Medication Administration: Enteral

CLINICAL GUIDELINES

A healthcare prescriber orders medications.
Medications are administered by a registered nurse (RN), licensed practical nurse (LPN), physician, or family member who is knowledgeable about the medication and techniques of administering enteral medications to a child.
Principles of pharmacologic management (see Chapter 6) are followed.
Medications are given by nasogastric (NG), gastrostomy, nasoduodenal, nasojejunal, or jejunostomy tube when the gastrointestinal (GI) tract is functional but the oral route is unavailable. The GI tract provides a vast absorptive area for medications. Absorption, distribution, metabolism, and elimination from the GI tract differ with maturation and some disease states. Factors such as gastric pH, gastric emptying time, motility, absorptive area, enzyme activity, and dietary factors affect GI absorption.
For enteral administration, the medication must be in liquid form when passed through the enteral tube so as not to obstruct the tube.
For patient safety, administer enteral medications through oral or catheter-tipped syringes only because needles cannot be attached to oral or catheter-tipped syringes, preventing inadvertent administration of enteral medications intravenously or intramuscularly. Use the largest syringe size that is practical—larger syringes generate less psi (pounds per square inch) than smaller syringes, thus reducing the potential of tube rupture.
Medications are administered within 1 hour of prescribed time.

EQUIPMENT

Prescribed medication
Individual pill crusher or mortar and pestle, if needed for crushing pills
Pill cutter, if needed to cut pills
Medication cup
Water or other appropriate diluents
Syringes, oral, or catheter-tipped (appropriately sized for drawing up prescribed medication and flushes, 10 to 50 mL unless small volume of medication to be administered)
Catheter-tip adapter (if catheter-tipped syringes are unavailable)
Nonsterile gloves and goggles
Disposable waterproof pad

CHILD AND FAMILY ASSESSMENT AND PREPARATION

Refer to Chapters 38 and 39 for assessment and preparation for enteral tube use.
Determine the child’s height and weight. Accurate determination of weight ensures correct dosage of medications.
Assess the child’s and the family’s previous experience with enteral medications.
Prepare the child, as appropriate to cognitive level, and family before administration.
Provide therapeutic play as indicated, or involve a child-life specialist, to allow the child to work through his or her fears and master control of the situation.
Explain the medication’s actions and side effects and administration procedure.
Teach the family how to administer medications to the child, if necessary, in preparation for discharge from the hospital.
Assess for drug allergies; if present, notify healthcare prescriber of drug allergy. Label the child’s record and apply identification band indicating allergies.

PROCEDUREAdministering Enteral Medications

Steps	Rationale/Points of Emphasis
1 Verify the order with the child’s medical record, including calculation of appropriate dose. Check for allergy to drug; if present, do not administer drug and notify prescriber. Determine whether the prescribed drug should be given on full or empty stomach. Determine compatibility of drug-food-route interactions when giving medication through the enteral tube (Table 61-1 ). Determine if medication is enteric coated, sustained release or a medication on the hazardous medication list.	Verifies correct drug, dose, route, time, and patient. Allergic reactions to medications may be life threatening. Provides best absorption of drug and avoids adverse outcomes such as congealing and possible tube obstruction. These medications should not be crushed, see safety note in step 6.
2 Perform hand hygiene and gather necessary equipment and supplies.	Reduces transmission of microorganisms. Promotes efficient time management and provides an organized approach to the procedure.
3 Obtain medication and read the label to verify with the order. Check for expiration date; if expired, do not administer.	Route, dose, frequency, and time to be administered must be verified each time a medication is given. Expired medications may not give the intended effect. Check institutional policy for automatic discontinuation of oral and enteral medications after surgery; check NPO status and postoperative orders to verify if the child is to continue to receive the medications.
4 Prepare the medication for administration. Remove the cap from the medication container or open the unit dose package. If the medication is dispensed as a liquid, it is in a form ready for administration. Medications in pill or capsule form must be modified to liquid; follow steps 5-9 below.	Facilitates medication administration.
5 Score the tablet properly or pour the correct number of tablets into pill crusher or clean mortar.	To avoid contaminating the medication with previously crushed drugs, thoroughly wash and dry the individual pill crusher or mortar and pestle before and after use.
6 Crush solid medications that are not sustainedrelease preparations into a fine powder with the pestle or pill crusher.	Medications in powdered form dissolve more thoroughly than those that are solid. Check with the pharmacist or current drug manual before crushing tablets to ensure that it is not contraindicated. Enteric-coated or extended-release tablets are coated to release the medication appropriately over time in the gut; crushing destroys this protection and causes medication to be released all at once and may result in toxic levels of the drug. In addition, each institution has policy regarding crushing/manipulating medications on the hazardous drug list.
7 Pour the powder into a small medication cup.	The cup is used to aid in mixing the medication with the diluent.
8 Draw up 1-10 mL of warm diluent solution (e.g., formula, water) into a syringe and mix into medicine cup to dissolve the medication.	Provides diluent. Thoroughly dissolving the medication prevents pieces of medication from obstructing the gastric tube.
caREminder
When choosing amount of diluent, consider the child’s clinical status (e.g., infants and children with some medical diagnoses are at higher risk for fluid overload), size of tube lumen, amount of medication that must be diluted, number of medications and flushes given daily, and 24-hour fluid intake. Consideration of these multiple factors when selecting amount of diluent may reduce the incidence of adverse events.
9 Draw up the medication from the cup into a syringe, and clear the syringe of excess air. Label syringe appropriately.	Instilling excess air into stomach may cause flatus, cramping, and abdominal discomfort.
10 Draw up a small amount of diluent flush solution, 1-10 mL, depending on gastric or intestinal tube size, child’s fluid status (e.g., potential for fluid overload), institutional policy, and manufacturer recommendation, into a separate syringe and label appropriately.	Provides flush solution so that the medication reaches the stomach.
11 Verify medication with electronic record or take the medication, the flush solution, and the medication record to the child to administer. Verify the child’s identity by comparing name on medication (if verified electronically) or on medication record with child’s identification band and any other patient identifier required by the institution. Also verify which tube port the medication is to be administered through (e.g., a feeding tube may have both a gastrostomy tube port and jejunostomy tube port).	Ensures proper identification of the child and proper administration site.
12 Don appropriate protective wear.	Standard precaution to reduce transmission of microorganisms.
13 Elevate the head of the bed 30 to 45 degrees (unless elevation is contraindicated by the child’s condition).	Aids in preventing aspiration and increases absorption.
14 Place a waterproof pad between the gastric tube and the child’s bed and clothing.	Protects the linen and clothing from becoming damp or soiled.
15 Unclamp the gastric tube (if not in continuous use) and verify placement and patency of gastric tube (see Chapters 38 and 39 ).	Medications or other substances instilled down an improperly positioned tube could be aspirated.
16 Attach syringe to desired tube port and instill the diluted medication into the gastric tube by slowly and steadily pushing on the plunger.	Delivers medication.
17 Follow instilled administration of medication with 1-10 mL of diluent flush. Air may be used to flush if potential for fluid overload exists (e.g., small infants).	The diluent flushes the medication through the tube into the child’s stomach and prevents the tube from becoming obstructed with medication.
caREminder
When multiple medications are administered at one time, it is desirable to flush with water or saline between medications to help reduce potential drug interactions. Calculate total fluid intake to avoid fluid overload. If air is used, it is especially important to verify compatibility of medications because air may not clear the line as completely as fluid.
18 Clamp the gastric tube for approximately 30 minutes after medication administration if the tube is not in continuous use.	Allows time for the medication to be absorbed.
19 Dispose of equipment and waste in appropriate receptacle.	Standard precautions.
20 Remove gloves and perform hand hygiene.	Reduces transmission of microorganisms.