Administering Tube Feeding

Administration of Tube Feedings Through Nasogastric Tube

Enteral Nutrition `
 It is a procedure whereby liquid food (Formula) is instilled directly into the stomach or small intestines using a tube.
 It is also referred to as “Gastric Gavage”.
 Tube feedings preserve gastrointestinal integrity by delivery of nutrients and medications intraluminally.
 It preserves the normal sequence of intestinal and hepatic metabolism.
 Liquid mixtures are available commercially or may be prepared by the dietary department.
 Standard formula – 1 Kcal per mL of solution with protein, fat, carbohydrates, minerals and vitamins in specified proportions.
 It can be given intermittently or continuously.
 Major goals include nutritional balance, normal bowel elimination pattern, reduced risk for aspiration, and adequate hydration.

Clinical Alert
 Enteral feedings should be started post-operatively in surgical clients without the need to wait for flatus or a bowel movement.
 Do not add colored food dye to tube feedings.

Indications
 Clients who have a functional gastrointestinal tract and will not, should not or cannot eat.
 Dysphagia.
 Malnourished patients who cannot tolerate oral feeding.

Purpose
 To restore or maintain nutritional status.
 To administer medications.

Special Nursing Considerations

 Assess for clinical signs of malnutrition or dehydration.
 Assess for allergies and other feeding limitations (Lactose Intolerance).
 Assess for bowel sound – if hypoactive, stop or withhold additional feeding and notify the physician.
 Watch out for signs and symptoms of aspiration – clients receiving enteral nutrition are at greater risk for aspiration due to
some causes.
 Displacement of tube into the esophagus.
 Large amount of gastric residual.
 Lowered intestinal motility.
 Delayed gastric emptying.
 Aspirate gastric content prior to feeding.
 Residual content must be < 100 cc.
 Assess gastric contents.
 Normal – clear and yellow to bile color.
 Check for signs of gastric distress – such as nausea and vomiting, and cramping.
 To determine the client’s tolerance for the tube feeding.

Complications of Causes Selected Nursing

Enteral Therapy Interventions
Gastrointestinal
Diarrhea  Hyperosmolar  Assess fluid
feedings. balance and
Most common.  Rapid infusion electrolyte
or bolus levels; report
feedings. findings.
 Bacteria-  Assess rate of
contaminated infusion and
feedings. temperature of
 Lactose formula.
deficiency.  Implement
 Medications or changes in
antibiotic tube feeding
therapy. formula or rate.
 Decreased  Replace
serum formula every
osmolality 4-hour; change
level. tube feeding
 Food allergies. container and
 Cold formula. tubing daily.
Nausea or Vomiting  Change in rate.  Check
 Hyperosmolar residuals; if >
formula. or = 200 mL
 Inadequate for nasogastric
gastric Tube or > 100
emptying. mL for
gastrotomy –
continue
feeding and
recheck, report
if residual is
still high.
 Review
medications.
Gas, Bloating or  Air in tube.  Keep the
Cramping tubing free of
air by covering,
accordingly.
Dumping Syndrome  Bolus feedings  Check fiber and
or rapid rate. water content,
 Cold formula. report findings.
 Check rate and
temperature of
formula.
Constipation  High milk  Check fiber and
(Lactose) water content,
content. report findings.
 Lack of fiber.
 Inadequate
fluid intake or
dehydration.
Mechanical
Tube Displacement  Excessive  Check tube
coughing or placement
vomitus. before
 Tension on the administering
tube or feeding.
unsecured
tube.
 Tracheal
suctioning.
 Airway
intubation.
Tube Obstruction  Inadequate  Follow policy
flushing or for flushing of
formula rate. tube and for
crushing
medications.
Residue  Inadequate  Flush feeding
crushing of tube before
medications and after
and flushing medication
after administration.
administration.  Obtain liquid
medications
when possible.
Nasopharyngeal  Tube position  Tape tube to
Irritation or improper prevent
taping. pressure on
 Use of large nares.
tubes.  Assess
nasopharyngeal
mucous
membranes
every 4-hour.
Aspiration  Improper tube  Implement
 Pneumonia placement. reliable method
 Vomiting and for checking
aspirated tube small-bore
feeding. enteral tube
 Flat in bed. placement –
 Use of large measuring
tube. length of
exposed tube.
 Keep head of
bed elevated
30,
continuously.
Metabolic
Hyperglycemia  Glucose  Check blood
intolerance. glucose levels,
 High periodically.
carbohydrate
content of the
feeding.
Dehydration and  Hyperosmolar  Report signs
Azotemia feedings with and symptoms
insufficient fluid of dehydration.
Excessive urea in intake.  Implement
the blood. changes in
tube feeding
formula, rate,
or ratio to
water.
Tube Feeding  Excessive urea  Implement
Syndrome from high- changes in
protein mixture tube feeding
and formulas formula, rate,
lacking fat. or ratio to
 Dehydration. water.

Priority Nursing Diagnosis

 Risk for altered nutrition: less than body requirement.
 Risk for fluid volume deficit.
 Risk for aspiration.

Equipment and Supplies

 Aspeto syringe or 20 to 50 mL syringe.
 Emesis basin.
 Clean towel.
 A pH test strip.
 60 mL of water – to follow feeding.
 Disposable gavage bag and tubing.
 Formula or feeding solution.
 Infusion pump for feeding tube.
 Non-sterile gloves.

Tube Feeding Administration

Procedure Rationale
Identify the patient.  To verify correct client.
Explain the procedure to the  Reduces anxiety and
patient and why this increases client
intervention is needed. Raise cooperation.
the bed. Pull the patient’s
bedside curtain. Perform key
abdominal assessments as
described above.
Assemble equipment. Check  Ensures efficiency when
amount, concentration, type, initiating feeding.
and frequency of tube feeding  Ensures safety.
on patient’s chart. Check
expiration date of formula.
Perform hand hygiene. Put on  Reduces cross-
non-sterile gloves. contamination.
Position patient with head of  This position enhances the
bed elevated at least 30 to 45 gravitational flow of the
or as near normal position for solution and prevents
eating as possible. aspiration of fluid into the
lungs.
Unpin tube from patient’s gown.  Ensures patency of the
Check to see that the nasogastric tube.
nasogastric tube is properly
located in the stomach, by first
instilling air, then aspirate for
gastric contents. At times, due
to the tendency of small-bore
tubes to collapse upon
aspiration, several attempts
may be necessary to aspirate
gastric contents. After repeated
instillations of 30 mL of air,
accompanied by repositioning
the patient, if unable to aspirate
gastric contents, the tube
placement should be checked
by radiograph verified by
physician’s order.
After multiple steps have been  This is done to evaluate
taken to ensure that the feeding absorption of the last
tube is located in the stomach feeding – that is whether
or small intestine, aspirate all undigested formula from
gastric contents with a syringe previous feeding remains.
and measure to check for the If the tube is in the small
residual amount of feeding in intestines, residual
the stomach. Flush tube with 30 contents cannot be
mL of water for irrigation. aspirated.
Proceed with feeding if amount
of residual does not exceed
agency policy or physician’s
guideline. Disconnect syringe
from tubing and cap end of
tubing while preparing the
formula feeding equipment.
Remove gloves.
Put on nonsterile gloves before  Reduces transmission of
preparing, assembling and pathogens from gastric
handling any part of the feeding contents.
system.
Administer feeding.  Provides nutrients as
prescribed.
 Clamping the tube prevents
air from entering into the
tubing.
 Gravity facilitates easier
flow of formula into the
tubing.
When using a feeding bag  Hanging the tube at 12”
(Open System). ensures a steady flow of
the formula into the tube.
 Hang bag on intravenous  This minimizes the risk of
pole and adjust to about contaminants entering the
12″ above the stomach. feeding syringe or bag.
Clamp tubing.  Controls the flow rate to
 Check the expiration date ensure absorption.
of the formula.  Allows remaining formula
 Cleanse top of feeding to be instilled into the tube.
container with a  Clamping prevents air from
disinfectant before entering the tube.
 opening it. Pour formula
into feeding bag and
allow solution to run
through tubing. Close
clamp.
 Attach feeding setup to
feeding tube, open
clamp, and regulate drip
according to physician’s
order, or allow feeding to
run in over 30-minute.
 Add 30 to 60 mL or 1 to 2
oz of water for irrigation
to feeding bag when
feeding is almost
completed and allow it to
run through the tube.
 Clamp tubing immediately
after water has been
instilled. Disconnect from
feeding tube. Clamp tube
and cover end with cap.
When using a large syringe  Regulating the flow at
(Open System). desired rate can prevent
 Remove plunger from 30 occurrence of flatus,
or 60 mL syringe. cramps or vomiting.
 Attach syringe to feeding  To allow remaining formula
tube, pour pre-measured to run through the tube.
amount of tube feeding  Holding the syringe higher
into syringe, open clamp, would prevent back flow of
and allow food to enter gastric contents.
tube. Regulate rate, fast  Clamping and covering the
or slow, by height of the tube prevents air from
syringe. Do not push entering into the stomach.
formula with syringe
plunger.
 Add 30 to 60 mL or 1 to 2
oz of water for irrigation
to syringe when feeding
is almost completed, and
allow it to run through
the tube.
 When syringe has
emptied, hold syringe
high and disconnect from
tube. Clamp tube and
cover end with cap.
When using an enteral feeding  Ensures correct and
pump. sustained administration of
formula.
 Close flow-regulator  Gravity facilitates
clamp on tubing and fill continuous flow of formula
feeding bag with into the tube.
prescribed formula.  Feeding pumps ensures a
Amount used depends on sustained flow of formula.
agency policy. Place label  Maintaining an upright
on container with position during feeding
patient’s name, date, and prevents reflux of gastric
time the feeding was contents into the tube.
hung.  Determines rate of
 Hang feeding container absorption and gastric
on IV pole. Allow solution emptying.
to flow through tubing.
 Connect to feeding pump
following manufacturer’s
directions. Set a rate.
 Maintain the patient in
the upright position
throughout the feeding. If
the patient needs to
temporarily lie flat, the
feeding should be
paused. The feeding may
be resumed after the
patient’s position has
been changed back to
30 to 45.
 Check residual every 4 to
8-hour.
Observe the patient’s response  Monitor for any untoward
during and after tube feeding signs and symptoms and
and assess the abdomen at apply appropriate
least once a shift. interventions.
Have patient remain in upright  Prevents back flow of
position for at least 1-hour after gastric contents into the
feeding. esophagus.
Wash and clean equipment or  Maintains infection control.
replace according to agency  Prevents transmission of
policy. Remove gloves and pathogenic
perform hand hygiene. microorganisms.

 Upper GIT study: Barium swallow

- Examines the upper GI tract
- Barium sulfate is usually used as contrast
- Pre-test: NPO post-midnight
- Post-test: Laxative is ordered, increase fluid intake, instruct that stools will turn white,
- monitor for obstruction
• Lower GIT study: Barium enema
- Examines the lower GI tract
- Pre-test: Clear liquid diet and laxatives, NPO post- midnight, cleansing enema
prior to the test
- Post-test: Laxative is ordered, increase patient fluid intake, instruct that stools will turn
white, monitor for obstruction