis, 4. elevating the head of the patient's bed to 30 degrees or more during feeding and at least 1 hour after feeding

What are normal pH ranges?

Gastric fluid from a patient who has fasted for at least 4 hours usually has a pH range of 1 to 4, and the fluid will be grassy green, off-white, or tan with the consistency of water. Intestinal fluid pH is usually higher than 6, and, since it contains bile, it will appear light to golden yellow or brownish green with a syrupy consistency. In contrast, respiratory fluid is usually clear with a pH above 7.

What are the most common complications of enteral feedings?

Displaced tubes, aspiration, and diarrhea are the most common complications of enteral feedings.

Which of the following formulas is appropriate to administer to a pt who has a dysfunctional gastrointestinal tract

Elemental

An older adult in a long term care facility is receiving intermittent enteral feeding in his room. His affect is flat and the nurse suspects that he is feeling isolated. Which intervention is appropriate for this patient.

Encourage him to go to the dining room at meal times to talk with other patients.

A patient with a gastric ileum postop requires nutritional support for approx. 2 weeks. Which of the following types of feeding is appropriate for the patient?

Nasointestinal tube

Nasogastric or nasointestinal tube feedings are usually administered for how long?

They are used for less than 4 weeks, gastrostomy or jejunostomy tubes are used for long-term therapy. Occasionally, an orogastric tube, placed from the mouth to the stomach, is used for premature infants, mechanically ventilated patients, and those with a history of craniofacial surgery or trauma.

jejunostomy tube

a hollow cylindrical device, inserted through a surgically created opening into the jejunum, that functions as a conduit for delivering enteral feedings mucous membrane

gastrostomy tube

a hollow cylindrical device, inserted through a surgically created opening into the stomach, that functions as a conduit for delivering enteral feedings

percutaneous endoscopic jejunostomy tube

a hollow cylindrical device, inserted through an endoscopically created opening into the jejunum, that functions as a conduit for delivering enteral feedings

aspiration

inadvertent inhalation of fluid or other substances into the lungs; also, the withdrawal or removal, via a syringe or other apparatus, of a substance or material from the body

intermittent and continuous feedings

intermittent feedings may be administered by the syringe technique or with a feeding pump whereas continuous feeding must be delivered via a feeding pump.

Nasogastric tube feeding are an appropriate choice for a patient who

is post op following laryngectomy

To prevent a common complication of continuous enteral tube feedings, a nurse should

limit the time the formula hangs to 4 hours