Enteral Feeding Tubes: Naso/Orogastric Placement and Management and Nasojejunal Management

A healthcare prescriber’s order is required for enteral tube placement and discontinuation of the tube.
The registered nurse (RN) or licensed practical nurse (LPN) accomplishes naso/orogastric enteral feeding tube placement by passing a small-bore tube (which may have a weighted or nonweighted tip) through the nostril or mouth, into the oropharynx, and then through the esophagus to the stomach. Nasojejunal tubes, which originate at the nose and terminate in the jejunum, may be placed by physicians or skillvalidated RNs.
Nasogastric and orogastric enteral tube placement is used for both diagnostic and therapeutic purposes. Nasojejunal tubes are primarily used therapeutically for administration of nutrition.
Selection of an enteral tube depends on the intended purpose (Chart 39-1); choose the smallest size tube

that will achieve the intended function while minimizing child discomfort. Tubes may have single, double, or triple lumens.
Enteral tubes are indicated for the following:
- Decompression of the stomach and proximal small intestine
- Evacuation of blood, secretions, gas, and ingested drugs or toxins
- Control of bleeding from gastric and esophageal varices
- Administration of medications, fluids, or nutrition
- Sampling of gastric contents for analysis
- Lavage or irrigation
Intake and output through the enteral tube is monitored every hour or as determined by institutional policy, the child’s clinical condition and intended purpose of the tube.

CHART 39-1 Enteral Tubes

Tube Characteristics

Single-lumen weighted or nonweighted; small-bore soft tube. Many types have a water-activated lubricant impregnated in tube material. Usually made of polyurethane or silicone. There is one opening at distal tip.
Single or double-lumen nonweighted tube; Larger-bore sized tube. Opening at distal tip and multiple openings spaced along distal side of tube. Salem Sump: doublelumen, less-flexible tube. Vented segment which usually is connected to low continuous suction to prevent suction of gastric mucosa. Levine tube: more flexible, single lumen, unvented. Usually connected to intermittent suction.
Triple-or quadruple-lumen nonweighted tube. One to two lumens are for aspiration from tip that terminates in the esophagus and/or stomach and one to two ports for inflation of balloons terminating in respective locations.

Purpose

Gastric or transpyloric feedings
Gastric decompression for ileus, obstruction, hastens return of bowel function, decreases postop nausea and vomiting, decreases risk for wound dehiscence. Gastric lavage.
Therapeutic interventions for GI bleeding. May not be used as much today due to other interventional options. Also known as an esophagogastric tamponade tube.

Enteral tube position and function are evaluated at least once every shift, before use for diagnostic or therapeutic reasons and to ensure the tube is patent without leaks, kinks, or occlusion.
Enteral feeding tubes placed through the nares are rotated to the other nostril every 3 to 7 days. This prevents necrosis of the nares tissue and nasal septum. Tubes for gastric decompression, lavage, nasojejunal tubes or those placed for gastrointestinal (GI) bleeding are not routinely changed unless the integrity of the tube is altered or occluded.
Enteral feeding tubes are irrigated with water as ordered by the healthcare prescriber every 4 to 6 hours to maintain patency. Some tubes may need to be flushed as often as every 2 hours.

Nasogastric tubes are contraindicated in children with a basal skull fracture. Other conditions that warrant a risk-benefit assessment include a history of esophageal varices, facial trauma, postoperative cleft palate repair.

EQUIPMENT

FOR PLACEMENT OF THE ENTERAL FEEDING TUBE

Enteral feeding tube of appropriate size, generally 5 to 8 French
Topical anesthetic agent (as prescribed)
Nonsterile gloves
Emesis basin
Water-soluble lubricant
Tape or semipermeable, transparent dressing
Cup of water with straw or ice chips (age appropriate)
Tissues
Towel
Catheter-tip syringe
pH product
Stethoscope
Cup or basin of water
Suction set up

FOR REMOVAL OF THE ENTERAL TUBE

Nonsterile gloves
Adhesive remover (if necessary)
Towel

CHILD AND FAMILY ASSESSMENT AND PREPARATION

Assess child for history of nasal deformity, surgery, or trauma, which may provide information as to the patency of the nares, whether passage of the tube may be difficult or impossible, or whether the tube may complicate breathing for the child.
Assess for factors that may complicate the placement of the enteral tube, such as patency of nares, a history of varices, recent sinus, esophageal, or gastric surgery, or oxygen needs.
Assess the child for signs and symptoms of gastric distention or irritation.
Assess the child for presence of orthodontic appliances if tube is to be inserted through the mouth. Instruct the child to remove appliance because dislodgement during the procedure and possible aspiration may occur.
Assess the child for a history of drug or toxin ingestion.
Assess the child’s potential for aspiration, secondary to accumulated gastric secretions and fluids or impaired gag reflex.
Assess the child and family’s cognitive level, readiness, and ability to process information. The readiness to learn and process information may be impaired as a result of age, stress, or anxiety. Explain the child’s role in assisting with passage of the tube (as developmentally appropriate).
Reinforce the need for, and identify and discuss the risks and benefits of, tube placement, as appropriate, to both the child and family.
Explain the procedure, as age and developmentally appropriate, to both the child and the family. Invite the family member to remain with the child to provide comfort and/or diversionary measures.
Consult child-life specialist, when available, for preparation or developmentally based distraction techniques.

PROCEDURE
Placement of the Naso/Orogastric Enteral Feeding Tube

Steps	Rationale/Points of Emphasis 1
1 Perform hand hygiene.	Reduces transmission of microorganisms. If the child may cough and splash secretions, wear proper eye protection and a mask to provide further protection from potential droplets/secretions.
2 Collect all necessary equipment and supplies for tube placement. Use the smallest size small-bore feeding tube that will deliver the formula.	Promotes efficient time management and provides an organized approach to the procedure. The small diameter of the tube causes less gagging on insertion and is more comfortable once placed. The small diameter may also allow the child to continue oral intake and ingest food around the tube. This tube type is also indicated for transpyloric feedings because it must pass through the pyloric sphincter.
3 Position the child using a developmental approach: Infants/toddlers may need to be restrained in a supine position before the procedure begins, either with swaddle-type restraint or a second person securely holding the child. The older child may be placed in a sitting position for placement if the child can cooperate or if a second care provider can effectively support the child and keep him or her calm during the procedure. If the child is in a supine position, elevate HOB about 30-45 degrees.	Keeping the child’s hands away from the tube helps prevent the child from pulling out the tube. KidKare Restraint may not be needed if the child can be effectively distracted using diversionary measures such as guided imagery and relaxation/breathing techniques.
4 Determine length of enteral tube to be inserted: Use age-related height based (ARHB) measurement if able to obtain an accurate height measure (see Table 39-1 ). Use morphologic measurements (NEMU—nose to earlobe to midumbilicus) in children with short stature, or if unable to obtain an accurate measure of height (Figure 39-1). For weighted tubes measurement, consider where the formula ports are positioned versus the total tube length with the weight. Note the measured tube length that will remain external.	Estimates the total length of tube to be passed. Noting the length of the external segment and the length inserted assists in assessing proper tube position. Accurate measurement of height and accurate calculation and interpretation of the prediction equations are critical. Height should be measured by two raters or by two measurements by the same rater if a second rater is unavailable; reevaluate and resolve discrepancies between measures. Double check prediction equation calculations.
Figure 39-1 To determine the length of tube to insert based upon morphologic measurement, measure the pore of the tube from the tip of the patient’s nose to the earlobe and from the earlobe to the point midway between the xiphoid process and umbilicus (NEMU—nose-ear-mid-umbilicus) and note mark on the tube, or mark the total length of tubing to be passed with a piece of tape on the tube.
5 Place emesis basin and tissues within easy access. Verify suction is functioning as indicated.	Allows for easier use, if needed during procedure.
6 Place towel over child’s gown.	Protects clothing from emesis or secretions.
7 Don gloves.	Standard precaution to reduce transmission of microorganisms. If the child may cough and splash secretions, wear proper eye protection and a mask to provide further protection from potential droplets/secretions.
8 Dip the distal tip of the tube in water to activate the lubricant. The tube will feel slippery. If a wateractivated lubricant is not a characteristic of the tube, lubricate the distal tip of the tube liberally with watersoluble lubricant. If a stylet is present, check that the stylet moves freely.	Lubrication reduces friction and prevents trauma to the area. If aspirated, water-soluble lubricant will not lead to pneumonia.
9 Observe and orient the tube by its natural curvature prior to insertion. Gently insert tube into nostril or mouth, aiming down and back. While inserting the tube, position the child’s head to optimize passage into the esophagus by gently flexing the head forward.	Aids enteral tube to follow the normal nasopharyngeal anatomy. Extending the nasal pharynx during initial tube insertion may help decrease the gag reflex. Once the catheter tip is passed distal to the pharynx, flex the head gently forward to anatomically direct the catheter insertion into the esophagus, enhance swallowing, and prevent passage into the trachea.
10 When the enteral tube reaches the pharynx and the child gags, ask child to swallow or stimulate the swallow in the infant with a pacifier.	Swallowing promotes esophageal peristalsis, which facilitates passage of the enteral tube.
11 Allow the child to rest as needed and resume insertion procedure.	Allows child to gain control of self and allows the older child to be able to assist with procedure.
12 Continue to pass enteral tube until the premeasured insertion mark is at the nares opening. Do not pass the enteral tube beyond the original mark until further assessment is made.	Advances enteral tube into the stomach. Inserting the enteral tube too far may result in looping the enteral tube in the stomach, causing ineffective drainage, kinking, or, in advancing the enteral tube into the duodenum, excessive removal of bile. Signs of respiratory distress indicate the enteral tube is in the respiratory tree. Remove enteral tube at once if there are signs of distress, coughing, gasping cyanosis, or oxygen desaturation.
13 If an enteral tube with a stylet has been used, remove the stylet at this time. caREminder	Prevents blind passage of stylet advancing through the tube’s eyelets (openings) or puncturing the tube avoiding potential perforation.
Never reinsert the stylet into the enteral tube once the stylet has been removed.
14 Temporarily secure tube to avoid accidental dislodgement until placement is verified using the verifying enteral tube placement procedure below.	Minimizes medical trauma by stabilizing tube while tube position can be properly verified.