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Questions and Answers
Which of the following tasks related to enteral feeding administration is within the scope of practice for a practical nurse (PN) but not for assistive personnel (AP)?
Which of the following tasks related to enteral feeding administration is within the scope of practice for a practical nurse (PN) but not for assistive personnel (AP)?
- Documenting the volume of formula infused.
- Administering the prescribed enteral feeding. (correct)
- Performing routine oral care for the client.
- Reporting changes in the client's vital signs.
A nurse is preparing to administer an enteral feeding. What is the most important safety check the nurse should perform to prevent a potentially life-threatening error?
A nurse is preparing to administer an enteral feeding. What is the most important safety check the nurse should perform to prevent a potentially life-threatening error?
- Checking the pH of aspirated gastric contents.
- Verifying that enteral tubing is not connected to a nonenteral system. (correct)
- Ensuring the client's identification using two identifiers.
- Confirming the expiration date on the enteral formula.
A client receiving continuous enteral feedings develops a persistent cough, becomes dyspneic, and has decreased oxygen saturation. What immediate action should the nurse take?
A client receiving continuous enteral feedings develops a persistent cough, becomes dyspneic, and has decreased oxygen saturation. What immediate action should the nurse take?
- Position the client on their side with the head of the bed elevated and suction as needed. (correct)
- Flush the feeding tube with 50 mL of sterile water to clear any potential obstruction.
- Administer an antiemetic medication to prevent further vomiting.
- Increase the rate of the enteral feeding to compensate for the potential nutritional deficit.
A nurse is preparing to administer an enteral feeding via a nasogastric tube. After confirming the order and gathering supplies, what is the next essential step in ensuring the client's safety?
A nurse is preparing to administer an enteral feeding via a nasogastric tube. After confirming the order and gathering supplies, what is the next essential step in ensuring the client's safety?
A nurse is administering an enteral feeding via gravity using a syringe. Which action ensures appropriate technique and client safety during the feeding?
A nurse is administering an enteral feeding via gravity using a syringe. Which action ensures appropriate technique and client safety during the feeding?
A nurse is caring for a client receiving continuous enteral nutrition. What assessment finding requires the nurse to withhold the feeding and notify the provider?
A nurse is caring for a client receiving continuous enteral nutrition. What assessment finding requires the nurse to withhold the feeding and notify the provider?
A nurse is preparing to administer medication to a client who is receiving continuous enteral feedings. What is the most appropriate method for medication administration?
A nurse is preparing to administer medication to a client who is receiving continuous enteral feedings. What is the most appropriate method for medication administration?
A nurse is teaching a family member how to administer enteral feedings at home. Which instruction is most important to include in the teaching session?
A nurse is teaching a family member how to administer enteral feedings at home. Which instruction is most important to include in the teaching session?
While administering an enteral feeding, the nurse notes that the client's abdomen is distended and firm. What is the nurse's priority action?
While administering an enteral feeding, the nurse notes that the client's abdomen is distended and firm. What is the nurse's priority action?
A client receiving enteral feedings develops a clogged feeding tube. What is the most appropriate initial nursing intervention to attempt to resolve the obstruction?
A client receiving enteral feedings develops a clogged feeding tube. What is the most appropriate initial nursing intervention to attempt to resolve the obstruction?
A nurse is preparing to administer an enteral feeding to a client with a nasogastric tube. Which action is essential to perform immediately before initiating the feeding?
A nurse is preparing to administer an enteral feeding to a client with a nasogastric tube. Which action is essential to perform immediately before initiating the feeding?
During the administration of an enteral feeding, a client begins to experience nausea and reports feeling full. What is the nurse's best initial response?
During the administration of an enteral feeding, a client begins to experience nausea and reports feeling full. What is the nurse's best initial response?
A nurse is preparing to administer enteral nutrition to a pediatric client. What consideration is most important when flushing the feeding tube for this client?
A nurse is preparing to administer enteral nutrition to a pediatric client. What consideration is most important when flushing the feeding tube for this client?
A nurse is reviewing a provider's order for enteral nutrition. What information is critical to verify in the prescription to ensure safe administration?
A nurse is reviewing a provider's order for enteral nutrition. What information is critical to verify in the prescription to ensure safe administration?
Which of the following actions is most important for the nurse to take to prevent contamination during enteral feeding administration?
Which of the following actions is most important for the nurse to take to prevent contamination during enteral feeding administration?
A nurse is caring for a client receiving continuous enteral feedings. Which assessment finding indicates a potential complication that requires further investigation?
A nurse is caring for a client receiving continuous enteral feedings. Which assessment finding indicates a potential complication that requires further investigation?
A nurse is about to administer an enteral feeding to a client. After confirming tube placement, what is the next appropriate step?
A nurse is about to administer an enteral feeding to a client. After confirming tube placement, what is the next appropriate step?
What is the purpose of elevating the head of the bed to 30 to 45 degrees during enteral feeding administration?
What is the purpose of elevating the head of the bed to 30 to 45 degrees during enteral feeding administration?
A nurse is preparing to administer an enteral feeding using a feeding bag. What is the purpose of priming the feeding bag and tubing?
A nurse is preparing to administer an enteral feeding using a feeding bag. What is the purpose of priming the feeding bag and tubing?
The nurse is reviewing documentation guidelines for enteral feedings. Which element is most important to include in the client's medical record?
The nurse is reviewing documentation guidelines for enteral feedings. Which element is most important to include in the client's medical record?
A nurse is caring for a client receiving enteral feedings who reports persistent diarrhea. What is the most appropriate initial intervention?
A nurse is caring for a client receiving enteral feedings who reports persistent diarrhea. What is the most appropriate initial intervention?
What information should a nurse provide during client education regarding enteral feedings?
What information should a nurse provide during client education regarding enteral feedings?
A home health nurse is teaching a client and family how to administer enteral feedings. What statement by the family indicates a need for further teaching?
A home health nurse is teaching a client and family how to administer enteral feedings. What statement by the family indicates a need for further teaching?
A client receiving continuous enteral feedings has a gastric residual volume exceeding the facility's established parameters. What is the nurse's most appropriate action?
A client receiving continuous enteral feedings has a gastric residual volume exceeding the facility's established parameters. What is the nurse's most appropriate action?
A nurse is using pH testing to verify the correct placement of a nasogastric tube prior to initiating an enteral feeding. What pH reading indicates proper placement in the stomach?
A nurse is using pH testing to verify the correct placement of a nasogastric tube prior to initiating an enteral feeding. What pH reading indicates proper placement in the stomach?
A nurse is caring for a client receiving enteral feedings who is also prescribed phenytoin. What is an important consideration when administering this medication?
A nurse is caring for a client receiving enteral feedings who is also prescribed phenytoin. What is an important consideration when administering this medication?
A nurse is preparing to administer a bolus enteral feeding to a client. Which action is most appropriate to ensure client safety?
A nurse is preparing to administer a bolus enteral feeding to a client. Which action is most appropriate to ensure client safety?
A client receiving continuous enteral feeding suddenly develops shortness of breath and a new onset of wheezing. What is the nurse's priority action?
A client receiving continuous enteral feeding suddenly develops shortness of breath and a new onset of wheezing. What is the nurse's priority action?
A nurse is preparing an enteral feeding using a closed system container. What is the maximum hang time recommended for a closed system to minimize bacterial contamination?
A nurse is preparing an enteral feeding using a closed system container. What is the maximum hang time recommended for a closed system to minimize bacterial contamination?
A nurse is caring for a client with a gastrostomy tube (G-tube) who is receiving bolus feedings. Prior to each feeding, the nurse checks the gastric residual volume (GRV). Which GRV volume would warrant holding the feeding and notifying the physician?
A nurse is caring for a client with a gastrostomy tube (G-tube) who is receiving bolus feedings. Prior to each feeding, the nurse checks the gastric residual volume (GRV). Which GRV volume would warrant holding the feeding and notifying the physician?
A nurse is caring for a client receiving enteral feedings who is on a fluid restriction. What is the most accurate method to determine the client's fluid balance?
A nurse is caring for a client receiving enteral feedings who is on a fluid restriction. What is the most accurate method to determine the client's fluid balance?
A nurse is teaching a client about managing their enteral feeding tube at home. What should the nurse emphasize regarding the storage of enteral formula?
A nurse is teaching a client about managing their enteral feeding tube at home. What should the nurse emphasize regarding the storage of enteral formula?
A nurse is caring for a client receiving enteral feedings via a nasogastric tube. What is the most reliable method to confirm correct tube placement immediately before each intermittent feeding?
A nurse is caring for a client receiving enteral feedings via a nasogastric tube. What is the most reliable method to confirm correct tube placement immediately before each intermittent feeding?
A nurse is assessing a client receiving enteral feedings. Which assessment finding is most indicative of fluid overload?
A nurse is assessing a client receiving enteral feedings. Which assessment finding is most indicative of fluid overload?
A nurse is caring for a client receiving enteral feedings who develops hyperglycemia. What is the most appropriate initial intervention?
A nurse is caring for a client receiving enteral feedings who develops hyperglycemia. What is the most appropriate initial intervention?
When initiating enteral feeding, what is the rationale behind verifying the provider's prescription and checking the expiration date on the formula?
When initiating enteral feeding, what is the rationale behind verifying the provider's prescription and checking the expiration date on the formula?
A client receiving continuous enteral feeding exhibits new onset restlessness, coughing, and decreased oxygen saturation. Which of the following actions would be the MOST appropriate initial nursing intervention?
A client receiving continuous enteral feeding exhibits new onset restlessness, coughing, and decreased oxygen saturation. Which of the following actions would be the MOST appropriate initial nursing intervention?
A nurse is preparing to administer an enteral feeding to a client. The client's medical record indicates a latex allergy. What modification to the standard procedure is most important?
A nurse is preparing to administer an enteral feeding to a client. The client's medical record indicates a latex allergy. What modification to the standard procedure is most important?
The PN is administering enteral nutrition via a feeding bag. What frequency of tubing changes is MOST appropriate to minimize the risk of bacterial contamination?
The PN is administering enteral nutrition via a feeding bag. What frequency of tubing changes is MOST appropriate to minimize the risk of bacterial contamination?
A client receiving enteral feedings develops diarrhea. Which nursing intervention is MOST appropriate to implement FIRST?
A client receiving enteral feedings develops diarrhea. Which nursing intervention is MOST appropriate to implement FIRST?
Flashcards
Enteral Nutrition
Enteral Nutrition
Delivering nutrition through a tube inserted into the GI tract for clients unable to meet nutritional needs orally.
Nasogastric/Nasointestinal Tubes
Nasogastric/Nasointestinal Tubes
Tubes inserted through the nose into the stomach or intestines for enteral nutrition.
Gastrostomy/Jejunostomy Tubes
Gastrostomy/Jejunostomy Tubes
Surgically placed tubes for enteral nutrition.
Bolus Feedings
Bolus Feedings
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Enteral Feeding Bags
Enteral Feeding Bags
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Infusion Methods
Infusion Methods
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RN Responsibility
RN Responsibility
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PN Delegation
PN Delegation
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Nursing Process
Nursing Process
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Allergy Check
Allergy Check
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Client Identification
Client Identification
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Standard Precautions
Standard Precautions
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Tube Labeling
Tube Labeling
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No Mixing Meds
No Mixing Meds
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PPE Use
PPE Use
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Reviewing Medical Record
Reviewing Medical Record
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Verifying Prescription
Verifying Prescription
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Obtaining Supplies
Obtaining Supplies
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Providing Privacy
Providing Privacy
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Introducing Yourself
Introducing Yourself
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Hand Hygiene
Hand Hygiene
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Client Education
Client Education
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GI Dysfunction Signs
GI Dysfunction Signs
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Checking Expiration Date
Checking Expiration Date
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Elevating Head of Bed
Elevating Head of Bed
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Confirming Tube Placement
Confirming Tube Placement
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Flushing the Tube
Flushing the Tube
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Room Temperature Formula
Room Temperature Formula
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Gravity Feeding
Gravity Feeding
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Pinching Feeding Tube
Pinching Feeding Tube
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Labeling and Changing Tubing
Labeling and Changing Tubing
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Priming Feeding Bag
Priming Feeding Bag
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Connecting Feeding Bag
Connecting Feeding Bag
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Administering via Pump
Administering via Pump
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Client Positioning
Client Positioning
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Ensuring Client Safety
Ensuring Client Safety
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Home Enteral Nutrition
Home Enteral Nutrition
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Displaced Tube
Displaced Tube
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Nausea or Vomiting
Nausea or Vomiting
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Client Experiences Aspiration
Client Experiences Aspiration
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Obstructed Tube
Obstructed Tube
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Enteral Tubing Connected to Nonenteral System
Enteral Tubing Connected to Nonenteral System
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Accurate Documentation
Accurate Documentation
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Study Notes
Enteral Nutrition
- For clients with a functioning GI tract who cannot meet nutritional needs orally, enteral nutrition is an option.
- It involves delivering nutrients through a tube inserted into the GI tract.
- Tube options include nasogastric, nasointestinal, gastrostomy (GT), or jejunostomy (J) tubes, determined by the client's needs and duration of therapy.
- Enteral feeding can be administered via syringe for bolus feedings or enteral feeding bags for intermittent or continuous infusions, using gravity or a feeding pump.
- RNs are responsible for safe and accurate administration of prescribed feedings.
- A PN can administer enteral feedings after assessment by the RN.
- Administering enteral feeding is outside the scope of practice for assistive personnel (AP).
Safety Considerations
- Check for allergies, including food allergies, to prevent allergic reactions.
- Verify client identification to ensure the correct procedure and client.
- Use standard and infection control precautions to prevent transmission of infectious organisms.
- Clearly label tubing from the enteral feeding pump to avoid misconnections with other systems.
- Never mix medications directly into the feeding formula to prevent altered medication action or tube occlusion.
Equipment Required
- Nonsterile gloves and PPE (if indicated)
- Prescribed formula
- Feeding bag with tubing
- Stethoscope
- Alcohol preps
- Disposable pad
- 60-mL syringe
- IV pole
- Feeding infusion pump (if applicable)
- Sterile water
- pH paper
Step-by-Step Procedure
- Step 1: Review the client’s medical record to identify allergies, medical history, medications, vital signs, lab values (blood glucose, protein, albumin, electrolytes, BUN, creatinine, CBC), and the provider’s prescription.
- Step 2: Gather and prepare all necessary supplies.
- Step 3: Provide privacy for the client.
- Step 4: Introduce yourself to the client to promote a therapeutic relationship.
- Step 5: Perform hand hygiene and apply appropriate PPE.
- Step 6: Identify the client using two unique identifiers.
- Step 7: Confirm the client’s allergy status. Review allergies again to promote safety.
- Step 8: Educate the client about the procedure, addressing any questions or concerns.
- Step 9: Assess for gastrointestinal dysfunction, such as nausea, vomiting, distension, absent bowel sounds, pain, or rigidity; delay feeding and notify the provider if present.
- Step 10: Verify the provider’s prescription and check the formula expiration date to prevent adverse reactions.
- Step 11: Elevate the head of the bed to 30° to 45° to reduce aspiration risk.
- Step 12: Confirm tube placement using two methods:
- Visually inspect and measure pH (should be 5 or less).
- Check the marking on the tube at the naris against documentation.
- Capnography to rule out airway placement.
- Check tube placement every 4 hours.
- If you can't confirm, withhold feeding and notify the provider.
- Step 13: Flush the tube with 30 to 50 mL of water to prevent occlusions or to determine if an occlusion is present.
- Step 14: Disinfect the top of the formula can with an alcohol wipe to reduce contamination risk.
- Step 15: Ensure the formula is at room temperature to prevent gastric cramping.
Administration Via Syringe
- Step 16: Remove the plunger from the syringe; use gravity for feeding.
- Step 17: Pinch the feeding tube before inserting the syringe to prevent leakage.
- Step 18: Pour formula into the syringe, allowing it to drain by gravity until the prescribed amount is administered for patient tolerance.
- Step 19: Flush the tube with water, per facility policy, to prevent occlusions.
- Step 20: Clamp the feeding tube, disconnect the syringe, and cover with an end cap to maintain sterility.
- Step 21: Remove gloves and perform hand hygiene for infection control.
Administering via Feeding Bag
- Step 23: Label the bag and tubing per facility policy and change tubing every 24 hours to minimize bacterial growth and reduce infection risk.
- Step 24: Fill the bag with the prescribed amount of formula. Fill the flush bag, if provided, to prevent formula waste and contamination.
- Step 25: Prime the feeding bag and tubing to prevent air from entering the stomach.
- Step 26: Connect the feeding bag to the feeding tube port for secure administration.
- Step 27: Administer the feeding and water flush at the prescribed rate using a feeding pump or regulating clamp.
- Step 28: Clamp the feeding tube, stop the infusion, and cover the end cap.
- Step 29: Remove gloves and perform hand hygiene.
Upon Completion of the Feeding
- Step 30: Keep the client on their right side, slightly upright, or in Fowler’s position for 30 minutes to prevent reflux, vomiting, and aspiration.
- Step 31: Discuss findings with the client to reduce anxiety and promote involvement.
- Step 32: Ensure client safety by placing the call light and needed items within reach, and lowering the bed, per individual needs.
Client Considerations
- Enteral nutrition can be administered at home with RN supervision.
- For neonatal and pediatric clients, adjust nutritional needs by weight and age and use minimal flush volumes (2-5 mL for pediatric, 1 mL or less for neonates) to prevent vomiting or intolerance.
Interventions for Unexpected Outcomes
- Withhold feedings and notify the provider if the tube is displaced due to aspiration risk.
- For nausea, vomiting, or cramping, maintain semi-Fowler’s, high-Fowler’s, or reverse Trendelenburg position; administer prescribed medications; ensure formula is at room temperature; slow bolus administration; and notify the provider if symptoms persist due to GI dysfunction or tube displacement.
- If aspiration occurs, remove the tube, position the client on their side with the head elevated, suction as needed, and notify the provider; signs include decreased oxygen saturation, wheezing, coughing, choking, restlessness, and cyanosis.
- For tube obstruction, flush with warm water using a gentle motion; if unsuccessful, consult facility policy about using an unclogging product; do not use cranberry juice or carbonated beverages.
- If enteral tubing is connected to a nonenteral system, notify the rapid response team and the provider immediately is considered a life-threatening emergency.
Documentation
- Accurately record GI assessment findings, tube placement confirmation, date and time of feeding, type of formula, volume, rate, mode of delivery, flush type and amount, and the client’s response in the medical record.
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