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Questions and Answers
A client receiving continuous enteral feeding develops a sudden onset of coughing, choking, and wheezing. What is the immediate nursing action?
A client receiving continuous enteral feeding develops a sudden onset of coughing, choking, and wheezing. What is the immediate nursing action?
- Stop the feeding, position the client on their side, and suction the airway. (correct)
- Slow down the rate of the enteral feeding.
- Administer an antiemetic medication as prescribed.
- Increase the head of the bed to a 90-degree angle.
When administering enteral nutrition via a gastrostomy tube, a nurse notes the client’s abdomen is distended and firm. What is the priority nursing intervention?
When administering enteral nutrition via a gastrostomy tube, a nurse notes the client’s abdomen is distended and firm. What is the priority nursing intervention?
- Reposition the client to their left side to promote gastric emptying.
- Measure the abdominal girth and document the findings.
- Continue the feeding at a slower rate to promote tolerance.
- Hold the feeding, assess bowel sounds, and notify the provider. (correct)
A nurse is preparing to administer an enteral feeding to a client with a nasogastric tube. What is the most reliable method to confirm correct placement of the tube before initiating the feeding?
A nurse is preparing to administer an enteral feeding to a client with a nasogastric tube. What is the most reliable method to confirm correct placement of the tube before initiating the feeding?
- Measure the length of the exposed tube and compare with the insertion measurement.
- Check the pH of aspirated gastric contents. (correct)
- Auscultate over the stomach while injecting air into the tube.
- Observe for respiratory distress during a small water flush.
A nurse is teaching a family member how to administer bolus enteral feedings at home. Which instruction is most important to emphasize for preventing aspiration?
A nurse is teaching a family member how to administer bolus enteral feedings at home. Which instruction is most important to emphasize for preventing aspiration?
What is the primary reason for changing enteral feeding tubing and bags every 24 hours?
What is the primary reason for changing enteral feeding tubing and bags every 24 hours?
A client receiving continuous enteral feedings develops diarrhea. Which action should the nurse take first?
A client receiving continuous enteral feedings develops diarrhea. Which action should the nurse take first?
A nurse is preparing to administer medication through a client's nasogastric tube who is also receiving continuous enteral feedings. What is the appropriate nursing action?
A nurse is preparing to administer medication through a client's nasogastric tube who is also receiving continuous enteral feedings. What is the appropriate nursing action?
When administering an enteral feeding, what does the nurse recognize as the primary purpose of flushing the feeding tube with water?
When administering an enteral feeding, what does the nurse recognize as the primary purpose of flushing the feeding tube with water?
What information should the nurse provide when educating a client about potential complications of enteral feedings?
What information should the nurse provide when educating a client about potential complications of enteral feedings?
What action should the nurse perform to ensure the safety of a client receiving continuous enteral feedings via a feeding pump?
What action should the nurse perform to ensure the safety of a client receiving continuous enteral feedings via a feeding pump?
The provider orders an enteral feeding to be administered at 80 mL/hr. The nurse should program the infusion pump to deliver the feeding at which rate?
The provider orders an enteral feeding to be administered at 80 mL/hr. The nurse should program the infusion pump to deliver the feeding at which rate?
A nurse is caring for a client receiving enteral feedings. The client’s albumin level is low. How does hypoalbuminemia affect enteral nutrition?
A nurse is caring for a client receiving enteral feedings. The client’s albumin level is low. How does hypoalbuminemia affect enteral nutrition?
What is a contraindication that would prevent a practical nurse (PN) from administering an enteral feeding?
What is a contraindication that would prevent a practical nurse (PN) from administering an enteral feeding?
A nurse is teaching a client how to check the pH of their gastric aspirate at home. What pH range should the nurse instruct the client to expect if the tube is correctly placed in the stomach?
A nurse is teaching a client how to check the pH of their gastric aspirate at home. What pH range should the nurse instruct the client to expect if the tube is correctly placed in the stomach?
A client is ordered intermittent enteral feedings. Which nursing action is essential immediately before each feeding?
A client is ordered intermittent enteral feedings. Which nursing action is essential immediately before each feeding?
A client receiving enteral feedings develops a fever, and the nurse suspects a healthcare-associated infection. What is the nurse's priority action?
A client receiving enteral feedings develops a fever, and the nurse suspects a healthcare-associated infection. What is the nurse's priority action?
A nurse is preparing to administer an enteral feeding to a client who is confused. Which intervention is most important to ensure client safety during the feeding?
A nurse is preparing to administer an enteral feeding to a client who is confused. Which intervention is most important to ensure client safety during the feeding?
A client experiencing persistent nausea and vomiting related to enteral feedings needs intervention. What is an appropriate nursing action to alleviate this issue?
A client experiencing persistent nausea and vomiting related to enteral feedings needs intervention. What is an appropriate nursing action to alleviate this issue?
A client on enteral feedings develops signs of refeeding syndrome. Which electrolyte imbalance would the nurse most likely assess?
A client on enteral feedings develops signs of refeeding syndrome. Which electrolyte imbalance would the nurse most likely assess?
A client receiving continuous enteral nutrition suddenly develops a distended abdomen and reports abdominal discomfort. What immediate action should the nurse perform?
A client receiving continuous enteral nutrition suddenly develops a distended abdomen and reports abdominal discomfort. What immediate action should the nurse perform?
What nursing action should be taken when administering a bolus feeding via a syringe?
What nursing action should be taken when administering a bolus feeding via a syringe?
A client is scheduled to receive an intermittent enteral feeding. Prior to administering the feeding, the nurse aspirates 150 mL of residual volume. Which action should the nurse take?
A client is scheduled to receive an intermittent enteral feeding. Prior to administering the feeding, the nurse aspirates 150 mL of residual volume. Which action should the nurse take?
A nurse is preparing to administer enteral feeding. The client has a nasogastric tube. What is the most important action to take to verify correct tube placement?
A nurse is preparing to administer enteral feeding. The client has a nasogastric tube. What is the most important action to take to verify correct tube placement?
A nurse is providing education to a client who will be receiving enteral feedings at home. Which statement by the client indicates a need for further teaching?
A nurse is providing education to a client who will be receiving enteral feedings at home. Which statement by the client indicates a need for further teaching?
The nurse is caring for a client with a nasogastric tube receiving continuous enteral feedings. What frequency is recommended for checking the tube placement?
The nurse is caring for a client with a nasogastric tube receiving continuous enteral feedings. What frequency is recommended for checking the tube placement?
A nurse is unable to flush a client's feeding tube. What is the initial nursing action to resolve this issue?
A nurse is unable to flush a client's feeding tube. What is the initial nursing action to resolve this issue?
A nurse is planning to administer an enteral feeding to a pediatric client. What volume is typically used to flush the feeding tubes of pediatric clients?
A nurse is planning to administer an enteral feeding to a pediatric client. What volume is typically used to flush the feeding tubes of pediatric clients?
The nurse is preparing to administer medications through a nasogastric tube (NGT) to a client receiving enteral nutrition. Which of the following actions is MOST appropriate?
The nurse is preparing to administer medications through a nasogastric tube (NGT) to a client receiving enteral nutrition. Which of the following actions is MOST appropriate?
What is the most appropriate intervention for a nurse to implement to prevent a client from aspirating during enteral feeding?
What is the most appropriate intervention for a nurse to implement to prevent a client from aspirating during enteral feeding?
A client receiving enteral nutrition at home reports persistent diarrhea. What is the nurse's BEST initial recommendation?
A client receiving enteral nutrition at home reports persistent diarrhea. What is the nurse's BEST initial recommendation?
A client had a nasogastric tube (NGT) inserted and is ordered to start enteral feedings. Which nursing action is the MOST accurate way to verify tube placement after insertion and before starting the feeding?
A client had a nasogastric tube (NGT) inserted and is ordered to start enteral feedings. Which nursing action is the MOST accurate way to verify tube placement after insertion and before starting the feeding?
What should a nurse do to ensure that the formula is at the appropriate temperature before administering an enteral feeding?
What should a nurse do to ensure that the formula is at the appropriate temperature before administering an enteral feeding?
A client with a gastrostomy tube is receiving continuous enteral feedings. The nurse notices that the skin around the insertion site is red and irritated. Which action should the nurse take FIRST?
A client with a gastrostomy tube is receiving continuous enteral feedings. The nurse notices that the skin around the insertion site is red and irritated. Which action should the nurse take FIRST?
A nurse is teaching a client and their family about home enteral nutrition. What information is MOST important to include to prevent infection?
A nurse is teaching a client and their family about home enteral nutrition. What information is MOST important to include to prevent infection?
Which action is essential for the nurse to take when initiating enteral feeding through a nasogastric tube in a client who is post-stroke and has impaired swallowing?
Which action is essential for the nurse to take when initiating enteral feeding through a nasogastric tube in a client who is post-stroke and has impaired swallowing?
A nurse is administering enteral nutrition to a client with a nasogastric tube. During the feeding, the client reports cramping and nausea. What is the priority nursing intervention?
A nurse is administering enteral nutrition to a client with a nasogastric tube. During the feeding, the client reports cramping and nausea. What is the priority nursing intervention?
A practical nurse (PN) is preparing to administer an enteral feeding. Which of the following actions requires intervention by the registered nurse (RN)?
A practical nurse (PN) is preparing to administer an enteral feeding. Which of the following actions requires intervention by the registered nurse (RN)?
A client receiving continuous enteral feedings via a gastrostomy tube exhibits signs of respiratory distress, including increased coughing and decreased oxygen saturation. After stopping the feeding, what is the next nursing action?
A client receiving continuous enteral feedings via a gastrostomy tube exhibits signs of respiratory distress, including increased coughing and decreased oxygen saturation. After stopping the feeding, what is the next nursing action?
The nurse is preparing to administer a bolus enteral feeding via syringe. What nursing action demonstrates appropriate technique?
The nurse is preparing to administer a bolus enteral feeding via syringe. What nursing action demonstrates appropriate technique?
A client receiving continuous enteral nutrition develops diarrhea. After reviewing potential causes, the nurse suspects the medication administration through the feeding tube is contributing. What is the most appropriate intervention?
A client receiving continuous enteral nutrition develops diarrhea. After reviewing potential causes, the nurse suspects the medication administration through the feeding tube is contributing. What is the most appropriate intervention?
Which nursing action is most important to ensure the patency of a feeding tube for a client receiving intermittent enteral feedings?
Which nursing action is most important to ensure the patency of a feeding tube for a client receiving intermittent enteral feedings?
Flashcards
What is enteral nutrition?
What is enteral nutrition?
Delivery of nutrition via a tube into the GI tract for those unable to meet nutritional needs orally.
Who is responsible for enteral feedings?
Who is responsible for enteral feedings?
Registered Nurse. Responsible for safe and accurate administration of prescribed feedings.
Why is client identification important?
Why is client identification important?
Ensures correct procedure on correct patient.
Why verify allergies before enteral feeding?
Why verify allergies before enteral feeding?
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What are signs of GI dysfunction before feeding?
What are signs of GI dysfunction before feeding?
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Why elevate the head of the bed (30-45 degrees)?
Why elevate the head of the bed (30-45 degrees)?
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How is tube placement verified?
How is tube placement verified?
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Why must the tube be flushed with 30-50 mL of water?
Why must the tube be flushed with 30-50 mL of water?
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Why use room-temperature formula?
Why use room-temperature formula?
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How is enteral bolus feeding administered via syringe?
How is enteral bolus feeding administered via syringe?
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How often should enteral feeding bags/tubing be changed?
How often should enteral feeding bags/tubing be changed?
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What is the patient position after feeding?
What is the patient position after feeding?
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What action should the nurse take if the tube is displaced during enteral feeding?
What action should the nurse take if the tube is displaced during enteral feeding?
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What should a nurse do if a patient reports nausea, vomiting, or abdominal cramping during enteral feeding?
What should a nurse do if a patient reports nausea, vomiting, or abdominal cramping during enteral feeding?
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What is the intervention for aspiration during enteral feeding?
What is the intervention for aspiration during enteral feeding?
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What action should the nurse take if an enteral feeding tube becomes obstructed?
What action should the nurse take if an enteral feeding tube becomes obstructed?
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What action should the nurse take if enteral tubing is connected to a nonenteral system?
What action should the nurse take if enteral tubing is connected to a nonenteral system?
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What documentation is required for enteral feeding?
What documentation is required for enteral feeding?
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Study Notes
Enteral Nutrition Overview
- Enteral nutrition is indicated for clients with a functioning GI tract who cannot meet nutritional needs orally.
- It's delivered through tubes like nasogastric, nasointestinal, gastrostomy (GT), or jejunostomy (J-tube).
- The delivery method includes syringe for bolus feedings or enteral feeding bags for intermittent or continuous infusions.
- Registered Nurses (RNs) are responsible for safe and accurate administration; administering can be delegated to Practical Nurses (PNs), not Assistive Personnel (AP).
Safety Considerations
- Check for client allergies to prevent allergic reactions.
- Verify client identification to ensure the correct procedure for the correct client.
- Use standard precautions to prevent transmission of infectious organisms.
- Label enteral feeding tubing clearly to avoid misconnections.
- Avoid mixing medications directly into the feeding formula to prevent altered medication action or tube occlusion.
Equipment Needed
- Needed supplies include nonsterile gloves, prescribed formula, feeding bag with tubing, stethoscope, alcohol preps, disposable pad, 60-mL syringe, IV pole, feeding infusion pump (if applicable), sterile water, and pH paper.
Step-by-Step Procedure: Assessment/Data Collection
- Review the client’s medical record for allergies, medical history, medications, vital signs, lab values, and provider's orders
- Pertinent lab values include blood glucose, protein, albumin, electrolytes, BUN, creatinine, CBC, and differential.
- Verify the provider’s prescription for enteral formula type, administration route, rate, and amount.
- Identify the client using two identifiers and confirm the allergy status to prevent allergic reactions.
- Assess for GI alterations: nausea, vomiting, abdominal distension, absent bowel sounds, pain, tenderness, or rigidity; delay feeding if present and notify the provider.
Step-by-Step Procedure: Implementation
- Obtain all necessary supplies before starting the procedure
- Provide privacy for the client
- Introduce yourself to the client
- Perform hand hygiene and wear PPE as necessary
- Educate the client about the procedure and address any questions or concerns.
- Double-check the expiration date on the formula
- Elevate the head of the bed to 30° to 45° to decrease aspiration risk.
- Confirm tube placement using two methods: pH of aspirated contents (should be ≤5), checking the marking on the tube at the naris, or capnography.
- If unable to confirm tube placement, withhold feeding and notify the provider.
- Flush the tube with 30 to 50 mL of water to prevent occlusions.
- Disinfect the top of the formula can with an alcohol wipe before opening.
- Ensure the formula is at room temperature to prevent gastric cramping.
Administration Via Syringe
- Remove the plunger from the syringe; feedings should drain by gravity
- Pinch the feeding tube before inserting the syringe to prevent leakage.
- Pour the formula into the syringe, allowing it to drain by gravity until the prescribed amount is administered.
- Flush the tube with water per facility policy to prevent occlusions.
- Clamp the feeding tube, disconnect the syringe, and cover with the end cap to prevent leakage and contamination.
- Remove gloves and perform hand hygiene to prevent infection.
Administration via Feeding Bag
- Label the bag and tubing per facility policy; change tubing every 24 hours to reduce bacterial growth.
- Fill the bag with the prescribed amount of formula and the flush bag, if provided.
- Prime the feeding bag and tubing to prevent air from entering the stomach.
- Connect the feeding bag to the feeding tube port securely.
- Administer the feeding and water flush at the prescribed rate via a feeding pump or by adjusting the regulating clamp.
- Clamp the feeding tube, stop the infusion pump, and cover the end cap to prevent leakage and contamination.
- Remove gloves and perform hand hygiene to prevent infection.
Upon Completion of the Feeding (Syringe or Feeding Bag)
- Position the client on their right side, slightly upright, or in Fowler’s position for 30 minutes to decrease the risk of reflux and aspiration.
- Discuss findings with the client to reduce anxiety
- Ensure client safety by placing the call light and needed items within reach, and lowering the bed.
Client Considerations
- Enteral nutrition can be administered at home with proper training and RN supervision.
- Neonatal and pediatric clients require adjusted nutritional needs; flush feeding tubes with minimal volume to prevent vomiting or feeding intolerance.
Interventions for Unexpected Outcomes
- Withhold feedings if the tube is displaced and notify the provider for possible x-ray confirmation.
- If nausea, vomiting, or cramping occurs, elevate the client, administer medications as prescribed, ensure formula is at room temperature, slow administration, and notify the provider if symptoms persist.
- For aspiration, remove the nasogastric tube, position the client on their side with the head elevated, suction as needed, and notify the provider.
- If the tube is obstructed, flush with warm water using a gentle motion; avoid cranberry juice or carbonated beverages.
- If enteral tubing connects to a nonenteral system, immediately notify the rapid response team and the provider.
Documentation
- Document GI assessment findings, tube placement confirmation, date and time of feeding, formula type, volume, rate, delivery mode, flush type and amount, and the client’s response.
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