GI	Gastro-intestinal
gtt	Drops
gtt/min	Drops per minute
IV	Intravenous
mL	Milliliter
mL/hr	Milliliters per hour
NG	Naso-gastric
NPO	Nothing by mouth
oz	Ounce
PEG	Percutaneous endoscopic gastrostomy
TPN	Total parenteral nutrition

Many persons cannot eat or drink because of illness, surgery, or injury. They may have chewing, swallowing, or other eating problems. Aspiration is a risk. Aspiration is breathing fluid, food, vomitus, or an object into the lungs. Some persons refuse to eat or drink. Others cannot eat enough to meet their nutritional needs. The doctor may order nutritional support or intravenous (IV) therapy to meet food and fluid needs.

See Delegation Guidelines: Nutritional Support and IV Therapy.

Delegation Guidelines

Nutritional Support and IV Therapy

Your state and agency may not allow you to assist with some of the care measures in this chapter or perform procedures involving nutritional support and IV therapy. Before assisting with a care measure or performing a procedure, make sure that:

Enteral Nutrition

Some persons cannot or will not ingest, chew, or swallow food. Or food cannot pass from the mouth into the esophagus and into the stomach or small intestine. Poor nutrition results. Common causes are:

• Cancer, especially cancers of the head, neck, and esophagus

• Trauma to the face, mouth, head, or neck

• Nervous system disorders (Chapter 44)

• Prolonged vomiting

• Major trauma or surgery

• Acquired immunodeficiency syndrome (AIDS) (Chapter 43)

• Illnesses and disorders affecting eating and nutrition

Enteral nutrition is giving nutrients into the gastro-intestinal (GI) tract (enteral) through a feeding tube. Gavage is the process of giving a tube feeding. Tube feedings replace or supplement normal nutrition.

Types of Feeding Tubes

These feeding tubes are common.

• Naso-gastric (NG) tube. A feeding tube is inserted through the nose (naso) into the stomach (gastro) (Fig. 28-1). A doctor or an RN inserts the tube.

FIGURE 28-1 A naso-gastric (NG) tube is inserted through the nose and esophagus and into the stomach.

• Naso-enteral tube. A feeding tube is inserted through the nose (naso) into the small bowel (enteral) (Fig. 28-2). A doctor or RN inserts the tube.

FIGURE 28-2 A naso-enteral tube is inserted through the nose and into the small intestine.

• Gastrostomy tube. A doctor inserts a feeding tube through a surgically created opening (stomy) in the stomach (gastro). It is also called a stomach tube. See Figure 28-3.

• Jejunostomy tube. A feeding tube is inserted into a surgically created opening (stomy) in the jejunum of the small intestine (Fig. 28-4).

• Percutaneous endoscopic gastrostomy (PEG) tube. A doctor inserts a feeding tube into the stomach (gastro) through a small incision (stomy) made through (per) the skin (cutaneous). A lighted instrument (scope) is used to see inside a body cavity or organ (endo). See Figure 28-5.

FIGURE 28-5 A, A percutaneous endoscopic gastrostomy (PEG) tube is inserted. B, PEG tube in place.

NG and naso-enteral tubes are used for short-term nutritional support—usually less than 6 weeks. Gastrostomy, jejunostomy, and PEG tubes are used for long-term nutritional support—usually longer than 6 weeks.

Formulas

The doctor orders the type of formula, the amount to give, and when to give tube feedings. Most formulas contain proteins, carbohydrates, fats, vitamins, and minerals. Commercial formulas are common.

Formula is given at room temperature. Cold fluids can cause cramping. Opened formula can remain at room temperature for about 8 hours. Microbes can grow in warm formula.

See Teamwork and Time Management: Formulas.

Teamwork and Time Management

Formulas

Refrigerated formula is warmed to room temperature. To warm formula, place the container in a wash basin filled with warm water. If warmed in the sink, other staff cannot use the sink. They waste time and energy going elsewhere. Or someone may remove the container to use the sink. The container does not warm in a timely manner. That affects the person, you, and the nurse.

The nurse and manufacturer’s instructions tell you how long formula can hang. Check the time that the feeding started. Remind the nurse when the time limit is near. For example, a feeding that started at 0800 can hang for 8 hours. At 1530 or 1545, tell the nurse how much time is left. Also report the amount of formula left.

Feeding Times

Tube feedings are given at certain times (scheduled feedings). Or they are given over a 24-hour period (continuous feedings).

Scheduled Feedings.

Such feedings also are called intermittent feedings. (Intermittent means to start, stop, and then start again.) Feeding times are scheduled. At least 4 feedings are given each day. Usually 8 to 12 ounces (oz) (240 to 360 milliliters [mL]) are given over about 30 minutes. The frequency, amount, and time are like a normal eating pattern.

The nurse uses a syringe or a feeding bag (Fig. 28-6). The syringe attaches to the feeding tube. Connecting tubing connects the feeding bag to the tube. Formula is added to the syringe or to the feeding bag. Then it slowly flows through the feeding tube into the stomach.

FIGURE 28-6 A, A tube feeding is given with a syringe. B, Formula drips from a feeding bag into the feeding tube.

The nurse removes the syringe or connecting tubing after the feeding. Then the nurse clamps and covers the end of the feeding tube with a cap or gauze. Gauze is secured in place with a rubber band. Clamping prevents air from entering the tube and fluid from leaking out of the tube. Covering the end of the tube also prevents leaking.

Continuous Feedings.

These feedings are usually given over 24 hours. A feeding pump is used (Fig. 28-7). Formula drips into the feeding tube at a certain rate per minute. The person receives a certain amount each hour.

FIGURE 28-7 Feeding pump. (From Potter PA, Perry AG, Stockert PA, Hall AM: Fundamentals of nursing, ed 8, St Louis, 2013, Mosby.)

A pump alarm sounds if something is wrong. When you hear an alarm, tell the nurse.

Observations

Diarrhea, constipation, delayed stomach emptying, and aspiration are risks. Report the following at once.

• Nausea

• Discomfort during the feeding

• Vomiting

• Distended (enlarged and swollen) abdomen

• Coughing

• Complaints of indigestion or heartburn

• Redness, swelling, drainage, odor, or pain at the ostomy site

• Fever

• Signs and symptoms of respiratory distress (Chapter 39)

• Increased pulse rate

• Complaints of flatulence (Chapter 26)

• Diarrhea (Chapter 26)

Preventing Aspiration

Aspiration is a major risk from tube feedings. It can cause pneumonia and death. Aspiration can occur:

• During insertion. NG tubes and naso-enteral tubes are passed through the nose into the esophagus and then into the stomach or small intestine. The tube can slip into the airway. An x-ray is taken after insertion to check tube placement.

• From tube movement out of place. Coughing, sneezing, vomiting, suctioning, and poor positioning are common causes. A tube can move from the stomach or intestines into the esophagus and then into the airway. The RN checks tube placement before every scheduled tube feeding. With continuous feedings, the RN checks tube placement every 4 hours. To do so, the RN attaches a syringe to the tube. GI secretions are withdrawn through the syringe. Then the pH of the secretions is measured (Chapter 34). You never check feeding tube placement.

• From regurgitation. Regurgitation is the backward flow of stomach contents into the mouth. Delayed stomach emptying and over-feeding are common causes.

To help prevent regurgitation and aspiration:

• Position the person in Fowler’s or semi-Fowler’s position before the feeding. Follow the care plan and the nurse’s directions.

• Maintain Fowler’s or semi-Fowler’s position after the feeding. This allows formula to move through the GI tract. The position is required for 1 to 2 hours after the feeding or at all times. Follow the care plan and the nurse’s directions.

• Avoid the left side-lying position. It prevents the stomach from emptying into the small intestine.

Persons with NG or gastrostomy tubes are at great risk for regurgitation. The risk is less with intestinal tubes. Formula passes directly into the small intestine and is given at a slow rate. During digestion, food slowly passes from the stomach into the small intestine. The stomach handles larger amounts of food at one time than does the small intestine.

Before a tube feeding, the nurse checks tube placement and residual stomach contents. Residual means what remains. For an NG tube or gastrostomy tube, the nurse aspirates stomach contents and measures the amount. Depending on the amount, the nurse decides if the feeding should be given or delayed. The intent is to prevent aspiration from regurgitation caused by over-feeding.

See Focus on Children and Older Persons: Preventing Aspiration.

Focus on Children and Older Persons

Preventing Aspiration

Older Persons

Digestion slows with aging. Stomach emptying also slows. Older persons are at risk for regurgitation and aspiration. Less formula and longer feeding times prevent over-feeding.

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