Enteral Nutrition


1.  Verify order for enteral feedings

2.  Assemble all equipment and supplies at the bedside

    *   a.  Formula
    *   b.  Tap water
    *   c.  Irrigation tray
    *   d.  Stethescope

3.  Elevate the head of the bed at least 30-45 degrees for patients receiving prepyloric feedings.  If patient must be supine (e.g., because of a neck fracture), extreme caution must be exercised to monitor for aspiration.

4.  Perform hand hygiene, and don gloves.

5.  Examine tube, check placement of feeding tube and gastric residual.

    *   a.  Nasogastric, nasoenteric, or gastrostomy tube: Aspirate intestinal contents if more than 60 ml; place returns in a clean cup at the bedside.
    *   b.  Jejunostomy tube: Unable to assess intestinal residual.
    *   c.  If gastric residual is more than 200 ml with continuous feedings, or greater than 50% of bolus volume for intermittent feedings, the feeding should be delayed 1 hour.
    *   d.  If unable to withdraw residual from small-bore feeding tube, some manufacturers recommend first instilling 30 to 60 ml of air through the tube. This helps to move the tube away from the gastric or intestinal wall and clear it of any residual water, formula, or medications.
    *   e.  Notify the physician or advanced practice nurse if the residual is greater than 150 ml after 2 hours.

6.  For continuous feeding:

    *   a.  Close the clamp on the enteral feeding bag and pour up to 8 hours of formula into the bag, or hang prepackaged, closed-system container of prescribed formula. For intermittent feeding: Hang 100 to 480 ml of formula in the bag at a time.
    *   b.  Hang bag on IV pole and prime tubing. For continuous enteral feeding, load administration set into enteral feeding pump.
    *   c.  Evaluate for residual tube feeding every 4 to 8 hours. Attach a 60-ml syringe to the feeding tube.
    *   d.  After determining the volume of residual, complete guaiac test. If guaiac is negative, return up to 125 ml of gastric aspirate to stomach using the same syringe.
    *   e.  Flush feeding tube with 30 to 50 ml of water.
    *   f.  Connect feeding bag administration set to distal end of feeding tube with safety tape connection.
    *   g.  Remove gloves, and perform hand hygiene.
    *   h.  Begin infusion:

    *     1.  Feeding pump: Set prescribed infusion flow rate for continuous feeding; begin infusion via pump.
    *     2.  Gravity feeding: Adjust roller clamp to infuse formula via gravity over 30 to 60 minutes for intermittent feeding.
    *     3.  Syringe method: Remove the plunger from a 60-ml syringe. Pour the enteral formula to be administered slowly, trying not to introduce air into the GI system. Allow formula to flow in by gravity.
    *   i.  Label enteral feeding bag and administration set with date and time hung and type and amount of formula. Change bag and administration set every 24 hours.
    *   j.  Administer water boluses as prescribed.

7.  For Intermittent Bolus Procedure:

    *   a.  Repeat steps 1-5
    *   b.  To deliver feeding, remove syringe plunger.
    *   c.  Insert syringe tip into administration port of tube.
    *   d.  Slowly pour formula into the syringe.
    *   e.  As syringe empties, add more formula.
    *   f.  After total volume is administered, flush tube with a minimum of water or air.
    *   g.  Clamp or cap feeding tube.
    *   h.  Remove gloves, and perform hand hygiene

8.  For Gravity Method with Bag and Administration set:

    *   a.   Label tubing and set with date/time.
    *   b.   Spike with tubing and prime same.
    *   c.   Examine feeding tube to check for gastric residual.
    *   d.   Insert administration set into feeding port and unclamp feeding.
    *   e.   Administer gravity feeding slowly by regulating roller clamp.
    *   f.   Remove gloves, and perform hand hygiene
    *   g.   When feeding is completed, flush tube with water.
    *   h.   Clamp/cap feeding tube.

9. Cleaning and storage between usage:

    *    a.   Rinse equipment thoroughly with tap water.
    *    b.   Dry or allow to dry. Store syringe in clean irrigation tray.

10. Documentation on nurses notes:

    *    a.   Amount of residual prior to feeding
    *    b.   Amount of feeding
    *    c.   Amount of flush
    *    d.   Patient response to feeding

11. Medication administration:

    *    a.    Prior to administration of medications via feeding tube, determine drug/nutrient incompatibilities
    *    b.    To administer medications:
    *          a.       Stop feeding infusion.
    *          b.      Flush feeding tube with 20 to 30 ml of water. Liquid medications are preferred for administration via feeding tube. If tablets need to be crushed, do so with the use of a commercial tablet crusher.

    *         c.       Administer crushed tablets or liquid medications.

    *        d.      Flush with 20 to 30 ml of water.
    *        e.       Resume feeding.

Declogging the Tube

 

   1. Attach a 60-ml syringe to the end of the enteral tube and aspirate as much fluid as possible.
   2. Fill the syringe with 5 ml of warm water. Instill using manual pressure for 1 minute; use a back-and-forth motion with the plunger.
   3. Clamp the tube for 5 to 15 minutes.
   4. Try to aspirate or flush the tube.
   5. If tube remains clogged, use the following procedure: 1 tablet baking soda or ½ teaspoon of baking soda (NaHCO3) in 5 ml of water (may also use a carbonated beverage).

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