Enteral feeding: Indications,

complications, and nursing care

Get up to date on current enteral nutrition guidelines.
By Amanda Houston, MSN, MHA, RN, and Paul Fuldauer, RD, LDN

ENTERAL FEEDINGS deliver Types of enteral feeding tubes

nourishment through a tube di- The practitioner selects the type
rectly into the GI tract. of feeding tube based on the
They’re ordered for patients specific enteral formula the
with a functioning GI tract patient requires and the an-
who can’t ingest enough nu- ticipated duration of enteral
trition orally to meet their feeding. The two main types
needs. The feeding tube may of feeding tubes are prepy-
stay in place as briefly as a few loric and postpyloric.
days or permanently, until the pa- • Prepyloric tubes end in the stom-
tient’s death. (See Indications for ach above the pyloric sphincter.
enteral feeding.) They’re preferred for intermittent
This article discusses types of nia, osteomalacia, osteoporosis, feeding and to allow gastric ab-
enteral feeding tubes, methods, and muscle weakness, increased frac- sorption.
formulas. It also reviews enteral ture risk, polyneuropathy, paresthe- • Postpyloric tubes end beyond
feeding complications and de- sias, confusion, dementia, and pan- the pyloric sphincter in the je-
scribes related nursing care. cytopenia. Some also may have junum. They’re indicated for pa-
low albumin and prealbumin lev- tients with gastroparesis, acute
Defining malnutrition els, which can cause fluid to pool pancreatitis, gastric outlet steno-
People experiencing the physiolog- in a localized or generalized distri- sis, hyperemesis (including
ic stress of illness may have in- bution. But before blaming malnu- gravida), recurrent aspiration,
creased metabolic demands with re- trition for abnormal albumin or tracheoesophageal fistula, and
duced capacity to take in nutrition. prealbumin levels, clinicians must stenosis with gastroenterostomy.
Prolonged calorie restriction can consider such factors as persistent Postpyloric feedings must be ad-
lead to malnutrition. According to inflammation and hepatic or renal ministered on a continuous ba-
the Academy of Nutrition and Di- impairment. sis. (See Comparing enteral
etetics and the American Society for feeding tubes.)
Parenteral and Enteral Nutrition
(A.S.P.E.N.), patients with at least Enteral feeding formulas
two of the following criteria are CNE
1.4 contact
Entering feeding formulas fall into
malnourished: hours several general categories, such as
• insufficient energy intake polymeric formulas, feeding mod-
• weight loss L EARNING O BJECTIVES ules, elemental, and specialized or
• muscle mass loss 1. Compare types of enteral feeding disease-specific formulas. Practition-
• subcutaneous fat loss delivery methods. ers choose the formula that bests
• localized or generalized fluid ac- 2. Describe complications of enteral meet the patient’s individual needs.
cumulation that may mask feeding. Nutritional demands vary with age,
weight loss 3. Discuss the nursing care of pa- weight, height, current nutritional
• diminished functional status as tients receiving enteral feeding. status, laboratory values, and activi-
measured by handgrip strength. The authors and planners of this CNE activity have ty level. Also, enteral feeding re-
disclosed no relevant financial relationships with
Malnourished patients with inad- any commercial companies pertaining to this
quirements may vary even within
equate caloric and protein intake activity. See the last page of the article to learn similar groups of patients, such as
how to earn CNE credit.
may suffer emaciation, poor heal- those with renal dysfunction or liv-
ing, and pressure injuries. In severe Expiration: 1/1/20 er failure.
cases, they may develop osteope- To calculate the correct volume to

20 American Nurse Today Volume 12, Number 1 AmericanNurseToday.com

 Indications for enteral feeding that affect the esophageal sphinc-
Indications for enteral feeding include traumatic brain injury, stroke, dementia, ters (such as an indwelling endotra-
and gastric dysfunction with malnutrition. cheal or tracheostomy tube with
• Traumatic brain injury can alter the level of consciousness to the point where dysfunction of the upper esopha-
the patient can’t eat or drink safely. Occasionally, a coma is induced to reduce geal sphincter and a nasogastric or
pressure inside the brain or promote respiratory support. an enteral tube traversing both
• About 55% of patients with stroke experience dysphagia. Enteral feeding is an
esophageal sphincters).
option if a speech therapist can’t find a safe consistency of food that the pa-
Studies show that patients who
tient can tolerate by mouth.
• For patients with dementia, enteral feeding is controversial if the condition received tube feedings of 500 to
stems from a progressive disease. In 2014, the American Geriatrics Society re- 1,500 mL/day didn’t have a higher
leased a position statement against enteral feeding in advanced dementia, aspiration risk than those fed lower
stating that hand feeding produces the same outcomes in terms of aspiration daily volumes; even some who re-
pneumonia, functional status, comfort, and death rates. However, family mem- ceived low volumes aspirated.
bers may opt for enteral feedings out of concern that their loved one may ex- However, relatively fast feeding
perience hunger. rates with volumes exceeding 1,500
• Gastric dysfunction with malnutrition (for instance, from chronic pancreatitis mL/day did place patients at higher
or gastroparesis) may warrant a postpyloric (jejunal [J]) feeding tube. Patients risk for aspiration.
with chronic pancreatitis also may benefit from a J tube due to complications
To help reduce risk, monitor
of prolonged decreased nutrient intake. J tube feedings help prevent ileus in
GRV every 4 hours (or according to
these patients, minimize further organ damage, and reduce pancreatic stimu-
lation. In patients at high risk for aspiration due to gastroparesis, a postpyloric protocol) in patients receiving con-
tube can help prevent tube-feeding intolerance. tinuous tube feedings. A.S.P.E.N.
and the Society of Critical Care
Other indications Medicine guidelines for critically ill
Patients recovering from treatment for cancer of the throat, esophagus, or stom-
patients advise against halting tube
ach also may require nutrition through enteral feeding. Sedated and mechanically
feedings for GRVs below 500 mL
ventilated patients may receive nutrition through an orogastric tube. Other con-
ditions that may require enteral feeding include liver failure, prolonged anorexia, unless the patient has other signs
and critical illness that causes significant nutrient depletion. and symptoms of intolerance.
Sometimes, healthcare providers or-
der withholding of tube feedings at
lower GRVs because of specific risk
deliver, practitioners consider the factors.

Verify feeding tube

total protein, fat, and carbohydrates If you find tube feeding contents
needed to restore the patient’s in the patient’s mouth during oral
health. Some dietitians start with a care, assume the presence of reflux,
basic formula of 25- to 35-cal/kg and
adjust it to the patient’s condition.
intergrity at the which increases aspiration risk. To
help prevent this problem, keep the
Certain medical conditions create a
higher metabolic demand, necessitat- start of each shift. head of the bed elevated 30 de-
grees or higher when possible.
ing increased feeding volume. During patient transport or when
Enteral formulas can be adminis- placing the head of the bed flat for
tered using either an open or a sess the patient before tube feed- patient repositioning, turn the tube
closed (ready-to-use) system and ing begins and monitor closely feeding off, especially if the patient
can be delivered through several during feedings. (For information has a high aspiration risk. However,
methods. (See Understanding en- on insertion-site infection and agi- be aware that no conclusive evi-
teral feeding systems and methods.) tation, see Other enteral-feeding dence shows that pausing tube
complications.) feeding during repositioning re-

Aspiration
Complications of enteral feeding duces aspiration risk for patients
Patients with feeding tubes are with high GRVs.

Tube malpositioning or
at risk for such complications as Gastrostomy (G) tube feedings can

dislodgment
aspiration, tube malpositioning or cause pulmonary aspiration. Multi-
dislodgment, refeeding syndrome, ple factors contribute to aspira-
medication-related complications, tion, including recent hemorrhagic During initial placement, the feed-
fluid imbalance, insertion-site stroke, high gastric residual volume ing tube may be positioned im-
infection, and agitation. To identi- (GRV), high bolus feeding volumes, properly. To prevent this problem,
fy these problems, thoroughly as- supine positioning, and conditions the tube should be placed by expe-

AmericanNurseToday.com Janaury 2017 American Nurse Today 21

rienced personnel and its position Comparing enteral feeding tubes
confirmed radiographically. After This table lists types of enteral feeding tubes along with their features.
initial placement, the tube may be-
come fully or partially dislodged, Tube type Features
causing such problems as bleeding,
tracheal or parenchymal perfora- PREPYLORIC
Nasogastric tube • Can be placed at bedside by qualified nurse
tion, and GI tract perforation.
• With weighted tube (Dobhoff ), fluoroscopic or radiologic
To help prevent malpositioning
confirmation of placement required before stylet removal
and dislodgment, verify feeding tube • For short-term use (4-6 weeks); longer use poses risk of
integrity at the beginning of each nasal mucosal damage or sinusitis
shift. Be aware that verbal patients
with dislodged tubes may complain Gastrostomy tube • Inserted surgically
of new-onset pain at or near the in- • Terminates in stomach
sertion site of a percutaneous endo- • Poses risk of implantation in stomach wall
scopic gastrostomy (PEG) tube, G • Allows administration of crushed medications
tube, gastric-jejunal (GJ) tube, or J
tube. Nonverbal patients may re- Percutaneous • Inserted endoscopically
endoscopic • Minimally invasive
spond with vital-sign changes (such
gastrostomy tube • Allows administration of crushed medications
as increased blood pressure or heart
rate), increased agitation, and rest- POSTPYLORIC
lessness. Nasojejunal tube • Terminates in jejunum

Refeeding syndrome
• Commonly placed in radiology lab under fluoroscopic
guidance; can be placed at bedside with radiographic
Patients with sustained malnutrition confirmation
are at risk for refeeding syndrome— • For short-term use (4-6 weeks); poses risk of nasal mucosal
the body’s reaction to digestion af- damage or sinusitis with longer use
ter depleted electrolytes shift from
the serum to the intracellular space. Gastric-jejunal tube • Terminates in small intestine
• Can be used in patients requiring both stomach drainage
This syndrome may trigger life-
and intestinal feeding at same time
threatening arrhythmias and multi-
• Poses risk of jejunal extension becoming clogged from
systemic dysfunction. It occurs inappropriate medication administration or from attempt
when a depleted metabolic system to rotate tube (as with G tube), causing it to curl back into
with little to no mineral reserve (for stomach or protrude out through skin
instance, from vitamin B deficiency)
becomes exhausted by the body’s Percutaneous • Terminates in small intestine
increased demands to process pro- endoscopic jejunal • Preferred for patients who need single tube for feeding
teins and produce glycogen. An in- tube into small bowel
sulin response to reintroducing nu- • Required for gastrectomy or esophagectomy patients with
trition causes an anaerobic state, as gastric pull-up
the body can’t meet the demand for

Fluid imbalance
oxygen and other resources needed
to metabolize nutrients. Serum elec- To reduce the risk of refeeding syn-
trolytes then move into the intracel- drome in patients with vitamin and Most patients need supplemental
lular space to help satisfy the high- mineral deficiencies, supplements free-water flushes to maintain ade-
er demands, resulting in acute may be ordered for parenteral ad- quate hydration; on average, they
electrolyte abnormalities. ministration before enteral feedings need 30 mL/kg of water per day,
In patients with long-term mal- begin. Refer to specific guidelines given either as free-water flushes
nutrition, monitor for intolerance at based on total energy needs and or I.V. hydration.
the onset of enteral feedings by specific micronutrient deficiencies; If a free-water flush is ordered,
checking heart rate and rhythm and thiamine and other B-vitamin defi- calculate its volume by subtracting
electrolyte levels. Although refeed- ciencies are the most pressing ones the volume of water in the feeding
ing syndrome incidence is low, fail- to address before initiating enteral formula from the patient’s total dai-
ure to recognize the sudden drop feeding. As the tube-feeding goal ly requirement; then divide the re-
in potassium and magnesium levels rate is achieved, taper micronutrient maining volume over a regular rou-
can have catastrophic consequences. supplement dosages as indicated. tine of tube flushing. Before and

22 American Nurse Today Volume 12, Number 1 AmericanNurseToday.com

Understanding enteral feeding systems and methods
An enteral feeding system may be open or closed.
• With an open system, a bolus of formula from a container is • With a closed ready-to-hang system, a container of prefilled
placed in the feeding tube with a syringe formula is spiked by the feeding tube and
or poured into a feeding bag and de- delivered by pump. A closed system offers
livered through the tube. This system better protection against contamination
allows continuous feedings when closed by limiting contact between the enteral
ready-to-hang options aren’t available. nutrition formula and the outside
environment.

Enteral feeding methods • For high-risk patients*, check GRV every 4-6 hours (or accord-
Be sure you understand how to care for patients receiving en- ing to facility policy) while infusion is running.
teral feedings through the various methods. Generally, check • Know that A.S.P.E.N. guidelines don’t require routine GRV
gastric residual volume (GRV) every 4 hours during the first 48 checks for patients without signs or symptoms of intolerance.
hours for gastrically fed patients. Once the feeding goal rate is • Be aware that closed system is preferred to avoid formula con-
achieved, check GRV every 6 to 8 hours, unless the patient is tamination. Change system every 24 hours.
critically ill. In that case, continue to monitor every 4 hours. If • When closed system isn’t available, hang only 8 hours’ worth
of formula at a time.
GRV is 250 ml or greater after a second residual check, notify
the healthcare provider, who may order a promotility agent. Continuous pump feeding
If GRV exceeds 500 mL, withhold the feeding and reassess • Check GRV before starting infusion and every 6-8 hours
the patient’s tolerance by evaluating GI status and glycemic thereafter.
control. If possible, minimize sedation and give a promotility • For high-risk patients, check GRV every 4-6 hours (or accord-
agent, as prescribed. ing to facility policy) for first 48 hours if patient tolerates
Review the nursing considerations below for the three feedings.
main types of enteral feeding methods. • Stop feeding and contact healthcare provider for GRV > 500
mL, unless lower threshold is ordered.
Gravity-feed infusion
• Know that A.S.P.E.N. guidelines don’t require routine residual
• Check GRV before starting every infusion.
checks for patients without signs or symptoms of intolerance.
• Know that this method can be used only with prepyloric
• Be aware that closed system is preferred to avoid formula
tubes.
contamination. Change system every 24 hours.
• Attach syringe without piston to unclamped tube, elevate
• When closed system isn’t available, pour only 8 hours’ worth of
tube above stomach level to create flow of fluid
feeding volume into open system; refill open system every 8
into stomach, and pour in feeding solution until ordered
hours until system is due to be changed (usually every 24 hours).
amount is delivered or as tolerated (whichever comes first).

Intermittent pump feeding *High-risk patients are those with endotracheal tubes or known feeding intoler-
• Check GRV before starting every infusion. ance and those receiving medications that relax the upper esophageal sphincter.
A.S.P.E.N. = American Society for Parenteral and Enteral Nutrition

after medication administration, medications, especially those high stomach acts as a buffer to medica-
flush the tube with about 30 mL of in sorbitol, as the main culprit. So tions and reduces osmolarity of fluid
fluid or more, depending on drug be sure to rule out medications as entering the small intestine.) Consid-
characteristics. Note: Be aware that the cause of diarrhea before look- er a pharmacy consult for patients
some patients are at high risk for ing for other causes, including mal- who experience diarrhea while re-
fluid overload and depend on a absorption and rapid delivery rates. ceiving multiple sorbitol-based
concentrated feeding formula to The sorbitol content of certain drugs. Changing the administration
meet dietary needs. premade liquid drugs (such as time as appropriate or switching to

Medication-related complications
potassium chloride, acetaminophen, a non-sorbitol-based alternative may
and theophylline) can cause a rapid relieve diarrhea without necessitat-
Until recently, clinicians assumed fluid shift into the intestines, leading ing feeding-rate adjustment.
diarrhea in patients receiving enter- to hyperosmolarity and diarrhea. Medications administered through
al feedings stemmed from malab- This effect increases when sorbitol- a feeding tube also may cause clog-
sorption and feeding intolerance. based liquid medications are given ging, especially if they’re crushed.
But more recent research points to through a J tube. (Gastric acid in the Don’t give medications that must be

AmericanNurseToday.com Janaury 2017 American Nurse Today 23

crushed through a J tube, because
Other enteral-feeding complications
the clogging risk is greater than with As described below, take steps to prevent infection at the tube insertion site and
a G tube. Take additional precau- to manage patient agitation.
tions with medications linked to a • Infection at the insertion site of an abdominally placed tube. Secure the
higher clogging risk, including psylli- tube to minimize movement and erosion at the site. Assess the site daily and
um, ciprofloxacin suspension, seve- cover it with a dry gauze dressing. Change the dressing daily or more often as
lamer, and potassium chloride tablets needed for drainage or suspected infection. Monitor for redness and drainage
at the site, and report these findings to the provider promptly.
that can be dissolved in water.
• Agitation. Patients with traumatic brain injury or other cognitive deficits may
Know that tube replacement due become agitated by tube presence. To help prevent them from removing it,
to clogging is costly and subjects apply an abdominal binder, mitten restraints, or limb restraints as necessary.
the patient to anesthesia. To help (Use the least restrictive method before resorting to limb restraints.) If an agi-
prevent clogging, maintain proper tated patient is at risk for pulling out the tube, encourage family members to
tube maintenance and flushing. For stay at the bedside to help distract their loved one. However, know that in
instance, massage potential clots in some cases, their presence may increase agitation, not reduce it. Nonetheless,
the tube, irrigate with warm water, they may be able to tell you what techniques could help calm the patient. As
administer alkalinized enzymes as indicated, take steps to provide a calm environment by dimming lights, play-
ordered, and use a manual declog- ing soft music, and offering comfort, as appropriate.
ger (such as the Bionix DeClogger®
or CorPak Clog Zapper®) if needed.
Be aware that some medications the benefits and risks of continuing
must be given on an empty stom-
ach to ensure effective absorption,
Successful enteral feeding and help clinicians
navigate ethical issues, such as
including phenytoin, carbamaze- management of the whether to continue enteral feed-
pine, alendronate, carbidopa lev- ings and other life-prolonging
odopa, and levothyroxine. You may patient’s nutritional measures. They can also help man-
need to withhold tube feedings for age symptoms and make sugges-
1 to 2 hours before and after ad- needs requires a team tions based on the patient’s or fami-
ministering these medications. For a ly’s goal of care.
patient with a GJ tube, as long as approach.
medications are given through the Future of enteral feedings
gastric port, you needn’t withhold Enteral feedings have the potential
feedings from the jejunal port; fol- Multidisciplinary approach to to advance patient care. For exam-
low pharmacy guidelines. Keep in patient care ple, enteral formulas specific to the
mind that patients receiving multi- Successful management of the pa- patient’s condition and fluid re-
ple drugs may have absorption tient’s nutritional needs requires a quirements are now available. Also,
problems due to extended with- team approach. Each discipline is trials currently are underway in crit-
holding of feedings, causing dehy- responsible for managing and mon- ical care units to study the use of
dration and malnutrition. itoring the patient’s physiologic and feeding tubes with magnetic com-
psychological needs. Caloric re- ponents at the end, which could al-
Nursing care quirements calculated by a dietitian low confirmation of correct tube
When beginning enteral feedings, must be ordered by a healthcare placement with a magnet instead of
monitor the patient for feeding toler- provider and delivered and moni- radiography. As technology pro-
ance. Assess the abdomen by auscul- tored by a nurse. (However, some gresses, enteral feeding efficiency
tating for bowel sounds and palpating states permit dietitians to initiate will progress as well. For the best
for rigidity, distention, and tender- nutritional interventions.) Nursing outcomes, healthcare providers
ness. Know that patients who com- assistants can help with patient po- must work as a team to treat the
plain of fullness or nausea after a sitioning and comfort care as well patient holistically.
feeding starts may have higher a GRV. as behavioral monitoring. Consult
On an ongoing basis, monitor additional specialists, such as a Visit AmericanNurseToday.com/?p=24736 for
a list of selected references.
patients for gastric distention, nau- wound ostomy nurse, about the
sea, bloating, and vomiting. Stop risk of pressure injuries compound- The authors work at Halifax Health in Daytona
the infusion and notify the provider ed by malnutrition or dehydration. Beach, Florida. Amanda Houston is a professional de-
if the patient experiences acute ab- Keep the goal of care in mind. velopment education specialist at Halifax Health in
dominal pain, abdominal rigidity, or For terminally ill patients, palliative Daytona Beach, Florida. Paul Fuldauer is a clinical
vomiting. care specialists can help evaluate nutritional coordinator.

24 American Nurse Today Volume 12, Number 1 AmericanNurseToday.com

 POST-TEST • Enteral feeding: Indications, complications, and nursing care
CNE
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Please mark the correct answer online. d. For patients with endotracheal tubes, 9. A 75-year-old homeless man is brought to
GRV should be checked every 4 to 6 the emergency department with severe
1. Your 72-year-old male patient with a hours when the infusion is running. malnutrition and inability to take food by
tracheoesophageal fistula will require enteral mouth. A G tube is placed. Because he is at
feeding. Which type of tube would be most 6. Which statement about continuous risk for refeeding syndrome, what should you
appropriate for him? enteral feeding via a pump is correct? keep in mind?
a. Gastrostomy a. GRV doesn’t need to be checked in a. Refeeding syndrome refers to the body’s
b. Percutaneous endoscopic gastrostomy patients without signs or symptoms of reaction to digestion after depleted
(PEG) intolerance. electrolytes shift from the intracellular
c. Percutaneous endoscopic jejunal (PEJ) b. GRV should be checked every 4 hours in space to the serum.
d. Nasogastric (NG) patients without signs or symptoms of b. Refeeding syndrome refers to the body’s
intolerance. reaction to digestion after depleted
2. A 54-year-old woman develops c. An open system is preferred for electrolytes shift from the serum to the
postoperative ileus after small-bowel continuous enteral feeding. intracellular space.
resection surgery. An NG tube is placed for d. The feeding system should be changed c. Micronutrient deficiencies should be
enteral feeding. Which complication could every 72 hours. corrected at least 48 hours after enteral
occur if the tube stays in place longer than
feeding begins.
expected? 7. Your 65-year-old patient is receiving
d. Micronutrient deficiencies should be
a. Nasal mucosal damage or sinusitis continuous enteral feeding via a gastros-
corrected within 24 hours after enteral
b. Tube implantation in the stomach wall tomy (G) tube. How can you reduce the pa-
feeding begins.
c. Curling of the tube into the jejunum tient’s risk of aspiration?
d. Tube implantation in the small intestine a. Don’t check GRV as frequently as with 10. Which statement about supplemental
other patients. free water is correct?
3. Which tube is appropriate for a patient b. Don’t turn the feeding off when a. Calculate free flush volume by subtracting
who requires short-term enteral feeding? transporting the patient. the volume of water in the feeding
a. PEG c. Keep the head of the bed elevated 30 formula from the patient’s total daily
b. Nasojejunal degrees or higher when possible. requirement.
c. PEJ d. Keep the head of the bed flat when b. Calculate free flush volume by adding the
d. Gastric-jejunal (GJ) possible. volume of water in the feeding formula to
4. Which statement about gravity-feed the patient’s total daily requirement.
8. Which statement about tube
infusion is correct? c. Patients receiving enteral feeding rarely
malpositioning or dislodgment is not
a. Gastric residual volume (GRV) should be require supplemental free water.
accurate?
checked every 2 hours. d. Patients receiving enteral feeding need an
a. Patients with a dislodged tube may
b. GRV should be checked daily. average of 100 mL/kg of water per day.
complain of new-onset pain at or near
c. This method can be used only with the insertion site of a PEG tube. 11. According to the Academy of Nutrition
prepyloric tubes. b. Patients with a dislodged tube may and Dietetics and the American Society for
d. This method can be used only with complain of new-onset pain at or near Parenteral and Enteral Nutrition (A.S.P.E.N.),
postpyloric tubes. the insertion site of an NG tube. malnutrition criteria include:
c. Placement of the feeding tube should a. increased subcutaneous fat and
5. Which statement about intermittent
be confirmed radiographically before it’s diminished handgrip.
enteral feedings via a pump is correct?
used for feeding. b. reduced fluid accumulation and weight
a. Use of an open system is preferred.
d. Tube dislodgment can cause bleeding, loss.
b. The system should be changed every 72
tracheal or parenchymal perforation, or c. increased handgrip strength and loss of
hours.
GI tract perforation. muscle mass.
c. For patients with endotracheal tubes, GRV
should be checked every 8 to 12 hours d. insufficient energy intake and muscle
when the infusion is running. mass loss.

AmericanNurseToday.com Janaury 2017 American Nurse Today 25