What are the main nursing considerations for patients under enteral feeding?
Objective: To describe the management practices of nurses when providing care to patients receiving enteral tube feedings. Show
Design: A descriptive study was conducted with use of questionnaires distributed to registered nurses (RNs). Setting: A midwestern university medical center. Sample: A total of 235 questionnaires were distributed to RNs. Two hundred nineteen were considered eligible and 180 were usable. This represents an 82% response. Method: A 43-item questionnaire with a return envelope was placed in the mailbox of RNs. Data analysis: Descriptive statistics were used to analyze data. Results: (1) Checking the flow rate of enteral feeding: Flow rates were checked between 1 to 4 hours by 70% of the nurses, whereas 16% checked every 8 hours, and the remaining 14% checked every 12 hours or longer. (2) Flushing the enteral tube: Ninety-four percent of respondents indicated they regularly flushed the enteral tube before each feeding (29%), after each feeding (43%), and every 4 hours (59%). The types of irrigants that were used for flushing included tap water, sterile water, and sterile normal saline solution. (3) Method of unclogging obstructed tubes: An irrigant solution is the primary intervention reported by nurses to unclog tubes (94%). The types of solutions reportedly used most frequently were carbonated beverage (81%), sterile water (49%), dissolved papain (46%), and tap water (42%). (4) Checking residuals: Most RNs (95%) reported that they check residuals every 4 hours; of these, 50% stated they discard residuals, and 49% stated that they readminister residuals. In regard to the volume of residual deemed to be excessive, 50% of the respondents stated that an amount greater than or equal to 100 ml is excessive. (5) Administering medications: Flushing the enteral tube with water is reported to be done before (47%) and after (95%) giving medicines. When multiple medicines are given, 38% report flushing the enteral tube between each medication. Conclusion: The findings of this self-report study suggest that practices regarding management of enteral feedings vary widely among nurses. Enteral feeding is a method of supplying nutrients directly into the gastrointestinal tract. This guideline will use this term describe Orogastric, Nasogastric and Gastrostomy tube feeding. A wide range of children may require enteral feeding either for a short or long period of time for a variety of reasons including:
Enteral feeding tubes can be used to:
It is imperative that nursing staff caring for children who have enteral tubes in understand why it is in-situ. This guideline aims to support nurses in administering feeds and medications via a nasogastric, orogastric or gastrostomy tube in a safe and appropriate manner.
Link for insertion of Nasogastric and Orogastric Tube Insertion policy, Nutrition on PICU Guidelines and Jejunal Feeding Guideline. Nasogastric Tube/Orogastric Tube- Checking the PositionPrior to accessing a NGT/OGT for any reason nursing staff members must ensure that the tube is located in the stomach. Coughing, vomiting and movement can move the tube out of the correct position.The position of the tube must be checked:
Nursing staff should perform the following observations and obtain a gastric aspirate to establish tube position.
Please note: patients who have a history of Liver Failure and known/or suspected oesophageal varices should not have a gastric aspirate removed from the NGT. Instead tube position should be initially confirmed via x-ray with clear documentation of NGT position marker. The medical team should document rationale for not obtaining gastric aspirate in the patient’s progress note as well as an alternative plan to confirm NGT placement. Obtain gastric aspirateTo check the position of the tube nursing staff members need to have prepared the following equipment: Procedure:
Gastrostomy tubeCorrect placement of the tube should be confirmed prior to administration of an enteral feed by checking insertion site at the abdominal wall and observing the child for abdominal pain or discomfort. If the nurse is unsure regarding the position of the gastrostomy or jejunostomy tube contact the medical team immediately. Ongoing AssessmentDuring Continuous feeds – Nasogastric/Orogastric Tube: 1. The position of the tube needs to be checked 4 hourly with change of feeds
2. The following needs to be checked 2 hourly during the feed:
Other assessment considerations for the child receiving enteral feeds
Flushing enteral tubesThe purpose of flushing is to check for tube patency and prevent clogging of enteral tubes. Flushing is not routine on the Neonatal unit and flushing with air is the preferred method. Enteral feeding tubes should be flushed regularly with water (or sterile water if appropriate):
Nurses should prepare an enteral/oral syringe, enteral tube connector and water for a flush.
Flushing
Venting
Link to High Flow Nasal Prong (HFNP) therapy clinical guideline. FeedsFeeds can be administered via syringe, gravity feeding set or feeding pump. The method selected is dependent of the nature of the feed and clinical status of the child. There is limited evidence available to support one method of feeding over the other.
Administration of FeedsWhen preparing to administer feeds nursing staff must confirm the position of the enteral tube. Prior to and after feeds nurses should adequately flush the enteral tube. Position:
Using a syringe for a bolus feed
Using gravity feeding for bolus, intermittent feeds and continuous feeds.
Using an enteral feeding pump for bolus or intermittent enteral feedingAn enteral feeding pump can be used intermittent, bolus or continuous administration of feeds, but is best suited for continuous feeding when tolerance to rate of feeding is an issue. Enteral feeding pumps can be obtained via CARPS if the ward area does not have its own supply. Infinity pumps are now in use throughout RCH and the giving set can be primed by pushing the fill set button. For further information regarding the use of the infinity pump please see the manufactures instructions. Please note: in most situations an IV syringe pump is not recommended for administration of enteral feeds and should not be used on the ward. If very small rates are required, consider using frequent syringe bolus feeding techniques as an alternative. Temperature of the feedBolus feeds For older children feeds given as a bolus should be removed from the fridge 15-20 minutes before administration to bring them to room temperature. Feeds given as a bolus may be warmed in an approved bottle warmer. This would be appropriate for all infants and older children who experience discomfort with cooler feeds. Continuous feeds Continuous feeds should NOT be warmed. They may be removed from the fridge 15-20 minutes prior to administration to bring it to room temperature and should not hung for longer than 4 hours – use the dose limit function on the feed pump to ensure this occurs. Please Note: Feeds should NOT be warmed in a microwave or in jugs of boiling water. Completion of feedThe tube must be flushed with water (air in neonates) to prevent tube from blocking (see above). Giving sets:
Titrating feeds Nursing staff may need to titrate the rate/volume of an enteral feed up or down depending on the clinical status, nutritional needs, size and ability to tolerate feeds of the child. Types of feeds The decision for which type of enteral feed a child should receive should be made in consultation with the dietician, medical team, nursing staff and family, taking into account the nutritional needs, clinical status and tolerance of feeds of the child.
Nurses who are preparing and administrating medication via an enteral tube must adhere to the Medication Management Procedure.
Choice of drug preparation Consult your ward pharmacist or call Medicines Information (ext: 55208) for advice on how to prepare a drug for enteral administration.
Unblocking tubes Blocking of tubes can occur due to:
Flushing is the single most effective action that prolongs the life of nasogastric tubes. It is recommended that flushing occur BEFORE, DURING and AFTER administration of enteral medications and feeds. To unblock enteral tubes, flush the tube in a pulsating manner (push/pull) with 10-20ml with warm water, if it is safe to do so taking into account the child’s age, size and clinical status. It may be appropriate to allow the warm water to soak, by clamping/capping the tube, in the tube to assist with unblocking. Please note there is no evidence to support the practice of using carbonated drinks such as Coca Cola™ to unblock enteral tubes.
Nurses should consider titrating feeds down or ceasing feeds for a short period of time depending on the clinical status and nutritional needs of the child.
Evidence Table - Enteral Feeding and Medication Administration Please remember to read the disclaimer. The development of this nursing guideline was coordinated by Stacey Richards, Nurse Consultant, Nursing Research, and approved by the Nursing Clinical Effectiveness Committee. Published December 2017. What are three nursing considerations for client safety when receiving a tube feeding?Nursing Considerations. Provide oral and skin care. Give mouth rinses and apply lubricant to the patient's lips and nostril. ... . Verify NG tube placement. Always verify if the NG tube placed is in the stomach by aspirating a small amount of stomach contents. ... . Wear gloves. ... . Face and eye protection.. What must be monitored in patients on enteral feeding?Monitoring should be done by suitably trained health care professionals, however patients on long term enteral feeding and their carers should be educated to monitor parameters such as bowels, weight and nutritional intake; identify potential problems; and report concerns to the relevant health care professional as ...
What special considerations should be taken when administering medications through an enteral feeding tube?How to Safely Administer Medication Through a Feeding Tube. Administer each medication separately.. Stop the feeding and flush the tube with water before and after medication administration.. Crush only those medications which are immediate-release. ... . Use liquid medications when available.. What are assessments that need to be done on a client receiving enteral feedings?Objective assessments for patients with enteral tubes include assessing skin integrity, tube placement, gastrointestinal function, and for signs of complications: Assess the tube insertion site daily for signs of pressure injury and skin breakdown.
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