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 very lethargic. 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’s 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 is dyspneic and emaciated. 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 found crackles on the right side, a cough producing tenacious, green sputum, and +3 pitting ankle and sacral edema. Vital signs are T 99.6º F, P 92 and weak, R 24 and shallow, BP 128/72. Physician’s 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. Insert nasogastric (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. Continue digoxin 0.125 mg qd, give furosemide 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 and blood glucose, complete blood count (CBC), and albumin level. On the morning of the third day, Mr. Stevens’s 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 with diarrhea 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’s 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’s 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: Rationale: Will demonstrate effective deep breathing and coughing techniques Effective deep breathing and coughing will help clear and maintain a patent airway, and prevent airway collapse. Will have absent pitting ankle and sacral edema Decreased edema indicates a loss of body fluid volume. Will tolerate the formula tube feeding and not develop any complications 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 3000 calories/day. Most standard formulas range from 1 to 2 calories/ml and supply a percentage of protein, fat, and carbohydrate.

Outcome: Rationale: Outcome: Rationale:

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’s 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’s risk for aspiration if client has a distended stomach. Intervention: Maintain a semi-Fowler’s position during enteral tube feeding. Rationale: Semi-Fowler’s position lessens the possibility of pulmonary aspiration.

Content Mastery 1. The nurse is preparing to insert the NG tube on Mr. Stevens. Which nursing action is most important for the nurse to consider initially prior to inserting the feeding tube? a. Lubricate the tip of the NG tube. b. Measure tube placement. c. Place a tape mark on the tube to identify the length of insertion. d. Select a large-bore feeding tube. Answers and Rationales 1a. Incorrect: Although tube lubrication is important, it is not the most important nursing action for the nurse to consider initially. 1b. Correct: Measuring the placement of the tube is a recommended step prior to the insertion of the feeding tube. 1c. Incorrect: Placing a tape mark to identify the length of insertion is important. However, it is not the most important nursing action for the nurse to consider initially. 1d. Incorrect: The size of the feeding tube is important for the nurse to consider. However, more commonly feeding tubes are of the small-bore type. 2. Which of the following identifies the correct method of measurement for the placement of a feeding tube? a. Measure the feeding tube holding the tip of the tube and measuring from the tip of the nose to the xiphoid process. b. Hold the tip of the feeding tube at the tip of the earlobe and measure down to the xiphoid process. c. Hold the tip of the tube at the tip of the nose and reach back with the tube to the tip of the earlobe, continuing down to the xiphoid process. d. Measure the feeding tube holding the tip of the tube and measuring from the xiphoid process to the mandible and continue to the tip of the nose. Answers and Rationales 2a. Incorrect: This is not the correct method for the measurement of a feeding tube for placement. 2b. Incorrect: This is not the correct method for the measurement of a feeding tube for placement. 2c. Correct: This is the correct method of the measurement of a feeding tube for placement. 2d. Incorrect: This is not the correct method for the measurement of a feeding tube for placement. 3. A nursing student is assigned to take care of Mr. Stevens. Which statement made by the nursing student indicates an appropriate nursing action when caring for a client with a continuous tube feeding? a. “I will place Mr. Stevens in a supine position for 10 minutes while the feeding is infusing.” b. “I will assess Mr. Stevens’s bowel sounds every 4 hours while the feeding is infusing.”

c. “I will maintain minimal conversation with Mr. Stevens while the feeding is infusing.” d. “I will keep Mr. Stevens in semi-Fowler’s position while the feeding is infusing.” Answers and Rationales 3a. Incorrect: This is not an appropriate nursing action for a client who has tube-feeding infusing. 3b. Incorrect: Although assessment of bowel sounds is important, it is not necessary to assess every 4 hours unless the client is experiencing acute signs and symptoms of a gastrointestinal (GI) complication. 3c. Incorrect: This is not an appropriate nursing action for a client who has tube feeding infusing. 3d. Correct: It is important to maintain clients with continuous tube feeding in semi-Fowler’s position to prevent possible gastroesophageal reflux and aspiration of gastric contents. 4. Mr. Stevens’s NG tube is to be flushed with 100 ml of water q4h. Which explanation most likely explains the rationale for this order? a. Prevents signs of dehydration for clients on tube feedings b. Provides free water to the client and assists with preventing tube clogging c. Assists to dilute gastric contents for clients taking full-strength concentration formulas d. Reduces the risk of developing diarrhea associated with full-strength concentration formulas Answers and Rationales 4a. Incorrect: This is not the rationale for giving the client water through the feeding tube; 100 ml of water q4h by itself will provide a total of 600 ml/24 hr and is not a sufficient amount to prevent signs of dehydration in acutely ill clients. 4b. Correct: Giving free water for clients on tube feeding is necessary and simultaneously assists in preventing tube clogging. 4c. Incorrect: This is not the rationale for giving the client water through the feeding tube. 4d. Incorrect: This is not the rationale for giving the client water through the feeding tube. 5. After crushing separately the digoxin 0.125 mg and furosemide 40 mg, the nurse takes the medications to Mr. Stevens’s bedside. What nursing intervention is most appropriate for the nurse to do in the administration of the medications? a. Stop the tube feeding 30 minutes before administering the medication. b. Flush the NG tube with water between administration of the medications. c. Mix the medications into the formula feeding bag. d. Hold the formula tube feeding for 20 minutes after the administration of the medications. Answers and Rationales 5a. Incorrect: It is not necessary to stop the tube feeding before administering these medications. 5b. Correct: Flushing the NG tube between the administration of the medications is

recommended to prevent possible chemical and physical interaction. 5c. Incorrect: Medications should not be mixed into the formula bag because they will not be delivered in a timely manner. 5d. Incorrect: Certain medications (i.e., antacids) do require that the formula feeding be held after their administration, however, these medications do not require that the formula 6. The nurse checks the amount of residual q6h on Mr. Stevens. The nurse knows that a residual of more than 150 cc of formula in the stomach puts the client at greater risk for which one of the following? a. Electrolyte imbalance b. Diarrhea c. Fluid overload d. Pulmonary aspiration Answers and Rationales 6a. Incorrect: Electrolyte imbalance does not result from an over distended stomach. 6b. Incorrect: Diarrhea is not the result of a high residual in the stomach. 6c. Incorrect: Fluid overload results from more fluid in the circulating blood volume than the cardiac or renal system can handle. 6d. Correct: An overdistended stomach results from delayed gastric emptying and can contribute to the development of pulmonary aspiration. 7. One of the best actions a nurse can take to prevent bacterial contamination of Mr. Stevens’s tube feeding is to: a. change the feeding bag every 24 hours. b. rinse the feeding bag with water every 24 hours. c. fill the feeding bag with enough formula to infuse over 6 to 8 hours. d. flush the NG tube with water every 4 hours. Answers and Rationales 7a. Correct: Studies show that feeding bags that are allowed to hang for more than 24 hours have developed bacterial contamination. 7b. Incorrect: Rinsing the bag after hanging 24 hours is not adequate to prevent bacterial contamination. 7c. Incorrect: To prevent bacterial contamination, it is recommended that the nurse hang enough formula in the bag to infuse over a 4-hour limit. 7d. Incorrect: Flushing the NG tube with water does not accomplish the goal of preventing bacterial contamination of the hanging bag of feeding. 8. Mr. Stevens developed diarrhea after the third day of receiving NG tube feedings. The nurse recalls that the contributing factors for the development of diarrhea in the tube-fed client are: a. the high levels of potassium and glucose in formulas. b. antibiotics and the temperature of the formula.

c. formula feedings that have been diluted with too much water. d. delivering tube feedings through a feeding pump. Answers and Rationales 8a. Incorrect: Formulas mainly consist of a certain percentage of protein, carbohydrate, and fat. The caloric content of most standard formulas is based on usual requirements although variability among individual products is seen. 8b. Correct: Diarrhea associated with formula feeding is related to the administration of refrigerated formula because cold feeding is felt to increase peristalsis, the type of formula being administered, and the rate of flow. Formula should be administered at room temperature. Diarrhea can also result from the administration of certain medications. 8c. Incorrect: Water is not a factor in the cause of diarrhea. 8d. Incorrect: The use of a feeding pump to administer tube feedings is recommended as a way to ensure a steady delivery of formula feeding. 9. Accurate assessment of fluid and electrolyte balance is an important responsibility of the nurse caring for the client on tube feedings. When tube feedings are being administered, the electrolyte that should be monitored closely is: a. albumin b. BUN c. sodium d. carbon dioxide Answers and Rationales 9a. Incorrect: Serum albumin levels are not good indicators of a client’s response to nutritional support because it takes 20 days for any significant change to occur in measured laboratory values. 9b. Incorrect: BUN is used to evaluate renal function. 9c. Correct: Sodium balance is affected in tube-fed clients. The client needs to be monitored for hyponatremia (decrease sodium levels) or hypernatremia (increase sodium levels). Hyponatremia may develop due to excessive free water administration. Hypernatremia is more frequent among older individuals presumably because they have greater loss of free water and they lack fluid volume reserve. 9d. Incorrect: This electrolyte is not affected with formula administration. 10. The nurse finds Mr. Stevens’s NG tube clogged. The most appropriate nursing intervention at this time is for the nurse to: a. attempt to flush the tube with warm water. b. discontinue the tube and reinsert an new NG tube. c. connect the tube to the feeding pump and restart the pump. d. clamp the tube and notify the physician. Answers and Rationales

10a. Correct: Attempting to flush the tube with warm water may assist in reestablishing the patency of the feeding tube. 10b. Incorrect: This is not the most appropriate intervention at this time. 10c. Incorrect: This is not the most appropriate intervention at this time. 10d. Incorrect: This is not the most appropriate intervention at this time. Essay Questions Explain the correlation between nitrogen balance and nutritional status. Nitrogen balance provides an indication of a client’s nutritional status. Nitrogen is a by-product of protein metabolism and is often used to assess nutritional status. The body constantly breaks down and builds up protein. Protein is vital for growth and repair of body tissues. Nitrogen balance means that the anabolic and catabolic metabolism of protein is in equilibrium. This means that nitrogen output is equal to input. This occurs as the result of taking adequate amounts of protein for growth and repair as well as enough carbohydrates and fats for energy. The client who has been assessed with poor nutritional status typically has more breakdown of protein than buildup and is at risk for developing a negative nitrogen balance. Discuss the nursing considerations necessary to safely administer medications through a feeding tube, including the initial preparation of the medications and the actual administration of the medication at the client’s bedside. The nurse administering medications through a feeding tube must first observe the “six rights of medication administration” as well as know the drug classification, usual dosage and route, side effects, and adverse effects. It is also important for the nurse to know which medications can be crushed and administered through a feeding tube. For example, sustained-release capsules and enteric-coated tablets may not be crushed because the drug’s mode of absorption and distributed is altered. The nurse should gather all equipment before starting the administration of the medications. Before administering the medications, the nurse triple-checks all the medications, checks the client’s identification, and ensures that the client is in a semi-Fowler’s to Fowler’s position. Once the nurse has crushed the medications, he or she takes them to the bedside and mixes them separately with water. It is recommended that each medication be administered separately to reduce the possibility of a chemical and physical interaction. If the client has a continuous tube feeding, the nurse stops the feeding, unclamps the feeding tube from the pump, and flushes the tube with 5 ml of water. If the client has a feeding tube that is clamped, the nurse simply unclamps the tube and flushes the tube with 5 ml of water. The nurse then proceeds to administer the medications by gravity flow or inject the medications into the feeding tube with a syringe. After the administration of each medication, the nurse should flush the feeding tube with 5 ml of water. After all the medications have been administered, the nurse clamps the feeding tube or reconnects the tube to the pump if continuous feeding is ordered. The nurse cleans all the equipment and returns the

equipment to its proper place. The client is made comfortable and left in a semi-Fowler’s to Fowler’s position. Finally, the nurse documents the administration of the medications in the client’s medication record.