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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Skills [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2023.

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Nursing Skills [Internet]. 2nd edition.

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Chapter 17 Enteral Tube Management

17.1. ENTERAL TUBE MANAGEMENT INTRODUCTION

Learning Objectives

• Administer enteral nutrition

• Perform irrigation and suctioning of enteral tubes

• Select appropriate equipment

• Explain the procedure to the patient

• Assess tube placement

• Implement measures to prevent displacement of tube

• Modify procedures to reflect variations across the life span

• Document actions and observations

• Recognize and report significant deviations from norms

Enteral tubes are tubes placed in the gastrointestinal tract. Enteral tubes are used as an alternate route for feeding and medication administration, as well as for stomach decompression. Stomach decompression is a medical term that refers to removing stomach contents by using suctioning. Stomach decompression is commonly used after surgery or trauma to reduce pressure from fluids and gas that cause pain, nausea, vomiting, and potential aspiration of stomach contents into the lungs.

The nurse’s responsibilities when caring for a patient with an enteral tube include the following:

  • assessing tube placement and patency
  • assessing and cleansing the insertion site
  • administering tube feeding
  • administering medication
  • irrigating/flushing the tube
  • suctioning the tube
  • monitoring for complications

Administering enteral medication is discussed in “Administration of Enteral Medications.” The remaining responsibilities related to maintaining enteral tubes will be discussed in this chapter.

17.2. BASIC CONCEPTS OF ENTERAL TUBES

Gastrointestinal Function

It is important to understand the anatomy and functioning of the gastrointestinal system before administering feedings or medications through an enteral tube. See Figure 17.1[1] for an illustration of the anatomy of the gastrointestinal system.

Figure 17.1

Figure 17.1

Anatomy of the Gastrointestinal System

For more information about the digestive function of the gastrointestinal system, visit the “Gastrointestinal System” chapter in Open RN Nursing Pharmacology.

Enteral Nutrition

Enteral nutrition is indicated for patients who need nutritional supplementation and have a functioning gastrointestinal tract, but cannot swallow food safely. Feedings can be administered via enteral tubes placed into the stomach or into the small intestine (usually the jejunum). For example, enteral feeding is commonly used for patients with the following conditions:

  • Impaired swallowing (such as from a stroke or Parkinson’s disease)
  • Decreased level of consciousness
  • Respiratory distress requiring mechanical ventilation
  • Oropharyngeal or esophageal obstruction (such as in head or neck cancer)
  • Hypercatabolic states (such as in severe burns)[2]

For short-term feeding, NG tubes are used. If the duration of feeding is longer than four weeks or if access through the nose is contraindicated, a surgery is performed to place the tube directly through the gastrointestinal wall (for example, PEG or PEJ tubes).

Patients who are not candidates for enteral nutrition are prescribed parenteral nutrition. Parenteral nutrition is a concentrated intravenous solution containing glucose, amino acids, minerals, electrolytes, and vitamins. A lipid solution is typically administered as a separate infusion. This combination of solutions is called total parenteral nutrition because it supplies complete nutritional support. Parenteral nutrition is administered via a large central intravenous line, typically the subclavian or internal jugular vein, because it is irritating to the blood vessels.

Types of Enteral Tubes

There are several different types of enteral tubes based on their location in the gastrointestinal system, as well as their function. Three commonly used enteral tubes are the nasogastric tube, the percutaneous endoscopic gastrostomy (PEG) tube, and the percutaneous endoscopic jejunostomy (PEJ) tube. See Figure 17.2[3] for an illustration of common enteral tubes. NG tubes are typically used for a short period of time (less than four weeks), whereas PEG and PEJ tubes are inserted for long-term enteral nutrition. Some institutions also place nasoduodenal (ND) tubes to provide long-term enteral nutrition. [4]

Figure 17.2

Figure 17.2

Types and Placement of Enteral Tubes

A nasogastric (NG) tube is a single- or double-lumen tube that is inserted into the nasopharynx through the esophagus and into the stomach. NG tubes can be used for feeding, medication administration, and suctioning. NG tubes used for feeding and medication administration are small and flexible, whereas NG tubes used for suctioning are larger and more rigid. NG tubes are secured externally on the patient’s nose or cheek by adhesive tape or a fixation device, so this area should be assessed daily for signs of pressure damage. See Figure 17.3[5] for an image of a small bore feeding tube.

Figure 17.3

Figure 17.3

Small Bore NG Tube

An example of a large bore nasogastric tube is the Salem Sump. Large bore nasogastric tubes, such as the Salem Sump, are used for gastric decompression. The Salem Sump has a double lumen that includes a venting system. One lumen is used to empty the stomach, and the other lumen is used to provide a continuous flow of air. The continuous flow of air reduces negative pressure and prevents gastric mucosa from being drawn into the catheter, which causes mucosal damage. This terminal end also has an anti-reflux valve to prevent gastric secretions from traveling through the wrong lumen. See Figure 17.4[6] for an example of a double-lumen enteral tube.

Figure 17.4

Figure 17.4

Double-Lumen Enteral Tube

Other types of tubes are placed through the patient’s abdominal wall and are used for long-term enteral feeding. A percutaneous endoscopic gastrostomy (PEG) tube is placed via an endoscopic procedure into the stomach. Alternatively, a percutaneous endoscopic jejunostomy (PEJ) tube is placed in the jejunum of the small intestine for patients who cannot tolerate the administration of enteral formula or medications into the stomach due to medical conditions such as delayed gastric emptying. See Figure 17.5[7] for an image of a PEG tube insertion kit and the appearance of an enteral tube as it exits from a patient’s abdomen.

Figure 17.5

Figure 17.5

PEG Tube

Assessing Tube Placement

Feedings or medications administered into an incorrectly placed enteral tube result in life-threatening aspiration pneumonia. The placement of an enteral tube is immediately verified after insertion by an X-ray to ensure it has not been inadvertently placed into the trachea and down into the bronchi. See Figure 17.6[8] for an image of an X-ray demonstrating correct placement of an enteral tube in the stomach as indicated by the lower red arrow. (This X-ray also demonstrates an endotracheal tube correctly placed in the trachea as indicated by the top arrow.) After X-ray verification, the tube should be marked with adhesive tape and/or a permanent marker to indicate the point on the tube where the feeding tube enters the nares or penetrates the abdominal wall. This number on the tube at the entry point should be documented in the medical record and communicated during handoff reports. At the start of every shift, nurses evaluate if the incremental marking or external tube length has changed. If a change is observed, bedside tests such as visualization or pH testing of tube aspirate can help determine if the tube has become dislocated. If in doubt, a radiograph should be obtained to determine tube location. [9]

Figure 17.6

Figure 17.6

Placement Verification by X-Ray

After the initial verification of tube placement by X-ray, it is possible for the tube to migrate out of position due to the patient coughing, vomiting, and moving. For this reason, the nurse must routinely check tube placement before every use. The American Association of Critical‐Care Nursing recommends that the position of a feeding tube should be checked and documented every four hours and prior to the administration of enteral feedings and medications by measuring the visible tube length and comparing it to the length documented during X-ray verification.[10],[11],[12]

Older methods of checking tube placement included observing aspirated GI contents or the administration of air with a syringe while auscultating (commonly referred to as the “whoosh test”). However, research has determined these methods are unreliable and should no longer be used to verify placement.[13],[14]

Checking the pH of aspirated gastric contents is an alternative method to verify placement that may be used in some agencies. Gastric aspirate should have a pH of less than or equal to 5.5 using pH indicator paper that is marked for use with human aspirate. However, caution should be used with this method because enteral formula and some medications alter the gastric pH.[15]

Follow agency policy for assessing and documenting tube placement. Additionally, if the patient develops respiratory symptoms that indicate potential aspiration, immediately notify the provider and withhold enteral feedings and medications until the placement is verified.

Assessing and Cleaning the Tube Insertion Site

The area of tube insertion should be assessed daily for signs of pressure damage. For NG tubes, the adhesive used to secure the tube can be irritating and cause skin breakdown. PEG and PEJ tubes may have fluid seepage around the insertion point that can cause skin breakdown if not cleaned regularly. Follow agency policy for cleansing the external insertion site for PEG and PEJ tubes. Cleansing is typically performed using gauze moistened with water or saline and then allowed to air dry before the fixation plate is repositioned. Because skin surrounding the insertion site is prone to breakdown, barrier cream or dressings may be prescribed to prevent breakdown.[16],[17]

Tube Feeding

Enteral Nutrition (EN) refers to nutrition provided directly into the gastrointestinal (GI) tract through an enteral tube that bypasses the oral cavity. Each year in the United States, over 250,000 hospitalized patients from infants to older adults receive EN. It is also used widely in rehabilitation, long‐term care, and home settings. EN requires a multidisciplinary team approach, including a registered dietician, health care provider, pharmacist, and bedside nurses. The registered dietician performs a nutrition assessment and determines what type of enteral nutrition is appropriate to promote improved patient outcomes. The health care provider writes the order for the enteral nutrition. Prescriptions for enteral nutrition should be reviewed by the nurse for the following components: type of enteral nutrition formula, amount and frequency of free water flushes, route of administration, administration method, and rate. Any concerns about the components of the prescription should be verified with the provider before tube feeding is administered.[18]

Tube feeding can be administered using gravity to provide a bolus feeding or via a pump to provide continuous or intermittent feeding. Feedings via a pump are set up in mL/hr, with the rate prescribed by the health care provider. See Figure 17.7[19] for an image of an enteral tube feeding pump and the associated tubing. Note that tubing used for enteral feeding is indicated by specific colors (such as purple in Figure 17.7). A global safety initiative, referred to as “EnFit,” is in progress to ensure all devices used with enteral feeding, such as extension sets, syringes, PEG tubes, and NG tubes have specific EnFit ends that can only be used with tube feeding sets. This new safety design will avoid inadvertent administration of enteral feeding into intravenous tubing that can cause life-threatening adverse effects.

Figure 17.7

Figure 17.7

Enteral Feeding Pump and Tubing

Review the “Checklist for NG Tube Enteral Feeding by Gravity with Irrigation” section for additional information regarding administering bolus feedings by gravity.

Life Span Considerations

Enteral feeding is administered to infants and children via a syringe, gravity feeding set, or feeding pump. The method selected is dependent on the nature of the feeding and clinical status of the child.[20]

Complications of Enteral Feeding

The most serious complication of enteral feeding is inadvertent respiratory aspiration of gastric contents, causing life-threatening aspiration pneumonia. Other complications include tube clogging, tubing misconnections, and patient intolerance of enteral feeding.[21]

REDUCING RISK OF ASPIRATION

In addition to verifying tube placement as discussed in an earlier section, nurses perform additional interventions to prevent aspiration. The American Association of Critical‐Care Nurses recommends the following guidelines to reduce the risk for aspiration:

  • Maintain the head of the bed at 30°-45° unless contraindicated
  • Use sedatives as sparingly as possible
  • Assess feeding tube placement at four‐hour intervals
  • Observe for change in the amount of external length of the tube
  • Assess for gastrointestinal intolerance at four‐hour intervals[22]

Measurement of gastric residual volume (GRV) is performed by using a 60-mL syringe to aspirate stomach contents through the tube. It has traditionally been used to assess aspiration risk with associated interventions such as slowing or stopping the enteral feeding. GRVs in the range of 200–500 mL cause interventions such as slowing or stopping the feeding to reduce risk of aspiration. However, according to recent research, it is not appropriate to stop enteral nutrition for GRVs less than 500 mL in the absence of other signs of intolerance because of the impact on the patient’s overall nutritional status. Additionally, the aspiration of gastric residual volumes can contribute to tube clogging.[23] Follow agency policy regarding measuring gastric residual volume and implementing interventions to prevent aspiration.

MANAGING TUBE CLOGGING

Feeding tubes are prone to clogging for a variety of reasons. The risk of clogging may result from tube properties (such as narrow tube diameter), the tube tip location (stomach vs. small intestine), insufficient water flushes, aspiration for gastric residual volume (GRV), contaminated formula, and incorrect medication preparation and administration. A clogged feeding tube can result in decreased nutrient delivery or delayed administration of medication, and, if not corrected, the patient may require additional surgical intervention to replace the tube.[24]

Research supports using water as the best choice for initial declogging efforts. Instill warm water into the tube using a 60‐mL syringe, and apply a gentle back‐and‐forth motion with the plunger of the syringe. Research shows that the use of cranberry juice and carbonated beverages to flush the tube can worsen tube occlusions because the acidic pH of these fluids can cause proteins in the enteral formula to precipitate within the tube. If water does not work, a pancreatic enzyme solution, an enzymatic declogging kit, or mechanical devices for clearing feeding tubes are the best second‐line options.[25]

To prevent enteral tubes from clogging, it is important to follow these guidelines:

  • Flush feeding tubes at a minimum of once a shift.
  • Flush feeding tubes immediately before and after intermittent feedings. During continuous feedings, flush at standardized, scheduled intervals.
  • Flush feeding tubes before and after medication administration and follow appropriate medication administration practices.
  • Limit gastric residual volume checks because the acidic gastric contents may cause protein in enteral formulas to precipitate within the lumen of the tube.[26]
PREVENTING TUBING MISCONNECTIONS

In April 2006, The Joint Commission issued a Sentinel Event Alert on tubing misconnections due to enteral feedings being inadvertently infused into intravenous lines with life-threatening results. A color-coded enteral tubing connection design was developed to visually communicate the difference between enteral tubing and intravenous tubing. In addition to tubing design, follow these guidelines to prevent tubing misconnection errors:

  • Make tubing connections under proper lighting.
  • Do not modify or adapt IV or feeding devices because doing so may compromise the safety features incorporated into their design.
  • When making a reconnection, routinely trace lines back to their origins and then ensure that they are secure.
  • As part of a hand‐off process, recheck connections and trace all tubes back to their origins.[27]
MANAGING INTOLERANCES AND IMBALANCES

Patients should be monitored daily for signs of tube feeding intolerance, such as abdominal bloating, nausea, vomiting, diarrhea, cramping, and constipation. If cramping occurs during bolus feedings, it can be helpful to administer the enteral nutritional formula at room temperature to prevent symptoms.[28] Notify the provider of signs of intolerance with anticipated changes in the prescription regarding the type of formula or the rate of administration. Electrolytes and blood glucose levels should also be monitored, as ordered, for signs of imbalances.[29],[30]

Tube Irrigation

Enteral tubes are routinely flushed to maintain patency. Follow agency policy when flushing a tube. Typically, tap water and a 60-mL syringe are used to flush enteral tubes.[31] See Figure 17.8[32] for an image of a nurse irrigating an NG tube.

Figure 17.8

Figure 17.8

Irrigating an NG Tube

The steps for irrigating enteral tubes are typically the following:

  • Draw the required amount of water into the 60-mL syringe and dispel excess air.
  • If the tube has a clamp, close it.
  • Open the distal end of the tube and connect the syringe.
  • Open the clamp.
  • Administer the water.
  • Close the clamp.
  • Remove the syringe and refill it with water if indicated.
  • Repeat as needed to obtain the desired flushing volume.
  • Once completed, remove the syringe, close the tube cap, and reopen the clamp.[33]

Tube Suctioning

NG tubes may be used to remove gastric content, referred to as gastric decompression. In these situations, the stomach is drained by gravity or by connection to a suction pump to prevent nausea, vomiting, gastric distension, or to wash the stomach of toxins. This procedure is commonly used for post-operative patients who have not yet regained peristalsis or for patients with a small bowel obstruction to remove the accumulation of stomach bile. It is also used in the emergency department for patients with some types of poisonings or overdoses and is commonly referred to as “pumping out the stomach.”

For patients receiving suctioning via enteral tubes, the drainage amount and color should be documented every shift.

References

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Lemyze, M. (2010). The placement of nasogastric tubes. CMAJ : Canadian Medical Association Journal, 182(8), 802. 10.1503/cmaj.091099 ↵10.1503/cmaj.091099 [PMC free article: PMC2871204] [PubMed: 20351123] [CrossRef] [CrossRef]
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Simons, S. R., & Abdallah, L. M. (2012). Bedside assessment of enteral tube placement: Aligning practice with evidence. American Journal of Nursing, 112(2), 40-46.  ↵10.1097/01.naj.0000411178.07179.68 [PubMed: 22261653] [CrossRef]
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Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., McGinnis, C., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii‐Wolfe, C., Sullivan, J., Wood, A., Malone, A., & Guenter, P. (2017). ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15-103. . ↵10.1177/0148607116673053 [PubMed: 27815525] [CrossRef]
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Simons, S. R., & Abdallah, L. M. (2012). Bedside assessment of enteral tube placement: Aligning practice with evidence. American Journal of Nursing, 112(2), 40-46.  ↵10.1097/01.naj.0000411178.07179.68 [PubMed: 22261653] [CrossRef]
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Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., McGinnis, C., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii‐Wolfe, C., Sullivan, J., Wood, A., Malone, A., & Guenter, P. (2017). ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15-103. 10.1177/0148607116673053. ↵10.1177/0148607116673053. [PubMed: 27815525] [CrossRef] [CrossRef]
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Best, C. (2019). Selection and management of commonly used enteral feeding tubes. Nursing Times, 15(3), 43-47. https://www​.nursingtimes​.net/clinical-archive​/nutrition/selection-and-management-of-commonly-used-enteral-feeding-tubes-18-02-2019/ ↵
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Blumenstein, I., Shastri, Y. M., & Stein, J. (2014). Gastroenteric tube feeding: Techniques, problems and solutions. World Journal of Gastroenterology, 20(26), 8505–8524.  ↵10.3748/wjg.v20.i26.8505 [PMC free article: PMC4093701] [PubMed: 25024606] [CrossRef]
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Best, C.(2019). Selection and management of commonly used enteral feeding tubes. Nursing Times, 15(3), 43-47. https://www​.nursingtimes​.net/clinical-archive​/nutrition/selection-and-management-of-commonly-used-enteral-feeding-tubes-18-02-2019/ ↵
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Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., McGinnis, C., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii‐Wolfe, C., Sullivan, J., Wood, A., Malone, A., & Guenter, P. (2017). ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15-103. . ↵10.1177/0148607116673053 [PubMed: 27815525] [CrossRef]
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The Royal Children’s Hospital Melbourne. (2017, December). Enteral feeding and medication administration. https://www​.rch.org.au​/rchcpg/hospital_clinical​_guideline_index​/Enteral_feeding_and​_medication_administration/ ↵
21.
Blumenstein, I., Shastri, Y. M., & Stein, J. (2014). Gastroenteric tube feeding: Techniques, problems and solutions. World Journal of Gastroenterology, 20(26), 8505–8524.  ↵10.3748/wjg.v20.i26.8505 [PMC free article: PMC4093701] [PubMed: 25024606] [CrossRef]
22.
Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., McGinnis, C., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii‐Wolfe, C., Sullivan, J., Wood, A., Malone, A., & Guenter, P. (2017). ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15-103. . ↵10.1177/0148607116673053 [PubMed: 27815525] [CrossRef]
23.
Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., McGinnis, C., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii‐Wolfe, C., Sullivan, J., Wood, A., Malone, A., & Guenter, P. (2017). ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15-103.  ↵10.1177/0148607116673053. [PubMed: 27815525] [CrossRef]
24.
Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., McGinnis, C., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii‐Wolfe, C., Sullivan, J., Wood, A., Malone, A., & Guenter, P. (2017). ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15-103.  ↵10.1177/0148607116673053. [PubMed: 27815525] [CrossRef]
25.
Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., McGinnis, C., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii‐Wolfe, C., Sullivan, J., Wood, A., Malone, A., & Guenter, P. (2017). ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15-103. 10.1177/0148607116673053. ↵10.1177/014860711667305 [PubMed: 27815525] [CrossRef] [CrossRef]
26.
Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., McGinnis, C., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii‐Wolfe, C., Sullivan, J., Wood, A., Malone, A., & Guenter, P. (2017). ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15-103.  ↵10.1177/0148607116673053. [PubMed: 27815525] [CrossRef]
27.
Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., McGinnis, C., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii‐Wolfe, C., Sullivan, J., Wood, A., Malone, A., & Guenter, P. (2017). ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15-103. . ↵10.1177/0148607116673053 [PubMed: 27815525] [CrossRef]
28.
The Royal Children’s Hospital Melbourne. (2017, December). Enteral feeding and medication administration. https://www​.rch.org.au​/rchcpg/hospital_clinical​_guideline_index​/Enteral_feeding_and​_medication_administration/ ↵
29.
Blumenstein, I., Shastri, Y. M., & Stein, J. (2014). Gastroenteric tube feeding: Techniques, problems and solutions. World Journal of Gastroenterology, 20(26), 8505–8524.  ↵10.3748/wjg.v20.i26.8505 [PMC free article: PMC4093701] [PubMed: 25024606] [CrossRef]
30.
Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., McGinnis, C., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii‐Wolfe, C., Sullivan, J., Wood, A., Malone, A., & Guenter, P. (2017). ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15-103. . ↵10.1177/0148607116673053 [PubMed: 27815525] [CrossRef]
31.
Best, C. (2019). Selection and management of commonly used enteral feeding tubes. Nursing Times, 15(3), 43-47. https://www​.nursingtimes​.net/clinical-archive​/nutrition/selection-and-management-of-commonly-used-enteral-feeding-tubes-18-02-2019/ ↵
32.
33.
Best, C. (2019). Selection and management of commonly used enteral feeding tubes. Nursing Times, 15(3), 43-47. https://www​.nursingtimes​.net/clinical-archive​/nutrition/selection-and-management-of-commonly-used-enteral-feeding-tubes-18-02-2019/ ↵

17.3. ASSESSMENTS RELATED TO ENTERAL TUBES

When caring for patients with enteral tubes, it is important for the nurse to routinely assess and document the patient’s condition.

Subjective Assessment

When a patient is receiving enteral feeding, the nurse should assess the patient’s tolerance of tube feeding.

Table 17.3

Focused Interview Questions for Tube Feeding

Interview QuestionsFollow-up
How long have you been receiving tube feeding?Tell me more about why you are receiving tube feeding and how you feel about the tube feeding. (Patients may experience psychosocial reactions to receiving tube feeding that can be addressed with therapeutic communication.)
Are you experiencing symptoms of stomach cramping, nausea, vomiting, excess gas, diarrhea, or constipation?Please describe.
Are you experiencing any discomfort where the tube is inserted?Please describe.
Have you noticed any coughing or respiratory symptoms after receiving tube feeding?Please describe.

Objective Assessment

Objective assessments for patients with enteral tubes include assessing skin integrity, tube placement, gastrointestinal function, and for signs of complications:

  • Assess the tube insertion site daily for signs of pressure injury and skin breakdown. Cleanse and protect the area as indicated.
  • Assess tube placement every four hours and prior to administration of feedings or medications according to agency policy. Verify the visible tube length and compare it to the length documented after X-ray verification.
  • Trace the tubing from the insertion site to prevent tubing misconnections.
  • Assess the abdomen. If tube suctioning is in place, the suction should be turned off prior to auscultation. Bowel sounds should be present in all four quadrants, and the abdomen should be soft and nondistended.
  • Monitor the patient’s weight and overall nutritional status in collaboration with the multidisciplinary team.
  • Monitor serum electrolytes and blood glucose as indicated.

17.4. SAMPLE DOCUMENTATION

Sample Documentation of Expected Findings

Tube Feeding

Patient’s abdomen is soft, nondistended, and bowel sounds are present in all four quadrants. Head of the bed elevated to 45 degrees. Placement of tube verified with measurement of the tube at the nares at 55 cm and gastric aspirate had a pH of 4. Patient tolerated 240 mL of tube feeding by gravity followed by a 30-mL water flush.

Tube Irrigation

Irrigated NG tube with 30 mL of water with no resistance. Patient tolerated flush without symptoms.

Tube Suctioning

NG tube connected to low-intermittent suction (LIS) at 60 mmHg. Output from the NGT is green with a volume of 100 mLs in eight hours.

Sample Documentation of Unexpected Findings

Tube Feeding

Patient’s abdomen is soft, nondistended, and bowel sounds are present in all four quadrants. Head of the bed elevated to 45 degrees. Placement of tube verified with measurements of tube at nares at 55 cm and gastric aspirate with a pH of 4. After 100 mLs of tube feeding was infused, the patient complained of feeling full and nauseated. Tube feeding infusion stopped and the head of the bed maintained at a 45-degree angle. Will reassess gastric volume residual in one hour and determine if tube feeding will be resumed.

Tube Irrigation

Attempted to irrigate NG tube with 30 mLs of water, but resistance was felt with procedure. Unable to inject water flush into the NGT. Dr. Smith notified of findings at 1320.

Tube Suctioning

Patient’s abdomen is slightly distended and bowel sounds are hypoactive in all four quadrants. Patient reports increased nausea over the last two hours. NGT connected to low-intermittent suction (LIS) at 60 mmHg. Output from the NGT is mahogany colored with a volume of 800 mLs in eight hours. Dr. Smith notified of findings at 1640.

17.5. CHECKLIST FOR NG TUBE ENTERAL FEEDING BY GRAVITY WITH IRRIGATION

Use the checklist below to review the steps for completion of the “NG Tube Enteral Feeding by Gravity with Irrigation.”

Video Review of Enteral Nutrition Administration:[1]

Image ch17entrltubemgmt-Image001.jpg

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1.

Verify the provider’s order.

2.

Gather supplies: stethoscope, gloves, towel, irrigating solution (usually water), and irrigation set with irrigating syringe, pH tape, and prescribed tube feeding.

3.

Perform safety steps:

  • Perform hand hygiene.
  • Check the room for transmission-based precautions.
  • Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain the process to the patient and ask if they have any questions.
  • Be organized and systematic.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure the patient’s privacy and dignity.
  • Assess ABCs.
4.

Don the appropriate PPE as indicated.

5.

Perform abdominal and nasogastric tube assessment:

  • Assess skin integrity on the nose and ensure the tube is securely attached.
  • Use a flashlight to look in the nares to assess swelling, redness, or bleeding.
  • Ask the patient to open their mouth and look for curling of the tube in the patient’s mouth. The tube should go straight down into the esophagus.
  • Lower the blankets and move the gown up to expose the abdomen. Inspect from two locations.
  • Auscultate bowel sounds and then palpate the abdomen. If the patient is receiving NG suctioning, turn off the suction prior to auscultation.
6.

Check for tube placement:

  • Verify tube measurement at insertion site based on documentation.
  • If agency policy dictates, test the pH of the aspirate. The pH should be equal or less than 5.5.
  • If agency policy dictates, measure and document residual amount. Instill residual back into gastric tube if placement was confirmed.
7.

Draw up 30 mL of water in a 60-mL syringe. (If applicable, use sterile water according to agency policy.)

8.

Connect the syringe to the tubing port (not the blue pigtail).

9.

Instill 30 mL water.

10.

Reconnect the plug tube or clamp tube.

11.

Remove the plunger from the syringe and attach the syringe to the NG tube.

12.

Complete tube feeding administration:

  • Verify the order for the type of formula, amount, method of administration, and rate.
  • Check the expiration date on the formula.
  • Verify if the tops of the containers need cleaning or if feeding needs mixing/shaking.
  • Add the formula to the syringe until the ordered amount is administered. Hold the syringe above the insertion site and allow it to enter via gravity.
  • Assess the patient for tolerance of the feeding. Slow infusion as necessary. Do not allow air to enter the tube when refilling the syringe.
  • After formula is administered, flush the NG tube with 30 mL of water.
  • If a patient is unable to tolerate the feeding, slow or stop the infusion. Document and report the intolerance.
13.

Disconnect the syringe and plug the NG tube.

14.

Maintain the patient at or above a 30-degree angle for a minimum of one hour to prevent aspiration. Ask the patient if they have any questions and thank them for their time.

15.

Perform hand hygiene.

16.

Ensure safety measures when leaving the room:

  • CALL LIGHT: Within reach
  • BED: Low and locked (in lowest position and brakes on)
  • SIDE RAILS: Secured
  • TABLE: Within reach
  • ROOM: Risk-free for falls (scan room and clear any obstacles)
17.

Document assessment findings and report any concerns according to agency policy. When documenting the procedure, include the following:

  • Time performed
  • Irrigation solution used
  • Quantity instilled
  • Residual amount, color, odor, and consistency
  • Method for checking the placement (including pH of gastric contents, if performed)
  • Related assessments
  • Amount of tube feeding
  • Patient tolerance for the procedure

References

1.
Open RN Project. (2021, November 11). Enteral Nutrition Administration. [Video]. YouTube. Video licensed under CC-BY-4.0. https://youtu​.be/rZxlSgaujA4 ↵.

17.6. CHECKLIST FOR NG SUCTION

Use the checklist below to review the steps for completion of the “NG Suction.”

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1.

Verify the provider’s order.

2.

Gather supplies: nonsterile gloves.

3.

Perform safety steps:

  • Perform hand hygiene.
  • Check the room for transmission-based precautions.
  • Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain the process to the patient and ask if they have any questions.
  • Be organized and systematic.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure the patient’s privacy and dignity.
  • Assess ABCs.
4.

Don the appropriate PPE as indicated.

5.

Perform abdominal and nasogastric tube assessment:

  • Assess skin integrity on the nose and ensure the tube is securely attached.
  • Use a flashlight to look in the nares to assess swelling, redness, or bleeding.
  • Ask the patient to open their mouth and look for curling of the tube in the patient’s mouth. The tube should go straight down into the esophagus.
  • Lower the blankets and move the gown up to expose the abdomen. Inspect from two locations.
  • Auscultate bowel sounds and then palpate the abdomen.

Rationale: Performing a nasogastric and abdominal assessment is important for determining signs of complications such as skin breakdown and necessity for suction.

1.

Don gloves.

2.

Attach the NG tube to the suction canister.

3.

Set the rate of suction according to provider order:

  • Low intermittent suction is usually ordered. Low range on the suction device is from 0 to 80 mmHg. Starting between 40-60 mmHg is recommended. The suction level should not exceed 80 mmHg.
  • Observe for the gastric content to flow into the tubing and then the canister.
4.

Monitor canister output and document color, odor, consistency, and amount.

5.

Perform hand hygiene.

6.

Ensure safety measures when leaving the room:

  • CALL LIGHT: Within reach
  • BED: Low and locked (in lowest position and brakes on)
  • SIDE RAILS: Secured
  • TABLE: Within reach
  • ROOM: Risk-free for falls (scan room and clear any obstacles)
7.

Document the procedure and related assessment findings. Report any concerns according to agency policy.

17.7. LEARNING ACTIVITIES

Learning Activities

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

1.

As you are administering tube feeding to your patient, they complain of feeling full. What is the next step to take?

a.

Continue with administering the tube feeding.

b.

Stop the tube feeding and check the gastric residual.

c.

Stop the tube feeding and waste the remaining feeding.

d.

Slow or stop the infusion based on the patient’s response.

Video Review of Tube Feeding Calculations[1]

Image ch17entrltubemgmt-Image002.jpg

Image ch17entrltubemgmt-Image003.jpg

Image ch17entrltubemgmt-Image004.jpg

Image ch17entrltubemgmt-Image005.jpg

References

1.
RegisteredNurseRN. (2020, May 18). Tube feeding nursing calculations problems dilution enteral. [Video]. YouTube. All rights reserved. Video used with permission. https://youtu​.be/CwfJ-sQ-xOQ ↵.

XVII. GLOSSARY

Enteral Nutrition (EN)

Nutrition provided directly into the gastrointestinal (GI) tract through an enteral tube that bypasses the oral cavity.

Gastric Residual Volume (GRV)

Stomach contents aspirated with a 60-mL syringe, typically performed for patients receiving enteral feeding to assess aspiration risk with associated interventions such as slowing or stopping tube feeding. GRVs in the range of 200–500 mL should raise concern and lead to the implementation of measures to reduce risk of aspiration.

Stomach Decompression

Using suctioning through a nasogastric tube to remove the contents of the stomach.

Copyright Notice

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/.

Bookshelf ID: NBK596741
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