Which nursing action is appropriate when administering an enteral feeding to a patient?

Enteral feeds help maximize nutrition for patients in a variety of health care settings.  It is estimated that 345,000 people in America receive nutrients from tube feedings (Megan, 2011). Alarmingly, 60% of patients who receive nutrients through a tube will develop aspiration pneumonia (Megan, 2011). Multidisciplinary teams decide on a  patient’s nutritional needs and write orders for formula feeding when a patient requires nutritional supplementation by alternative feeding device. It is the nurses however who independently administer the nutrition and ensure the process is delivered accurately. Nurses also are the ones who  observe and notice when a patient is not tolerating tube feeding or when the patient is tolerating feeding and their feeding should be advanced to increase nutrition.

Many patients experience malnutrition at some point which can occur when a patient’s caloric intake does not meet the body’s metabolic demand.  The importance of nutritional screening is to the point where the Joint Commission mandates every patient admitted to an acute care organization receive a nutritional screening within 24 hours of admission (Mauldin & O’Leary-Kelley, 2015).  Although a  nutritional screening is more comprehensive than a feeding history, the patient’s feeding history should be included in the nutritional screening in addition to the  patient’s medical history, physical assessment, pertinent lab values as well as  a malnutrition assessment. (Lippincott, Williams & Wilkins, 2015).   For children and infants the frail and elderly patients receiving enteral nutrition and/or on formula, it is important to ask questions related to feeding and formula intolerances.  

Patient positioning can help facilitate gastric emptying and prevent aspiration of feed due to gastric reflux.  Keeping the head of bed (HOB) elevated at least to 30 degrees (45 degree is ideal) helps prevent gastric reflux that increases the risk for aspiration (Stewart, 2014).  If the patient’s head of bed needs to be lowered for patient care or an intervention, pausing feeds will help prevent aspiration (Stewart, 2014).  However, it is is of great importance to monitor the amount of time a patient’s feeds are paused for care or intervention.  Interruption of feeds for long periods and/or frequent interruptions can negatively impact the patient’s nutrition (Lippincott, Williams & Wilkins, 2015).   A patient’s age and/or developmental level may impact his/her ability to understand the need to remain in a particular position for feeding (Lippincott, Williams & Wilkins, 2015).  The nurse may consider positioning aides to help maintain a safe feeding position. A patient’s medical condition can directly affect the ideal  positioning. A pre- or post-operative patient may have mobility restrictions that may require him/her to remain flat (Lippincott, Williams & Wilkins, 2015).  Unique needs are important considerations when initiation and/or continuing feeds.  

Prior to the initiation of feeds, tube placement should be confirmed. If the tube has been inadvertently placed into the lungs, feeding may result in morbidity or mortality.  When the tube placement is in question the patient needs an x-ray to verify placement (Lippincott, Williams & Wilkins, 2015).  Cuffed endotracheal tubes and/or cuffed tracheostomy tubes do not prevent feeding tubes from being placed in the lungs.  It is also possible to check an aspirate by injecting 5 to 10 ml of air into the feeding tube and then slowly pulling back an aspirate sample. This aspirate can be tested for pH; a gastric pH is normally less than 5 (Lippincott, Williams & Wilkins, 2015).  Once placement is confirmed, it is helpful to mark the exit spot with a permanent marker or piece of tape. If numbers are pre-printed on the tube, it is important to document the exit mark number.  Remember feeding tubes can coil in the stomach and/or esophagus so the exit mark and/or exit number do not confirm definitive placement.  (Bourgault, Heath, Hooper, Sole, & NeSmith).

It is vital to confirm the provider’s nutrition/diet order prior to providing the patient enteral nutrition.  There are situations when the diet order may change frequently and if the order is not verified prior to administration,  formula may be administered incorrectly.  A feeding order should include the  patient’s identification information, type of formula, delivery device, method and rate (Bourgault, Heath, Hooper, Sole, & NeSmith).  The type of formula should be confirmed according to patient’s needs and medical conditions.  Actual administration of feeding involves gathering the proper equipment, supplies, formula and ensuring delivery method/rate according to the order (Lippincott, Williams & Wilkins, 2015).

Monitoring the patient’s nutritional status during the hospitalization helps to identify if the patient’s nutritional goals are being met.  Weight gain and/or loss can be monitored through daily weights (Bourgault, Heath, Hooper, Sole, & NeSmith, 2015).  Strict hourly intake and output provides a snapshot of a patient’s current fluid balance and helps assess for pending dehydration or fluid overload.  Monitoring the patient’s bowel sounds, flatus, and bowel movements help determine appropriate GI motility before and during feeding.   Malnutrition increases a patient’s risk for developing pressure ulcers therefore, it imperative to assess the skin integrity.  The nurse must also monitor for signs and symptoms of fluid overload (Bourgault, Heath, Hooper, Sole, & NeSmith, 2015).  It is also necessary to assess for skin breakdown around the feeding tube site.  Particular care must be taken to keep the skin and mucosa intact around nasally or orally inserted feeding tubes (Lippincott, Williams & Wilkins, 2015).  Laboratory studies, particularly chemistry studies, provide assessment of electrolyte imbalances and/or glucose levels (Lippincott, Williams & Wilkins, 2015).  

There are a wide range of risk factors associated with tube feeding including functional, developmental and structural abnormalities.  Age plays a determining role in the risk of requiring a tube feeding.  Infants and/or children that do not have the cognitive or developmental ability.  An impaired or declined cognitive status can affect the and/or comprehension which often may require tube feedings to provide adequate nutrition.  Older adults are also at an increased risk for needing tube feedings, especially when combined with an additional risk factor or disease process.

Tube feedings can be administered in the hospital, rehabilitation facility, skilled nursing facility and in the home.  There is increasing evidence that there are significant benefits of enteral nutrition compared to intravenous nutrition (Kudsk, 2007).  The growing movement toward enteral feedings necessitates nurses to understand the need, risk factors, proper patient positioning and importance of tube placement.  The knowledge will aid the nurse or healthcare professional to provide optimal patient care which will in turn improve patient outcomes.

References

Bougault, Heath, Hooper, Sole, Nesmith. (2015). Methods used by critical care nurses to verify feeding tube placement in clinical practice.  Critical Care Nurse, 35(1), 1-7. doi: 10.4037/ccn2015984

Kudsk, K. A. (2007). Beneficial Effect of Enteral Feeding. Gastrointestinal Endoscopy Clinics of North America, 17(4), 647–662. http://doi.org/10.1016/j.giec.2007.07.003

Lippincott, Williams & Wilkins. (2015). Tube Feeding.  In Lippincott’s nursing procedures (7th Ed.).  [Kindle DX Version].  Retrieved from www.amazon.com

Rakel, R., & Bop, E. (Eds.) (2011). Conn’s current therapy. Philadelphia, PA: Saunders, Elsevier.  

Stewart, M.L. (2014).  Interruptions in enteral nutrition delivery in critically ill patients and recommendations for clinical practice.  Critical Care Nurse, 34(4), 14-22.  doi: 10.4037/ccn2014243

Megan, T. (2011).  Enteral Nutrition Intolerance in Critical Care.  Critical Care Nurse, 13(2).  Retrieved from: http://www.todaysdietitian.com/newarchives/020911p30.shtml

Stewart, M.L. (2014).  Interruptions in enteral nutrition delivery in critically ill patients and recommendations for clinical practice.  Critical Care Nurse, 34(4), 14-22.  doi: 10.4037/ccn2014243