Module 14: Enteral Nutrition
Which of the following may be delegated to NAP? a. administering medication through a feeding tube b. administering a tube feeding c. Verifying feeding tube placement d. Inserting an NG feeding tube e. Assessing for peristalsis
B) Administering a tube feeding Administration of enteral tube feeding is a procedure that can be delegated to NAP (usually seen in a long-term care facility). The assessment for the presence of peristalsis and verification of tube placement should be performed by a nurse before the feeding. Instruct NAP to position patient upright in bed or chair and to infuse feeding slowly (in case of bolus and intermittent feedings). Have NAP immediately report any difficulty infusing the feeding or any distress experienced by patient. The skill of administering medication through a feeding tube or of inserting an NG feeding tube requires the critical thinking and knowledge application unique to a nurse, and may not be delegated.
The nurse just inserted an NG feeding tube. The health care provider's order states to administer all meds per tube and a continuous feeding of Isocal at 30 mL per hour. The order also states to check the patient's blood glucose every 6 hours. When can you begin to instill feedings, water, or medications through the feeding tube? a. Immediately after placement is verified by pH testing b. When the patient's blood glucose is verified to be within normal limits c. When tube placement has been verified by x-ray film d. After administering 30 mL of water, the medications may be given, followed by another 30 mL of water, and then the continuous feeding may be initiated.
C) When tube placement has been verified by x-ray film Proper position is essential before instilling anything through the feeding tube. Upon insertion, placement of tube is verified by x-ray examination. Blood glucose readings aid in monitoring the patient's tolerance of the feeding.
A patient has a nasogastric feeding tube. The nurse is aware of the need to monitor the patient for potential complications. Which of the following symptoms, if demonstrated by the patient, would potentially indicate the greatest risk related to tube feedings? a. diarrhea b. dyspnea c. abdominal distention d. throat irritation
B) Dyspnea Aspiration, generally from tube displacement, is the greatest risk related to tube feedings. Diarrhea may be an unexpected outcome and abdominal distention may be an indication of intolerance of the formula feedings. A patient with an NG or NI tube may complain of throat irritation from the presence of the tube in the nasopharynx, but this does not pose a risk.
You attempt to aspirate gastric contents from an established NG feeding tube and get zero return. What should you do next? a. document the finding b. reposition the patient c. assume that the tube is in the appropriate place and start tube feeding d. Get an order for a chest x-ray to verify placement before administering the tube feeding. e. Remove the tube and insert a new one.
B) Reposition the patient The nurse should first reposition the patient. The tip of the tube may be lying against the stomach wall. Changing the patient's position may move the tip away from the stomach wall. If, after repeated attempts, the nurse is still unable to aspirate fluid from a tube that was originally established by x-ray examination to be in the desired position and (a) risk factors for tube dislocation are absent, (b) the tube has remained in its original taped position, and (c) the patient does not experience any difficulty, assume that the tube is correctly placed. The nurse may flush the tubing with a large-bore syringe and warm water. If this fails, notify the health care provider. It is undetermined whether the tube needs to be removed. Documentation of how the issue is resolved will be necessary when the procedure is completed.
Instructions: Match the unexpected outcome with the related intervention. A. Hold feeding, notify physician, maintain patient in semi-Fowler's position, and recheck in 1 hour. B. Turn off tube feeding, place in Fowler's position, suction, and notify physician. C. Reposition patient, attempt to flush with large-bore syringe and warm water; if able to flush and absence of residual, determine the patient's risk of dislodgment—if risk is low and the tube has remained taped in original position, start next feeding. D. Notify physician and confer with dietitian to determine need to modify type of formula, concentration, or rate of infusion. E. Withhold tube feeding and notify physician. Be sure tubing is patent; aspirate for residual. Definitions 1) Patient develops nausea and vomiting 2) Patient aspirates formula 3) Unable to aspirate gastric contents 4) Gastric residual exceeds 250 mL 5) Patient develops diarrhea
A - 4 B - 2 C- 3 D- 5 E- 1 A. Hold feeding, notify physician, maintain patient in semi-Fowler's position, and recheck in 1 hour. B. Turn off tube feeding, place in Fowler's position, suction, and notify physician. C. Reposition patient, attempt to flush with large-bore syringe and warm water; if able to flush and absence of residual, determine the patient's risk of dislodgment—if risk is low and the tube has remained taped in original position, start next feeding. D. Notify physician and confer with dietitian to determine need to modify type of formula, concentration, or rate of infusion. E. Withhold tube feeding and notify physician. Be sure tubing is patent; aspirate for residual. Definitions 1) Patient develops nausea and vomiting 2) Patient aspirates formula 3) Unable to aspirate gastric contents 4) Gastric residual exceeds 250 mL 5) Patient develops diarrhea If gastric residual exceeds 250 mL (use agency policy), the nurse should hold the feeding and notify the health care provider. The patient should be maintained in the semi-Fowler's position or at least have the head of the bed elevated 30 degrees. The nurse should check the residual again in 1 hour. If the patient aspirates formula, the patient may exhibit the following symptoms: rapid and shallow respirations, ashen color, rhonchi upon auscultation of breath sounds, and coughing up secretions that are similar to tube feeding. The nurse should turn off the tube feeding immediately, position the patient in the Fowler's position, suction, and notify the health care provider immediately. Prepare for chest x-ray examination. If unable to aspirate gastric contents, reposition the patient, attempt to flush with large-bore syringe and warm water; if able to flush and absence of residual, determine the patient's risk of dislodgment—if risk is low and the tube has remained taped in its original position, start the next feeding. If unable to flush, notify the health care provider. If the patient develops diarrhea three or more times in 24 hours, indicating 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. Determine whether patient is receiving antibiotics and medications containing sorbitol, which can induce diarrhea. If the patient develops nausea and vomiting, it may indicate gastric ileus. Withhold the tube feeding and notify the health care provider. Be sure the tubing is patent; aspirate for residual.
The nurse is inserting an NG feeding tube. Which step in the procedure is inaccurate, indicating further instruction is needed? A) Perform hand hygiene and place patient in left lateral position. Determine length of tube from the xyphoid process to the tip of the patient's nose. Insert stylet into feeding tube. Inspect nares. Dip end of tube in ice water. B) Hand patient a cup of water with a straw. Gently insert the tube through the nostril to back of throat. Have patient flex head toward chest. Give small sips of water and advance the tube as patient swallows. Rotate tube 180 degrees while inserting. C) When tip of tube reaches carina, stop and listen for air exchange from distal portion of tube. Continue to advance tube until desired length has been passed. Check back of throat with a penlight and tongue blade. Check placement of tube. D) Mark exit site on tube with indelible ink. Apply tincture of benzoin to nose and allow to become "tacky." Remove gloves and apply stabilization device. Obtain an x-ray to verify tube placement.
A) Perform hand hygiene and place patient in left lateral position. Determine length of tube from the xyphoid process to the tip of the patient's nose. Insert stylet into feeding tube. Inspect nares. Dip end of tube in ice water. The patient should be placed in a high-Fowler's or sitting position to reduce the risk of pulmonary aspiration in the event the patient should vomit. If the patient is comatose, place in semi-Fowler's position. The nurse should first explain the procedure to the patient to gain cooperation and check the feeding tube for flaws which could injure the patient. The length of the tube to be inserted is determined by measuring the distance from the tip of the nose to the earlobe to the xyphoid process. Ten mL of water should be injected into the feeding tube to aid stylet insertion, and the stylet should be securely positioned against the weighted tip. The tube may be dipped in water, but not ice water as this would only make the tube less pliable for insertion.
Which of the following actions by the nurse help reduce the risk of aspiration? a. Elevating the head of the patient's bed b. Performing nasotracheal suctioning before instilling a tube feeding. c. Encouraging the patient to deep breathe and cough. d. keeping the patient well-hydrated
A) The nurse elevates the head of the bed Keeping the head elevated above the stomach helps reduce the risk of aspiration. Risk factors for tube dislodgment include frequent nasotracheal suctioning and severe coughing. Dislodgment of the tube places the patient at high risk for aspiration. Keeping the patient well-hydrated does not reduce the risk of aspiration.
Which of the following pH test results on the aspirate of a patient who receives intermittent feedings indicates that the feeding tube is in the stomach? a. pH of 1 to 5 b. pH of 6 or greater c. pH greater than 5 d. pH of 0 to 11
A) pH of 1 to 5 Gastric fluid from a patient who has fasted at least 4 hours usually has a pH range of 1 to 5. The range of 1 to 5 is a reliable indicator of stomach placement. Fluid from an NI tube of a fasting patient usually has a pH greater than 6. Intestinal contents are less acidic than stomach contents. The pH of pleural fluid from the tracheobronchial tree is also generally greater than 6. A patient with a continuous tube feeding may have a pH of 5 or higher. Formulas contain solutions that are basic.
Which of the following are accurate statements related to the use of water and administering medication through a feeding tube? (Select all that apply.) a. Cold water should be avoided as it may cause abdominal cramping. b. Tap water as hot as possible should be used to enable the medications to dissolve. c. The feeding tube should be flushed with 10 mL of water after each medication is administered. d. Patients who receive tube feedings do not require water. e. The feeding tube should be flushed with 30 to 60 mL of water after the last medication. f. Any time water is administered through the feeding tube, the amount should be documented on the intake and output record.
A, C, E, F a. Cold water should be avoided as it may cause abdominal cramping. c. The feeding tube should be flushed with 10 mL of water after each medication is administered. e. The feeding tube should be flushed with 30 to 60 mL of water after the last medication. f. Any time water is administered through the feeding tube, the amount should be documented on the intake and output record. After each medication is administered, the tube should be flushed with 10 mL of water. If a problem develops during medication administration (e.g., spillage, coughing, tube clogging), the nurse can tell which medications have been lost and which are still available for later administration. The last medication should be followed with 30 to 60 mL of water to avoid clogging of the tube and to ensure the medication enters the stomach, where it can be absorbed. The amount of water administered should be recorded on the patient's intake and output record. Cold water should be avoided because it may cause abdominal cramping. Hot water should be avoided because it may cause tissue injury. Patients receiving tube feedings still require water. Have the registered dietician recommend the total free water requirement per day.
Match the type of feeding with the patient condition: A. Parenteral nutrition B. Jejunostomy tube C. NG feeding tube 1) Patient with burns who cannot consume enough calories orally 2) Patient with difficulty swallowing after having a CVA and will need long-term nutritional support. 3) Patient with malabsorption syndrome.
A. Parenteral nutrition - 3 B. Jejunostomy tube - 2 C. NG feeding tube - 1 1) Patient with burns who cannot consume enough calories orally 2) Patient with difficulty swallowing after having a CVA and will need long-term nutritional support. 3) Patient with malabsorption syndrome. Patients who have a functioning GI tract and require nutritional support less than 30 days are candidates for nasoenteric or nasogastric tube feedings. Patients who have a functioning GI tract and require nutritional support longer than 30 days are candidates for a PEG tube or gastrostomy or jejunostomy tube. Patients who are unable to absorb nutrients in their GI tract will require parenteral nutrition.
The nurse is inserting an NG feeding tube. Which of the following supplies will the nurse need to perform the procedure? (Select all that apply.) A) Saline nasal spray B) 8 to 12 Fr feeding tube Correct C) 60 mL syringe Correct D) Stethoscope Correct E) Tube fixation device Correct F) Tincture of benzoin Correct G) Sterile specimen cup H) Cup of water/straw
B, C, D, E, F, H B) 8 to 12 Fr feeding tube Correct C) 60 mL syringe Correct D) Stethoscope Correct E) Tube fixation device Correct F) Tincture of benzoin Correct H) Cup of water/straw The necessary supplies to insert a NG feeding tube include the following: 8 to 12 Fr nasogastric tube, 60 mL syringe, stethoscope, hypoallergenic tape, semipermeable (transparent) dressing, or tube fixation device, tincture of benzoin or other skin protectant, pH indicator strip, cup of water and straw (for patients able to swallow), emesis basin, towel, facial tissues, clean gloves, suction equipment in case of aspiration, penlight to check placement in nasopharynx, tongue blade.
The nurse verified feeding tube placement by pH testing and administered the regularly scheduled medications at 10 a.m. The nurse flushed the feeding tube with 10 mL of water between medications and with 30 mL of water after the last medication. It is now 10:45 a.m. and the patient is requesting pain medication. The only pain medication ordered is to be administered per feeding tube. What action should the nurse take at this time? A) The nurse may administer the pain medication but it is unnecessary to recheck placement with a pH strip since it was verified within the last hour. B) The nurse should verify placement with a pH strip and administer the medication but avoid flushing afterwards since this would result in the patient receiving too much water within a short period of time. C) The nurse should call the health care provider and request a different route for pain medication administration since it would be contraindicated per tube at this time. D) The nurse should verify placement with a pH strip, administer dissolved medication, and flush with 30 mL of water.
D) The nurse should verify placement with a pH strip, administer dissolved medication, and flush with 30 mL of water. Feeding tube placement should be verified either by x-ray (upon insertion) or by pH testing of aspirate before instilling anything through the tube. Ongoing verification of feeding tube placement by pH testing should be performed before medications are administered through the tube. Flushing is necessary to ensure the medication reaches the patient's stomach where it can be absorbed and to prevent clogging of the feeding tube. It is unnecessary to contact the health care provider. The medication may be administered according to orders.
When should placement of a feeding tube be verified? (Select all that apply.) A. Before administering formula through the tube b. Before administering medications through the tube c. Before administering water through the tube d. At least once every 6 hours when continuous feedings are given e. If the patient is complaining of a sore throat f. Only when the health care provider orders it
a, b, c, d A. Before administering formula through the tube b. Before administering medications through the tube c. Before administering water through the tube d. At least once every 6 hours when continuous feedings are given The nurse is responsible for ensuring that the tube has remained in the intended position before administering formula or medications through the tube. Verification of tube placement is an expectation of competent nursing care of patients with feeding tubes. Therefore, verification of correct tube placement is performed before each intermittent feeding, at least once every 6 hours when continuous feedings are given, and before medications are administered through the tube. The patient may have a sore throat if it is an NG or NI tube from the presence of the tube in the back of the pharynx.