What are nursing interventions when administering continuous enteral feedings?
• To refresh your knowledge of the various routes that can be used for enteral feeding and medicines administration Show
• To enhance your awareness of the reasons why patients may require enteral feeding • To familiarise yourself with the common complications that may occur when undertaking enteral feeding Enteral feeding is defined as the intake of food directly into the gastrointestinal (GI) tract. Enteral feeding tubes can also be used to administer medicines. Patients who may require enteral feeding include those who are unconscious, or those with neurological swallowing disorders, upper GI obstruction, GI dysfunction or malabsorption. There are several routes that can be used for enteral feeding including gastrostomy, post-pyloric, nasogastric, continuous pump and bolus feeding. When undertaking enteral feeding, nurses and other healthcare professionals should be aware of the potential complications such as tube blockage and infection. This article examines the various enteral feeding routes, discusses the administration of medicines, and details the common complications associated with enteral feeding. Nursing Standard. 35, 3, 60-65. doi: 10.7748/ns.2020.e11520 Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software CorrespondenceConflict of interestNone declared McLaren S, Arbuckle C (2020) Providing optimal nursing care for patients undergoing enteral feeding. Nursing Standard. doi: 10.7748/ns.2020.e11520 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. Which nursing action is essential when providing continuous enteral feeding?Which nursing action is essential when providing continuous enteral feeding? Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines.
What nursing interventions are required when caring for a patient with a NGT?Section 4 – NGT Care and Daily management in the hospital. Check the patient's clinical record for the required level of NGT placement.. Attend hand hygiene before touching the patient by either hand washing or using ABHR.. Ensure privacy.. Explain the process and purpose of checking the NGT.. Obtain verbal consent.. What is the priority nursing action before administering enteral feeding through a gastric feeding tube?Correct 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.
What safety measures have to be maintained while the patient is receiving an enteral tube feeding?Wear gloves when handling feeding tubes and avoid touching can tops, container openings, spikes and spike ports. Label equipment: Labels should include the patient's name and room number, the formula type and rate, the date and time of administration and the nurse's initials.
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