Learning Package

Enteral Feeding

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Previous Revision: June/95, Mar/98
Revised: March 2003
May 2005

I:\Educational Services\Projects\Learning Packages\Enteral Feeding

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 Table of Contents

Pre-Learning Package for Skills Competency 1

Purpose, indications and contraindications of enteral feeding 2

The Digestive System 3

Routes of Administration 4

Types of nasogastric tubes 5

Methods of administration 6

Medication Administration 7

Potential side effects 8

Potential complications 9

Administration of Enteral feeding 10

Skills Checklist 12

References 13

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Pre-Learning Package for Skill Competency

I. Overview

This learning package contains standard learning content. Initial and continuous
learning is required to promote competence. Self-directed learning labs related
to this skill will be provided to facilitate your learning needs.

II. Guidelines for Achieving and Maintaining Competency

• successfully performs skill under clinical supervision (using skills checklist)

• performs skill frequently enough to promote competency within the approved
clinical area
• maintains successful performance of skill as per skills checklist (peer and team
leader evaluation)

III. Process for Maintaining Competency: Roles and Responsibilities

Facilitator
• provides self-directed learning material using evidence-based references to
cover relevant theory.
• facilitates clinical practice support within clinical setting
• evaluates continued need for providing learning opportunities.

RN/RPN
• completes self-directed learning package
• attends learning lab session
• seeks additional support and resources to meet your own learning needs
• reviews and demonstrates skill to unit designated clinical support nurse until
learning has taken place (using skills checklist).
• continually evaluates own competency in performing skill

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Objectives
• Understands the purpose for enteral feeding.
• Understands the indications and contraindications for enteral
therapy.
• Describes the common routes of administering enteral feedings.
• Describes the common methods of administering enteral feedings.
• Describes side effects, managing complications and troubleshooting.
• Describes care and storage of feedings.
• Explains the procedure for administering feedings.

Purpose of Enteral Feeding

Enteral nutrition is administered to prevent or correct malnutrition and

associated complications. It provides adequate nutrition via the
gastrointestinal tract, through the delivery of complete supplementary
formulas.

Indications

• Patient unable to swallow

• Patient unable or unwilling to consume adequate nutrition orally
• The patient must have a functioning GI tract

Contraindications

• Malfunctioning GI tract (i.e. short gut syndrome, severe acute

pancreatitis)
• Mechanical obstruction
• Prolonged ileus
• Severe GI bleed
• Severe diarrhea/intractable vomiting
• GI tract fistula

TPN should be considered instead for patients with contraindications

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The Digestive System

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Routes of Administration

There are five routes of administration available for enteral feeding. The
route of administration will be determined by the predicted therapy,
recovery time and/or disability.

a) Nasogastric (nose into stomach)

This route is used most frequently due to ease of placement of the tube.
This is for short-term enteral feeding (usually less than or equal to 8-12
weeks).

b) Nasoduodenal (nose into duodenum)

This route bypasses the stomach and administers feeding directly into the
small bowel. The main advantage of this route is less risk of aspiration and
is used if gastric emptying is impaired.

c) Nasojejuenal (nose into jejunum)

This route bypasses the stomach and administers feeding directly into the
small bowel. The main advantage of this route is less risk of aspiration and is
used if gastric emptying is impaired.

d) Gastrostomy (feeding tube inserted through abdominal wall into stomach)

This is the preferred method for long-term enteral feeding. Preferred for
patients who have an intact gag reflex, have normal emptying of gastric and
duodenal contents and whose stomach is not involved in the primary disease.

e) Jejunostomy (feeding tube is inserted through abdominal wall into jejunum)

This route is used for long-term enteral feeding for patients with impaired
gastric emptying.

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Types of Nasogastric Tubes

a) Levine vented tubes (size 8,10, 12, and 14)

Patients usually are not fed through these tubes but it may be ordered by
the physician. The vent must be tied off before feeding or else the formula
will escape out the vent.

b) Kaofeed Tubes
These tubes have a small diameter with a weighted tip to promote movement
of the tube into the small intestine.
These tubes may be inserted 6 to 10 inches longer than the GI system to
allow the end of the tube to move past the stomach.

EHC: Currently kaofeed tubes are inserted by a certified RN on the unit

and placement is confirmed by x-ray.

BMHC/GHC: Currently kaofeed tube are inserted in diagnostic imaging.

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Methods of Administration

There are four different methods of administration.

a) Continuous method
A slow feeding administered over a 24-hour period. The rate is determined
by the dietician/physician in accordance with the patient’s nutritional
requirements.

b) Modified continuous
A slow feeding divided over a 24 hour period.
i) continuous during day hours (17 hours) then off overnight.
ii) 3 hours ON (= 18 hour feeding per day)
1 hour OFF (=6 hours off feeding per day)
This method is recommended for the neurologically impaired patient.
Studies indicate these patients do not tolerate enteral feeding well in the
early post-injury period.

c) Intermittent method
A slow feeding administered over 30-45 minutes, 4-6 times daily. The
volumes usually range from 250-400 mls per feeding but the rate will depend
on the patient’s nutritional requirements, which are assessed by the
dietician.
With long term care patients, we usually start enteral feedings continuously
and progress to the intermittent method of feeding to allow breaks between
meals and at night.

d) Bolus method
A single feed administered rapidly (over 15 min), 4-6 times per day. Usually
the volume ranges from 250 – 400 ml per feeding. This method is not
recommended as it causes numerous side effects.

To ensure adequate nutritional intake while the patient is on enteral therapy, the
patient should be weighed: (minimum frequency)
• Daily in ICU
• Weekly on the ward
• Monthly on complex continuing care

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Medication Administration

 Use liquid preparations when available.

 Before administering a thick liquid, dilute it further with warm water.
 When you have to crush a tablet, be sure to crush it as fine as possible and
dissolve in warm water.
 Check tube placement.
 Question you need to ask yourself:
1. Where is the placement of the tube?
2. Where is the drug activated, mouth stomach or intestine?
3. Is the drug to be taken on an empty or full stomach?
 Never administer medication while the feeding is infusing. Stop the infusion,
and flush before administering the medication.
 There are some medications that cannot be delivered through the tube:
 Enteric coated or slow release, crushing may alter their effect.
 Drugs that come only in chewable or SL form because they need to be
absorbed by the blood vessels in the mouth. Crushing them renders them
ineffective.

Not all drugs can be crushed (eg. Capsules, enteric coated and lng actin/slow
release drugs) The coating of these drugs is designed to protect the stomach from
irritation or protect the drug from destruction from stomach acids.

Adequate preparation saves nursing time

Whenever possible, liquid medications are preferred to crushed tablets.

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Side Effects

Gastrointestinal side effects are the most common side effect associated with
enteral feeding. Some studies indicate they occur in over 25 % of patients being
fed.

POTENTIAL SIDE EFFECTS

SIDE EFFECT REASON ACTIONS

DIARRHEA • Feedings are administered too quickly • Do not stop feedings
• The patient has a lactose intolerance unless specifically
(All formulas at WOHC are lactose ordered by the
free) physician.
• A contaminated formula is administered • Investigate potential
(e.g. formula is hung too long in sun or causes and notify the
tubing not cleansed properly. ) physician and dietician.
• Use of antibiotics may lead to
overgrowth of C. difficile toxin leading
to frequent loose stools.
• Protein malnutrition (hypoalbuminemia)
• Malabsorption states
• Lack dietary fibre.
NAUSEA/VOMITING • Feedings are administered too quickly. • If vomiting occurs, stop
/BLOATING • Intolerance to concentration and/or feeding, turn patient to
volume exists. the side, assess need
• Reduced gastric motility associated for suctioning and
with gastric retention. notify physician and
• Feedings are too cold dietician.
• Paralytic ileus
• Obstruction
CONSTIPATION • Inadequate bulk in the diet • Reassess fluid status
• Associated with medication therapy and activity level
• Reduced gastrointestinal motility • Notify physician and
• Associated with decreased level of dietician
activity
• Inadequate fluid intake
• Advanced age
MECHANICAL • Skin and/or mucosal irritation • Hypoallergenic tape
• Pressure against nares of nose • Change dressings once
per day with Normal
Saline
• Secure taping of tube

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 POTENTIAL COMPLICATIONS

COMPLICATION REASON ACTION

ASPIRATION • Usually occurs after vomiting
• Altered gag reflex
• Reduced gastric emptying
• Decreased level of consciousness
• Deflated tracheostomy cuff
• This complication is particularly
significant for the brain injured patient
who often has gastroesophageal reflux,
altered gag reflex and an intolerance to
tube feeding in the acute stage.
DEHYDRATION May be secondary to:
• diarrhea/vomiting
• concomitant medication therapy (i.e
lasix)
• fever
• inadequate hydration
• excessive electrolyte intake
BLOCKED TUBES • Small bore feeding tubes
• Medication administered through feeding
tube
• Curdling of the feed
PULLING OUT TUBES • Patient pulls out feeding tube
• Stop feeding, turn patient to
the side, assess need for
suctioning and notify
physician and dietician.
• Whenever possible, a
nasojejunal tube feeding
will help prevent
aspiration.
• Feed with HOB elevated 30-
45 degrees
• Measure residual amount and
report to physician if
necessary.
• It is especially important to
monitor the elderly, any
patient unable to express
thirst, and the cognitively
impaired for signs and
symptoms of dehydration.
• Adequate water flushes
should be assessed and
adjusted by the
dietician/physician
• Assess patient for signs and
symptoms of dehydration –
tissue turgor, mucous
membranes, thirst and urinary
output.
• Adequate water flushes:
before and after medication;
after residuals; q 4h during
continuous feeds; after
intermittent feeds.
• Rinse feeding container
properly
• Notify physician
• Cover gastrostomy site with
4x4 dry dressings.

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 William Osler Health Centre

TITLE: Administration of enteral feeding

PURPOSE: To administer enteral nutrition via a feeding tube.

RESPONSIBILITY: Registered Nurse/Registered Practical Nurse

EQUIPMENT:
Disposable feeding system
Disposable K-basin
60 ml piston syringe
stethoscope
feeding

ACTIONS INCLUDING:

1. Check physician’s/dietitian’s order for type of feeding, strength, amount and

rate of administration.

2. Assemble equipment. Check that feeding is at room temperature (If feeding is

kept in the refrigerator, remove and allow to stand at room temperature for
one hour)

3. Check date, time of opening, name and expiry date on feeding.

4. Wash hands.

5. Establish patient’s identity by asking their name and/or checking arm band.

6. Prepare patient: Explain the procedure to the patient and elevate head of bed
to 30 degrees.

7. Prepare feeding: Shake contents of feeding, clean top of can, pour correct
amount of feeding into administration set (Maximum 4 hours X rate should be
hung at one time).

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8. Check tube patency, placement.

 instill 5-10 ml air through tube while auscultating patients’ stomach

with stethoscope (A gurgling sound will be heard as air enters the stomach)

9. Do Not check gastric residuals unless ordered by Dietitian or MD.

If ordered:
 Aspirate gastric contents by slowly withdrawing fluid using a large
piston syringe.
 The MD/Dietitian must specify the amount to be withdrawn and the
actions to be taken related to the withdrawn contents.
 If the residual is less than the acceptable amount as specified in
order, re-instill contents.
 If the residual is greater than the acceptable amount specified in the
order, discard the contents and follow the orders regarding actions to take.
Notify the physician/dietitian.

10. Connect feeding system tubing to patient’s feeding tube

11. Set feeding pump to appropriate rate or open roller clamp on feeding system
and adjust flow rate as per order.

12. Administer warm water by syringe as ordered on completion of intermittent

feeding or q 4hrs on continuous feeding.

13. Disconnect feeding at the end of prescribed period when feeding is finished.

14. Cap feeding tube.

15. Using tap water, rinse feeding system, syringes and k-basin.

ADMINISTRATION OF ENTERAL FEEDING

SKILLS CHECKLIST

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Name:_______________________________ Date:_____________________________

Evaluator:____________________________

S = Satisfactory performance
U = Unsatisfactory performance

ACTIONS S U
1. Assembles equipment.

2. Checks order for type of feed, strength, amount and rate of administration.

3. Check date, time of opening, name and expiry date of feeding.

4. Prepare patient: a) explain procedure to patient

b) elevate H.O.B

5. Prepare feeding: a) wash hands

b) shake contents of feed
c c) open and pour correct amount into administration set.
d) flush tubing to remove air.

6. Check tube patency, placement and residual: a) instill 10 cc air while auscultating the
stomach
b) aspirate stomach contents – able to
describe what is done if residual too
high.
7. Connect feeding tubing to patient tube.

8. Open roller clamp and adjust rate (pump setting).

9. Administer water as ordered.

10. Disconnect feeding tubing and cap patient tube.

11. Rinse system and syringes.

12. Documents appropriately.

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 REFERENCES

Gottschlick et al; Nutrition Support Dietetics – Core Curriculum, second edition,

(1993). American Society for Parenteral and Enteral Nutrition.

Hodges, M., Tolle, W.(1994). Tube-Feeding decisions in the elderly. Clinical Ethics.
10(3).

Miller, D. (1995). Giving meds through the tube. RN, Jan.

Ross Laboratories. (1990). Tube feeding complications – A guide to problem

solving.

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