Enteral Nutrition and Tube Irrigation

Enteral Nutrition

• Elevate HOB 30° to prevent aspiration
• Solution should be discarded after 24-48 hours
• Mouth care should be performed q2h
• Assess for side effects and skin integrity
• Administer H2O pre and post feeding, and with meds

Tube Irrigation

• Routine irrigation of the tube with H2O prevents occlusion
• Equipment needed: 60 ml syringe, water, towel, clean gloves, and stethoscope
• Irrigate routinely before, between, and after medication administration, and before intermittent feeding
• Change irrigation container every 24 hours or according to facility policy

Caring for the Site

• Dressings are changed daily and as needed
• Determine whether the exit site should be left open to air or if a dressing is indicated
• Assess exit site for tenderness, leakage, swelling, excoriation, infection, bleeding, or excessive movement of the feeding tube
• Clean skin around the exit site with warm water and mild soap or saline
• Rinse and dry site completely, and apply a dressing if prescribed

Ongoing Assessment and Monitoring

• Monitor for signs and symptoms of possible complications: SOB, vomiting, pain, redness and infection at site, abdominal distension, and loose stools
• Maintain good oral hygiene
• Verify feeding tube placement regularly, as the tip of the feeding tube can migrate into a different location

Verifying Feeding Tube Placement

• Use a combination of methods to monitor tube position during feeding, as no single bedside method is completely reliable
• Monitor the external length of the tube and observe the appearance, volume, and pH of fluid aspirated through it
• Test the pH of an aspirate at the bedside using pH paper to obtain information regarding the position of the feeding tube
• Obtain repeat x-ray film confirmation if bedside methods create any doubt regarding the location of the tube

Delegation and Collaboration

• Verification of tube placement cannot be delegated to PSW
• The nurse directs NAP to inform the nurse if patient respirations change, patient vomits, nasal skin irritation is present, or external length of tube changes

Administering Enteral Nutrition

• The most common type of enteral nutrition is gastric feedings
• Small bowel feeding may reduce the risk of aspiration
• An enteral pump is used to control the administration rate of small bowel and many continuous gastric feedings

Tube Feeding and Quality of Life

• Many patients associate tube feeding with low quality of life
• A multidisciplinary team can help patients and family caregivers use strategies to preserve or enhance quality of life

Maintenance of a Nasogastric Tube

• Provide oral and nasal hygiene
• Check location of external exit site and mark on tube
• Anchor tube to patient's gown to prevent displacement during routine care
• Report any signs of redness or irritation to the nares and provide comfort measures

Gastrostomy Tube (G Tube)

• Direct enteral access through the abdominal wall is optimal for tube feeding when duration is greater than 4 weeks or in situations where access via the nose or mouth is contraindicated
• Gastrostomy tube or Peg tube is commonly used for long-term tube feeding

Care of Gastrostomy or Jejunostomy

• Long-term tubes require endoscopic, radiologic, or surgical placement
• Post-insertion care may require specific nursing interventions
• Feedings delivered via a gastrostomy tube are relatively safe to administer, provided the patient has normal gastric emptying

Jejunostomy Tubes

• Indicated when risks for regurgitation and aspiration are especially high, such as in severely delayed gastric emptying or conditions like pancreatitis
• Placed directly into the small intestine

Verifying Feeding Tube Placement

• Monitor the external length of the tube
• Selection of tube type and placement method depends on anticipated duration of feeding and patient-related factors, such as gastric emptying and risk for pulmonary aspiration

Different Types of Tubes

• Nasogastric Tube: thin, soft tube made of plastic or rubber that is passed through the nose, down through the throat, and into the stomach
• Nasojejunal Tube: small tube passed through the nose and into the small bowel
• Jejunostomy Tube: soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine
• Gastrostomy Tube (G Tube): placed directly into the stomach or intestine
• Plastic Nasogastric Tubes: used for tube feeding and administering medications
• Small-bore Silicone Feeding Tubes: used only for tube feeding
• G Tube or Percutaneous Endoscopic Gastrostomy (PEG) Tube: used for tube feeding and administering medications

Indications for an NG Tube

• Aspiration of gastric contents
• Decompression
• Specimen analysis
• Gastric lavage in cases of poisoning or overdose of medication
• Nutritional support (usually less than six weeks in duration)
• Administration of medication

Patient-Centered Care

• Nursing responsibilities include caring for the tube, administering nutrient formula, and preventing complications
• Pulmonary aspiration is the most serious complication of tube feeding
• Patients requiring long-term tube feeding may feel a sense of loss regarding their ability to participate in life activities
• Emotional and psychological concerns are raised during tube feeding, and patients and family caregivers need reassurance and encouragement
• Nursing interventions such as providing oral hygiene and care of the nasal passage or tube insertion site promote patient comfort and reduce complications

Tube Feeding and Quality of Life

• Many patients associate tube feeding with low quality of life
• A multidisciplinary team can help patients and family caregivers use strategies to preserve or enhance quality of life

Maintenance of a Nasogastric Tube

• Provide oral and nasal hygiene
• Check location of external exit site and mark on tube
• Anchor tube to patient's gown to prevent displacement during routine care
• Report any signs of redness or irritation to the nares and provide comfort measures

Gastrostomy Tube (G Tube)

• Direct enteral access through the abdominal wall is optimal for tube feeding when duration is greater than 4 weeks or in situations where access via the nose or mouth is contraindicated
• Gastrostomy tube or Peg tube is commonly used for long-term tube feeding

Care of Gastrostomy or Jejunostomy

• Long-term tubes require endoscopic, radiologic, or surgical placement
• Post-insertion care may require specific nursing interventions
• Feedings delivered via a gastrostomy tube are relatively safe to administer, provided the patient has normal gastric emptying

Jejunostomy Tubes

• Indicated when risks for regurgitation and aspiration are especially high, such as in severely delayed gastric emptying or conditions like pancreatitis
• Placed directly into the small intestine

Verifying Feeding Tube Placement

• Monitor the external length of the tube
• Selection of tube type and placement method depends on anticipated duration of feeding and patient-related factors, such as gastric emptying and risk for pulmonary aspiration

Different Types of Tubes

• Nasogastric Tube: thin, soft tube made of plastic or rubber that is passed through the nose, down through the throat, and into the stomach
• Nasojejunal Tube: small tube passed through the nose and into the small bowel
• Jejunostomy Tube: soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine
• Gastrostomy Tube (G Tube): placed directly into the stomach or intestine
• Plastic Nasogastric Tubes: used for tube feeding and administering medications
• Small-bore Silicone Feeding Tubes: used only for tube feeding
• G Tube or Percutaneous Endoscopic Gastrostomy (PEG) Tube: used for tube feeding and administering medications

Indications for an NG Tube

• Aspiration of gastric contents
• Decompression
• Specimen analysis
• Gastric lavage in cases of poisoning or overdose of medication
• Nutritional support (usually less than six weeks in duration)
• Administration of medication

Patient-Centered Care

• Nursing responsibilities include caring for the tube, administering nutrient formula, and preventing complications
• Pulmonary aspiration is the most serious complication of tube feeding
• Patients requiring long-term tube feeding may feel a sense of loss regarding their ability to participate in life activities
• Emotional and psychological concerns are raised during tube feeding, and patients and family caregivers need reassurance and encouragement
• Nursing interventions such as providing oral hygiene and care of the nasal passage or tube insertion site promote patient comfort and reduce complications

NV and CRAMPS Complications

• Delayed gastric emptying can cause NV and cramps
• Formula that is too cold or has high osmolality can lead to NV and cramps
• Lactose intolerance can cause NV and cramps

BREAKDOWN Complications

• Skin around the tube can erode due to movement of the tube and moisture at the site
• Erosion can lead to infection and excessive granulation

OCCLUSION Complications

• Tube blockage can occur due to inadequate flushing, uncrushed medications, or reaction between medications and formula
• Ensure adequate flushing after each feeding and before and after medications to prevent occlusion

DISPLACEMENT Complications

• Tube displacement can cause coughing, vomiting, abdominal pain, and leaking at the site
• Tube placement must always be verified to prevent displacement

ASPIRATION Complications

• Aspiration can occur if feeding is too rapid, the patient is lying flat, or there are problems with peristalsis
• Aspiration can lead to fluid traveling into the lungs
• Often caused by an allergy or sensitivity to the formula
• Ensure rinsing and flushing of the feeding tube and bag
• Avoid hanging the feeding bag for more than 4 hours to prevent bacterial growth