A Ward Class on Nasogastric Tube and Enteral Tube Feeding

XAVIER UNIVERSITY ATENEO DE CAGAYAN COLLEGE OF NURSING

In Partial Fulfillment of the Requirement in NCM 104.1 School Year 2012-2013

Presented to: Mrs. Melanie Joy M. Bustamante, RN, MN

Presented by: Cabudoy, Caress Mae Cago, Aira Marie Lacsina, Charmaine Faye Pagute, Dwight Erwin Dexter

February 6, 2013

NASOGASTRIC TUBE AND ENTERAL FEEDING DEFINITION: Nasogastric tube (NGT) feeding is giving of liquid food through a tube that is inserted into the stomach through the nose. It is recommended for a person who is unable to chew or swallow. - Most common first line route. - Easy to place at bedside by nursing staff. - Use small flexible tubes to avoid nasal skin erosion. - Check position via auscultation/aspiration of gastric contents and gastric PH, as per nursing protocol. If in doubt regarding position by auscultation and aspiration then confirm with abdominal X-ray. - Literature review suggests no significant difference in pulmonary aspiration between gastric and post-pyloric feeding for patients with normal gastric motility. - Check residuals to evaluate tolerance. - Keep HOB elevated with standard aspiration precautions Percutaneous Gastrostomy Tubes (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is
passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate.

Can be placed with endoscopic or radiographic guidance. GI consult for endoscopic placement, Interventional radiology for radiographic placement. General Surgery will place PEG in OR but only in combination with another procedure (usually tracheostomy). Post-placement may start enteral feeds between 6 and 24 hours. Keep tube clamped until able to start enteral feeds. Recent studies support early enteral feeding with PEG tubes (6-12 hrs), however, many providers continue to support a 24 hour period of gravity drainage prior to feeding. Tube is secured to skin by outer flange that is carefully positioned during the procedure to prevent tube migration and keep stomach opposed to abdominal wall . Do not manipulate this flange or place any gauze beneath it as this may loosen the approximation with the abdominal wall. Flange should be loosened after 5 days by physicians performing the procedure to prevent skin necrosis. The PEG external bolster (skin disc) should be rotated every 8 hours for the first 24 hours. Do NOT loosen the bolster to rotate it! check the measurement of PEG depth before and after rotation to ensure that it has not changed. The tube should also be secured to the skin with tape to avoid traction on the tube leading to dislodgment. Care of site: Soap and water, Gauze over tube and tape securely for 24 hours.

INDICATION:
1. Multisystem Trauma a. Patients anticipated to require > 48 hrs of mechanical ventilation. b. Non-intubated patients with altered mental status or closed head injury that precludes oral intake. c. Patient's with an open abdomen should not receive enteral feeds until confirmation otherwise from primary surgical team Burn Patients Surgical/Neurology/NeuroSurgery Patients

2. 3.

4. 5.

6.

All necrotizing fascitis patients admitted to the ICU. Patients anticipated to be NPO more than 5 days or with severe malnutrition on admission. Pre-operative patients with malnutrition and altered mental status. All patients less than 15 years of age should be carefully evaluated for the need for early nutrition support MICU Patients All patients receive enteral feeds <48 hours after admission with exception of the following: a. Expected to be NPO less than 3 days. b. Acute pancreatitis unless decision is made for post-ligament of Treitz feeding tube placement. c. Ongoing GI bleeding. d. Bowel obstruction or ileus. e. Need for continued NPO status due to procedures. Medicine Wards a. Patients expected to be NPO for any reason for more than 5 days unless they have a contraindication to enteral feedings such as those above, provided they give consent. b. Special attention paid to patients who are nutritionally compromised at admission

a. b. c. d.

A. PREPARATION
1. Gather the required items: A. Recommended feed B. Measuring jug for feed C. Cup to receive stomach contents D. Water for flushing E. 60m1 syringe F. pH indicator paper in a container 2. Wash and dry hands. 3. Prepare the formula feed as recommended: Pour required amount of feed into a measuring jug. Keep the balance in the fridge.

B. FEEDING STEPS
1. Raise the patient to a sitting position or at least 45 degrees. 2. Check that the tube is in the stomach by using the following method: Kink the feeding tube and connect the tip of a syringe into the feeding tube. Gently draw back the plunger to withdraw the stomach contents. Dip a pH indicator paper into the stomach contents if any. It should range from 1 to 6. If there is no stomach contents, do the following: Check the mouth, ensure no coiling of tube Dip the tube into a cup of water: there should not be a continuous bubbling. Dip the tube into a cup of water

DO NOT FEED if bubbles are present. Seek professional help. 3. Check for undigested feeds from the previous feeding by withdrawing all the stomach contents with a 60 ml syringe.

If the amount is less than 120m1s. return the stomach contents and start to feed the balance amount.

Example: Feed to be given is 200m1 Stomach contents: Balance water: Water flushes: Total . 80 ml 120m1 20 ml 220m1(total volume)

Note; Total volume should not more than 300 mls for each feed

If the amount is more then 120m1 return the stomach contents, omit feed and check again 2 hours later. 2 hours later: Feed if the amount is reduced Do not feed if the amount is still 120m1s, or more. Contact your health care professional. 4. Place the tip of the syringe into the feeding tube and hold it at the level of the patient's head. Hold it at the level of the patient's head 5. Pour the prescribed feed into the syringe and allow it to flow slowly. 6. Observe the patient's tolerance while feeding.
C. AFTER FEEDING 1. 2. 3. 4. 5. Flush the tube with 20m1 of water (unless recommended otherwise by the healthcare professional). Kink the tube and disconnect the syringe. Replace the feeding tube stopper. Do not turn or lay patient flat for at least half an hour after the feeding. Wash the feeding set with water. Remove excessive water and store the feeding apparatus in a clean container. Wash and dry your hands. a. Gastric feeds - Check gastric residual volumes every 4 hours. Hold tubefeedings for residuals greater than 200cc. Reinfuse the residual and recheck in 2 hours. Notify MD if residuals remain so high that the patient cannot be fed for more than 2 hours. - Feeds should also be held for increasing abdominal distension and/or emesis. Notify MD. DO Keep the mouth and nose clean. Perform oral care 3 times a day. Ensure that the apparatus is clean and dry before each use. Wash and dry your hands before and after preparing the feeds. Check for expiry date of the enteral feeds formula before use. Clean the top of the can with a damp paper towel before opening. Store the feeds in cool dry place. Refrigerate balance feed immediately.

Monitoring tolerance

DO NOT:

Feed if patient coughs, chokes or has difficulty breathing. Use force to unblock the tube Mix medication with the formula feed. Use microwave to warm the feed.
Breathlessness Restlessness Nausea Vomiting Diarrhea Bloated stomach Aspirate more than 120m1s on 2 consecutive times Minor complications include nose bleeds, sinusitis, and a sore throat. Sometimes more significant complications occur including erosion of the nose where the tube is anchored, esophageal perforation, pulmonary aspiration, a collapsed lung, or intracranial placement of the tube.

Withhold feeding and seek professional advice if you observe:

The complications of nasogastric tube feedings may include:

obstruction of the tube perforation of the tube tube migration out of correct position regurgitation and aspiration of the feeding diarrhea nausea and vomiting (Place NG to suction, check function. Check existing NG function) abdominal distention, cramping and discomfort from too much feeding or a rate of feeding that is too rapid

COMPLICATIONS Feeding Intolerance

ASSESSMENT Assess for nausea, vomiting, abdominal distension and pain:

NSG MANAGEMENT Perform a physical examination of the abdomen including assessment for presence of abdominal pain and bowel sounds. Feeding should only be stopped abruptly for those patients who demonstrate overt regurgitation or aspiration.

RATIONALE Presence of nausea, vomiting, abdominal pain, distension, flatus, stool and bowel sounds, and abnormal abdominal X-ray may indicate tube-feeding intolerance. Inappropriate cessation of feeding may contribute to inadequate caloric intake and may not be physiologically

Declogging

Use warm water to declog obstructed feeding tubes. If unsuccessful, pancreatic enzyme with sodium bicarbonate may be used. (D4 ASPEN, 2005)

Diarrhea

Patients on antibiotics should be monitored for symptoms of diarrhoea.

Do not dilute enteral feeds.

sound. Warm water is the most effective irrigant in declogging blocked feeding tubes. However, a solution of digestive enzymes (pancrealipase) mixed with sodium bicarbonate (to activate the enzyme ) has been shown to be fairly effective in dissolving formula occlusions. -Characteristics of the formula composition, method of administration and contamination of formulas can cause diarrhea in tube fed patients. The antibiotics reduce bacteria within the colon that is necessary for the digestion of fiber and subsequent release of shortchain fatty acids. -Half strength dilution of enteral feeds does not decrease the patients diarrhea episode. It is not recommended to dilute formulas as osmolarity of formula does not cause diarrhea. -Supplementation of an enteral formula with soluble fiber significantly reduces the incidence of diarrhea in patients on enteral feeds. Larger syringes reduce collapse of the feeding tube upon aspiration. Smaller syringes exert a higher pressure per square inch and may cause the tube to collapse.

Aspiration Pneumonia

unexplained fever spikes; changes in sputum colour or consistency; changes in breath sounds; worsening oxygenation and setbacks in ventilator weaning. Be more alert when feeding elderly patients via nasogastric tube.

For patients with diarrhea, use enteral feeds with soluble fibre but do not dilute standard feeds. Use a 50 ml syringe to aspirate gastric content from nasogastric tubes that are 12F or less.

Possible Metabolic Complications of Enteral Feedings

Possible Etiology Hyponatremia Possible Causes Excessive free water, abnormal sodium loss Inadequate hydration, increased fluid losses, Diabetes Insipidus Anabolism/refeeding, diuretics/medications Renal Failure, metabolic acidosis, catabolism, GI bleed, Acute dehydration Anabolism/refeeding Renal failure Anabolism/refeeding, diuretics/medications Possible Treatment Change to Fluid restricted formula, discontinue water boluses/IVF, replace sodium losses Add or increase water boluses or IVF Supplement potassium Correct imbalance, Change to renal formula as appropriate Supplement phosphorus Change to renal formula, phosphate binders if necessary Supplement magnesium

Hypernatremia Hypokalemia Hyperkalemia Hypophosphatemia Hyperphosphatemia Hypomagnesemia

http://www.jameslau88.com/nasogastric_tube_feeding.html
(McClave, Snider, Lowen, McLaughlin, Greene, McCombs, Rodgers, Wright, Roy, Schumer and Pfeifer, 1992 and McClave & Snider, 2003) (McClave et al, 1992) Lord and Harrington, 2005 as cited in ASPEN, 2005; Reising and Neal, 2005; Wilson and Haynes-Johnson, 1987) (Eisenberg, 2002; Guenter, Settle, Perlmutter, Marino, DeSimone and Rolandelli, 1991)