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PURPOSE: To provide a “best practice” guideline for the management of enteral nutrition support in adult
patients based upon current research. To standardize practice throughout the organization.
A. Clean Technique
• Wash hands prior to handling feedings and administration systems
• Inspect for dents and expired product
• Shake product to ensure proper mixing
• Rinse top of cans with water before opening
• Use clean technique
• Assemble feeding systems on a clean, dry, disinfected surface.
• Label feeding bag with patient name, product name, rate and
time/date hung. Limit hang time of feeding to 8 hours
• Note location of tube termination and document on flowsheet
(ie post-pyloric, naso-jejunal)
• Treat bag as a closed system (no additives without MD order)
• If additives placed in formula bag, hang time decreases to 4 hours
• Before adding additional tube feeding, let current formula
completely run out from bag. Flush any remaining feeding from
tubing. (coordinate with scheduled flush)
• Change entire administration set every 24 hours
• Discard all opened cans of formula that are not infused
• Prosource , No Carb - Single serving liquid protein supplement- 15 grams protein each
- Flush tube with 30 ml water
− Mix each packet Prosource with 30 ml tap water (subtract water from routine fluid
flush or bolus)
− Deliver Prosource bolus via syringe
− Flush tube with 30 ml water
• Arginaid
− Mix each packet Arginaid powder with 60 ml water in styrofoam cup with spoon, mix
until fully dissolved
− Flush feeding tube with 30 ml water
− Deliver Arginaid bolus via syringe
− Flush tube with 30 ml water
• GlutaSolve
− Flush feeding tube with 15 ml water
− Mix each packet GlutaSolve with 60 ml warm water for 20 seconds in a styrofoam cup
with spoon and infuse immediately via syringe
− Flush feeding tube with 15 ml water
1. Tube Position
• OGT/NGT placement should be confirmed
a. q shift
b. after severe coughing
c. after vomiting or retching
d. if mark at exit site of tube is in a different position or not visible
e. if a question exists regarding placement, feeding and medication delivery should
be held until placement confirmed
2. Head of bed elevation
• minimum 30 – 45 degrees for continuous feedings via gastric route
• 45 – 90 degrees during and 30 minutes after intermittent feedings
• Hold all tube feeding if HOB needs to be lower because of hemodynamic instability.
• Hold gastric feedings if HOB decreased for bedside procedures.
3. Frequent suctioning in ventilated patients.
4. Check gastric residuals (GRV)
• Do not check residuals in post pyloric feeding tubes or jejunal feeding tubes
• Check gastric residual volumes q 6 hrs (use 60 ml syringe w/Luer tip).
• Gastric residual volume should be checked in all gastrically fed patients regardless of
type of feeding tube (NGT, OGT, Gastric Corpak/Keofeed, PEG)
• All residual volumes must be documented on the flow sheet even if residual volume
is “0” ml
• If GRV < 250 ml- re-feed aspirate and continue tube feedings in patients without
other clinical changes
• If GRV 250 – 350 ml- re-feed aspirate in patients without clinical changes or change
in GI exam. Hold tube feedings for 1 hour and re-check residual volume.
• If GRV > 350 ml or patient experiences emesis- hold tube feeding, discard aspirate,
notify physician and document on flow sheets
•Stop TF
•Discard
aspirate/emesis
•Notify MD
•Monitor clinical
condition(pressors,
hemodynamic instability)
•Monitor GI exam (firm,
distended,
N/V)
•Consider promotility agent
(e.g.metoclopramide)
•Verify tube placement & assess
Recheck GRV in 4
Nutritioncaresubcommittee/feb20 hours
04
Blue dye is no longer recommended for routine use in enterally fed patients.
Case reports have associated negative patient outcomes caused by the systemic absorption of
blue dye in critically ill enterally fed patients.
A. General considerations
B. Preparation of Medication
1. Crushing Tablets
• Crush tablets as finely as possible. Mix powder with 15-60 ml tap water depending on tube diameter.
If tablet is uncovered, wrap in clean paper towel before crushing.
2. Thick Liquids
• Dilute with 15-30 ml of water. Very concentrated liquids should be diluted with 30-60 ml.
4. Dilution
• Dilute medications that should be given with meals to avoid GI irritation.
• Dilute hypertonic or irritating medications with at least 15-30 ml of water to avoid GI irritation.
- This formula can be used to calculate the exact amount of water needed to bring the osmolality
of the hypertonic liquid medication down to isotonic levels:
- Final volume = volume of liquid med x mOsm of liquid med
desired mOsm (300-500)
- Example: a dilution with 30 ml of water can reduce a 10 ml amount of medication with an
osmolality of 2000 mOsm/kg to 500 mOsm/kg.
1. Liquid Antacids
• Administer into feeding tubes with the tip placed in the stomach only.
• Avoid giving via feeding tubes < 10 french in size.
• Aluminum containing antacids (e.g. Amphogel/ aluminum hydroxide, Maalox, Mylanta)
should be given 15 minutes after all other medications have been administered.
• Preferably, give the antacid following a feed (bolus or intermittently fed patients) and flush the tube
with 10-15 ml of warm water prior to administration.
3. Antibiotic Agents
• Clarithromycin and ciprofloxacin suspensions should NOT be administered via feeding tubes as they
clog easily. Used crushed ciprofloxacin tablets for medication administration via feeding tubes.
4. Gastrointestinal Agents
• Esomeprazole may be administered by opening and mixing the contents of the capsule with 25-50
ml of water or apple juice and giving immediately. Then flush the tube with 15 ml of water.
• Sucralfate should be administered into feeding tubes with the tip placed in the stomach only.
• Pancreatic enzymes (Creon, pancretin, Pancrease, pancrelipase) should be administered by
opening and mixing the contents of the capsule with 10-15 ml of apple or cranberry juice and given
immediately followed by flushing the tube with the juice. Then flush the tube with 15 ml of water.
5. Carbamazepine
• This suspension should NOT be given along with other medications or diluted with other liquids.
6. Phenytoin
• Hold tube feeds 1 hour before and 1 hour after dosing.
• Dilute phenytoin suspension with 30ml of water.
• Monitor blood levels of phenytoin.
• Phenytoin can not be delivered via J tube.
7. Ciprofloxacin
• Hold tube feeds for 1 hour before and 2 hours after dose is administered.
8. Moxifloxacin
• Hold tube feeds for 2 hours before and 2 hours after dose is administered.
A. Patient/Family Education
1. Explain procedure for enteral nutrition
2. If possible, teach patient to report signs/symptoms of intolerance such as nausea, abdominal
cramping, abdominal fullness
3. Discuss patient’s need for long term nutrition support if appropriate
B. Aspiration Precautions
1. HOB Elevation
2. Gastric Residual Volumes (GRV)/frequency/times/appearance
C. Fluid bolus (fluid and volume)
D. Weight
E. Feeding prescription
F. Feeding formula, rate, total volume delivered over 24 hours
G. Feeding hold with reason
H. Tube insertion
I. Confirmation of tube placement minimum of q shift (naso-gastric)
J. Feeding tube type and tip placement
K. GI exam including bowel sounds, tenderness, distention, flatus, nausea, vomiting, stooling (character,
volume, frequency)
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