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Enteral Tube Feeding
Objectives
At the completion of this module, the student will be able to:
1. Describe the meaning of a continuous tube feeding, an intermittent tube feeding, and

residual volume.
2. Identify the possible client complications associated with tube feedings.
3. Explain the correlation between nitrogen balance and nutritional status.
4. Discuss the nursing considerations necessary to safely administer medications through a

feeding tube.
Case Study

Mr. L. Stevens, age 80, has been admitted to the medical unit in acute distress. His respirations are
labored and he is verylethargic. He has been a resident of the Creek View skilled nursing facility
(SNF) for the past 10 months. He had previously lived with his niece until she became concerned
that he could no longer be left alone while she was working. Mr. Stevens\u2019s admitting diagnosis is
right upper lobe (RUL)pneumonia. The transfer notes from the SNF indicate that he has had little
or no appetite for the past 2 weeks. His fluid intake for the past few days has consisted of
occasional sips of apple juice. During the admission process, the nurse noticed that he isdyspneic
andemaciated. Shortly after his admission to the unit, his niece arrived and informed the nurse that
Mr. Stevens had developed a chest cold about 2 weeks ago and that the cold seemed worse each
time she visited him. He has been bedridden for most of the past week. The niece stated that she
knew he was sick when he refused to eat his favorite rice pudding that she made especially for him.

Past medical history is significant for mild congestive heart failure (CHF) for which he takes
digoxin 0.125 mg qd and furosemide 20 mg qd. He received these medications before leaving the

SNF today. Assessment of the respiratory system foundcrackles on the right side, a cough
producingtenacious, green sputum, and +3 pitting ankle and sacral edema. Vital signs are T 99.6\u00ba
F, P 92 and weak, R 24 and shallow, BP 128/72. Physician\u2019s notes state that Mr. Stevens is
manifesting a negative nitrogen balance and orders the following: start O2 at 4L/NC (nasal

cannula), IV of 1000 cc 5% D/W (Dextrose in Water) with KCl 20 mEq to infuse at 75 cc/hr.
Insertnasogastric (NG) tube for feeding. Begin administering enteral feeding at 50 ml/hr per pump,
check for residual per protocol, flush tube with 100 cc water q4h. Intake and output (I&O). Obtain
a sputum culture and sensitivity (C&S). Start cefotaxime sodium 1 g, IVPB (Intravenous
Piggyback) q12h after sputum culture obtained. Continuedigoxin 0.125 mg qd, givefurosemide
40 mg bid, and administer the medications per NG tube. Insert an indwelling urinary catheter. Also
have blood drawn for serum K+, Na+, blood urea nitrogen (BUN), serum creatinine andblood
glucose, complete blood count (CBC),and albuminlevel.

On the morning of the third day, Mr. Stevens\u2019s dyspnea is slightly improved, with crackles still
audible, and ankle edema +2. The tube feeding was increased to 75 ml/hr. Later that evening Mr.
Stevens began withdiarrhea and the nurse found the feeding tube kinked and infusion pump turned

off. While attempting to flush the NG tube, the nurse found that the tube was clogged.

Problems/Nursing Diagnoses
Based on the data in the case study for Mr. Stevens, what problem/nursing diagnosis do
you wish to address first? Choose the three nursing diagnoses with the highest priority.

Ineffective Airway Clearance
Ineffective Airway Clearance. Yes, this is a priority problem. The client has been diagnosed with

RUL pneumonia and assessed as having a productive cough with copious secretions. The client is also dyspneic and emaciated. These factors contribute to the client\u2019s inability to effectively clear his secretions from the respiratory tract and can lead to impaired gas exchange in the lower airways.

Excess Fluid Volume
Excess Fluid Volume. Yes, this is a priority problem. The nursing assessment of the respiratory
system found crackles on the right side, the client is dyspneic and has +3 pitting ankle and sacral
edema. These are physical indicators that the client is retaining fluid.
Imbalanced Nutrition: Less Than Body Requirements
Imbalanced Nutrition: Less Than Body Requirements. Yes, this is a priority problem. Mr. Stevens
is emaciated. The client\u2019s history indicates that he has had little or no appetite for the past 2 weeks.
His diagnosis of RUL pneumonia has made him weak, and this can contribute to his anorexia.
Clinical Decisions
Based on the data, what do you wish to accomplish? Choose three priority outcomes.
Outcome:
Will demonstrate effective deep breathing and coughing techniques
Rationale:
Effective deep breathing and coughing will help clear and maintain a patent airway,
and prevent airway collapse.
Outcome:
Will have absent pitting ankle and sacral edema
Rationale:
Decreased edema indicates a loss of body fluid volume.
Outcome:
Will tolerate the formula tube feeding and not develop any complications
Rationale:

Proper nutritional intake is necessary for maintenance of basic life processes, as
well as the ability to fight disease and infection. Depending on the level of physical
activity, a healthy person requires 2000 to 3000calories/day. Most standard
formulas range from 1 to 2 calories/ml and supply a percentage of protein, fat, and

carbohydrate.
Based on data for Mr. Stevens, the nursing diagnosis of Ineffective Airway Clearance, and
the expected outcomes you have identified, which actions will you take?
Intervention: Teach and monitor coughing and deep breathing exercises every 1 to 2 hours.
Rationale:
Coughing and deep breathing facilitate airway clearance.
Intervention: Hydrate the client via IV therapy and tube feedings and water supplements as
ordered.
Rationale:
Fluids liquefy secretions and promote airway clearance.
Intervention: Place the client in semi-Fowler\u2019s position
Rationale:
The upright position promotes chest expansion and facilitates ventilation and the
expectoration of secretions.
Based on data for Mr. Stevens, the nursing diagnosis of Excess Fluid Volume, and the
expected outcomes you have identified, which actions will you take?
Intervention: Weigh daily in the morning using the same weight scale.
Rationale:

Weight measurement provides an indication of the amount of body fluid retained or loss for a client on diuretic therapy. A loss of 2 pounds over a day or less indicates a loss of approximately 1 L of fluid.

Intervention: Assess edematous areas and elevate edematous extremities on a pillow.
Rationale:

Edematous areas are prone to skin breakdown. Frequent assessment of skin helps
promote early nursing intervention to prevent skin breakdown. Elevation of the
edematous extremities facilitates venous return, decreasing cardiac workload.

Intervention: Monitor intake and output every shift.
Rationale:
I&O is an extremely important means of monitoring fluid replacement. The client is
taking a diuretic and is expected to have increased urine output.

Based on data for Mr. Stevens, the nursing diagnosis of Imbalanced Nutrition: Less Than Body Requirements, and the expected outcomes you have identified, which actions would you take?

Intervention: Maintain NG tube feedings at 50 cc/hr as ordered.
Rationale:
If a client cannot ingest adequate amounts of nutritious food, enteral feedings via
NG tube is an option, especially for the elderly.
Intervention: Check gastric residual volumes q6h; return residual to stomach. If residual is 200 cc
or more (or as ordered by physician), hold feeding and call the physician.
Rationale:
High residual volumes indicate delayed gastric emptying and increase a client\u2019s risk
for aspiration if client has a distended stomach.
Intervention: Maintain a semi-Fowler\u2019s position during enteral tube feeding.
Rationale:
Semi-Fowler\u2019s position lessens the possibility of pulmonary aspiration.
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