NURSING PROTOCOL FOLLOWED WHIL ADMINISTERING

ENTERAL FEEDING

INTRODUCTION
Nutritional support is an important issue in the management of critically ill patients.
Critically ill patients are typically unable to maintain adequate nutritional intake to meet their
metabolic demands. Integrity and functioning of most of the cells of the body depends on
continuous delivery of nutrients. In critically ill patients, there is interference with storage
and mobilization of nutrients because of organ dysfunction. Implementation of an early
enteral nutrition (EEN) protocol within the first 48 hours of admission is effective to reduce
infection, hospital length of stay, and mortality.
I. ENTERAL NUTRITION:
Enteral feeding is the introduction of a nutritionally complete liquid formula directly
into the stomach or small intestine via a narrow, often specifically designed, tube.
II. ROUTES OF ENTERAL FEEDING
Enteral feeding tubes may enter the body at a number of different sites .The choice of
enteral feeding route depends on several factors, such as the intended duration of nutrition
support, the patient’s condition, and any limitations to access (such as trauma or
obstructions).
Short Term Access: Anticipated need for enteral feeding < 6-8 weeks
1. Nasogastric
2. Nasoduodenal
Long Term Access (anticipated need for enteral feeding > 6-8 weeks)
1. Percutaneous Endoscopic Gastrostomy (PEG)
2. Open gastrostomy
3. Transgastric jejunostomy
4. Surgical jejunostomy
III. INSERTING THE ENTRAL FEEDING TUBE
 Verify the patients need for enteral feeding
 Assess the patency of nares
 Assess the patient’s consciousness, medical history, gag reflex, and bowl sound
 Explain the patients how to communicate during intubation by raising index figure
to indicate gagging or discomfort
 Determine the size of the tube to be inserted
 Apply clean gloves
 Dip the tube with water soluble lubricant
 Gently insert the tube through h nostril to back of the throat & Check the position
with penlight
 Have patient flex head towards chest after tube passed through nasopharynx
 Emphasize need to mouth breath and swallow during insertion. Rotate the tube 180
degree while insertion
 Obtain the gastric aspiration and check placement of tube
 Anchor the tube to nose to avoid pressure on nares
 Assist patient with head of the bed elevated to 30 -450 unless contraindicated
 Patients with intestinal tube placement, needs to be positioned on the right side until
radiological confirmation of positioning
IV. CONFIRMING TUBE POSITION
 Know the policy and procedures for frequency and method of checking tube
placement
 Only use radio-opaque tubes for enteral feeding.
  Obtain radiographic confirmation that any blindly-placed tube is properly positioned
in the GI tract prior to its initial use for administration of feed or medications.
 Bedside pH checks can also be used to check position
 Mark the exit site of a feeding tube at the time of initial placement. Observe for a
change in the external tube length during feeding.
 Observe the patients for respiratory distress
 For intermittent tube feeding patients, test the placement just before the each feeding
and medication administration
 For intermittent tube feeding patients, test the placement every 4- hrs and before the
medication administration
 In adult patients do not rely on the auscultatory method to differentiate between
gastric and respiratory placement of feeding tube.

V. ADMINISTRING ENTERAL FEEDING:

The choice of enteral feeding regimen is based on assessment of the individual needs
of the patient. The goal is to provide safe enteral nutrition and hydration appropriate to the
clinical status of the patient, taking quality of life issues into consideration.
1. Continuous feeding
Defined as feeding for 24 hours continuously either by gravity drip or feeding
pumps. Continuous feeding at low volume is often used as the first step to
commencing a patient on an enteral feeding regimen.
The formula needs to be replenished every 4-24 hours depending upon whether
the system used is decanted feed or closed system.
2. Cyclic / intermittent feeding
Enteral nutrition is stopped for a 4-16 hour period either during the day or at night.
The shorter the period of feeding, the higher the rate may need to be in order to meet the
patient’s requirements. Suitable for pump and gravity drip.
3. Bolus feeding
Defined as rapid administration of a bolus feed /water by syringe. Bolus feeding
is usually into the stomach, which has the reservoir capacity to tolerate a large volume of
feed. A prescribed volume of feed is given (such as 100-400ml)

VI. INITIATION AND ADVANCEMENT OF FEEDING:

 Start slowly and advance the rate as tolerated
 Gradually increase full – strength formulas in rate or volume until achieving goal rate
 Derermine the feeding advancement as per patients clinical condition and the type of
administered enteral feeding method
Bolus feeding- Begin the initial feeding of 50 -100 ml bolus every three to four
hours, volume increased every two to three feeding by 50 -100 ml as tolerated . Bolus
feed usually reaches the goal within 48hrs In alert patients it is often possible to begin
with 250 ml boluses and increase the volume as high as 400 ml/feed
Pump controlled feeding – Tube placement and patients conditions determine rate of
advancement. Begin continuous undiluted feeding feedings at 10-40ml/hr; advance the
rate in increment of 10-25 ml/hr every four to six hours as tolerated. Pump controlled feed
usually reaches the goal within 48hrs
VII. MONITORING PATIENTS WITH ENTERAL FEED
Adequate monitoring is vital to reduce the incidence of complications, reduce electrolyte
and metabolic abnormalities and ensure adequate nutrition is delivered. The goals of
nutritional support should also be regularly reviewed
 Food chart (if appropriate) Daily
 Fluid balance charts Daily
 Weight Twice weekly, more frequently if fluid concerns
  Body Mass Index Weekly
 Temp/ pulse/ respiration Daily
 Stool output and consistency charts Daily
 Blood sugars Random daily initially until stable, more frequently if unstable
 Medication Daily
 Nausea and vomiting Daily
 Gastric Residual Volumes 4 hourly where clinically indicated
 Feeding Tube position As per care plan
 Feeding Tube insertion site As per care plan
 Tube integrity Daily
 General clinical condition of patient
 Aims and Objectives of feeding
 Sodium Potassium Urea Creatinine Daily until stable then twice weekly
 Glucose If needed
 Liver Function Tests Baseline then as needed
 Albumin Weekly
 Lipid profile
 Full blood count Twice weekly until stable then weekly
 Vitamins, minerals and trace element
VIII. PREVENTION OF FEEDING TUBE OBSTRUCTION
 Use 30 to 60 cc syringes, avoid small syringes due to high pressure.
 Use a large diameter tube when possible if formula is concentrated
 Flush with30 - 50 mls warm water every q4h – q6h in continuous feeding and before
and after all intermittent feeding, pre and post medication administration
 Use liquid medications by crushing thoroughly whenever possible. Some
medications can be crushed after consultation with pharmacy.
 Flushing pre and post gastric residual checks can also prevent the gastric acid
accumulation and henceforth formula coagulation.
 Flush with Carbonated beverage (approximately 5 ml).
 Don’t use acid liquids such as juices through the tubes
IX. GASTRIC RESIDUAL EVALUATION:
 Measure the residual volume by aspirating fluid through 50 ml syringes. Measure the
volume and return the fluid to stomach
 Check levels every four to five hours immediately after tube insertion, until the
volume is consistently less than 150 ml. Once consistent, check residuals on a daily
basis or whenever a sudden changes in condition arises
 If residuals are greater than the previous hour's feeding volume this is considered a
significant volume. Hold tube feeds for one hour.
 If the tube is in the duodenal or jejunum no need to evaluate residual volume
X. PREVENTION OF ASPIRATION:
 Position the patient with head and shoulder elevated to 30 – 45 degree above chest at
all times during feeding and immediately after following feedings
 If it is not possible to elevate the bed head due to the patient’s medical condition, the
need and appropriateness for enteral
 Feeding should be discussed with the doctors
 Check gastric residuals regularly for high risk patients q4h
 If patient continues to have a high residual, use of a prokinetic agent should be
considered.
 Consider post-pyloric feeding tube placement beyond the ligament of treitz
XI. PREVENTION OF INFECTION:
 Hands should be washed prior to preparing the feeding equipment & decanting feed
 Disposable non-sterile gloves should be worn when handling feeds or any part of the
feeding system.
  For high-risk patients, sterile gloves & disposable plastic apron should be worn.
 Closed enteral feeding systems should be used where possible.
 Administration sets for closed system enteral nutrition formulas should be changed at
least every 24 hours.
 Sterile liquid formulas should be used in preference to powdered reconstituted feeds.
 Use sterile water for flushing tubes or for enteral water infusion.
 Closed-system enteral nutrition formulas can hang for 24 hours.
 Sterile decanted formulas should have a maximum 8 hour hang-time.
 Reconstituted powdered feeds should have a maximum 4 hour hang-time.
 If preparation is required, feed and equipment should be prepared on a metal surface
which has been disinfected
 Enteral feeding pumps should be decontaminated daily.

XII. ORAL HYGIENE

Many patients receiving enteral nutrition are nil by mouth (NBM) although poor oral
hygiene will also adversely affect swallowing and nutritional intake if patients are allowed to
eat and drink. Poor mouth care will change the bacterial composition of saliva making it more
harmful if aspirated into the lungs. This will enhance the risk of aspiration pneumonia,
especially in patients unable to manage their own secretions.
Daily mouth care should include the following:
 Good oral hygiene procedures should be established at the start of enteral feeding
 Oral hygiene should be provided on a minimum twice daily basis.
 Regular brushing of teeth or dentures and gums.
 Mouth care using sponge swabs including brushing tongue and palate
 Lip salve or similar applied to lips regularly to avoid cracking.
 If mouth is persistently dry, consider use of artificial saliva and a medication review.
 A dentist should assess the patient's oral health when enteral feeding is started.
XIII. TRANSITION TO ORAL FEEDING
Patients on enteral tube feeding should be regularly assessed by the Dietician and
nurse to decide when enteral feeding can be reduced.
The following needs to be assessed and accurately documented to enable accurate nutritional
assessment:
1. Food record charts.
2. Fluid balance charts.
3. Weight (twice weekly unless otherwise specified).

CONCLUTION:
Adequate nutrition should be a part of management protocol for critically ill patients.
Enteral nutrition is as good as parentral nutrition with added advantages of being less costly
and easier to administer. A proper protocol and adequate monitoring are key points for
ensuring successful enteral feeding. A proper protocol and adequate monitoring are key
points for ensuring successful enteral feeding