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Tube feed Advantages over PN

low cost, safe, well tolerated, easy to use in extended care and home setting

o Preserve GI integrity
o Preserve usual sequence of intestinal + hepatic metb
o Maintain fat metb + lipoprotein synthesis
o Maintain appropriate insulin/glucagon ratios


WHere are these tubes placed and what are they called?
WHy would one be used over the other?

• NG intubation or gastrostomy = into stomach
• Nasoduodenal or nasojejunal = to distal duodenum or proximal jejunum → this is indicated when esophagus or stomach need to be bypassed or when pt is at risk of aspiration


Gastronomy or jejunostomy tubes when?

for med or food over long term (>4weeks)


Conditions requiring enteral feeding:

o Preop bowel prep
o GI issues (fistula, Crohn’s, UC, etc)
o CA therapy (radiation + chemo)
o Convalescent care (survery, injury, severe illness)
o Coma, semiconsciousness
o Hypermetabolic conditions (burns, trauma, AIDS, organ transplantation)
o Alcoholism, chronic depression, anorexia nervosa
o Debilitation
o Facial or cervical sx
o Oropharyngeal or esophageal paralysis


WHy is osmolarity an important consideration for tube feeds?
WHat is the osm of body fluids?

• Osm important for duodenal or jejunal because high osmo may lead to dumping syndrome
• Osm of body fluids approx 300mmol/kg - body tries to maintain this by moving fluids by osmosis


WHich molecules have small/large effects osmotic effects?
Amino acids

• Amino acids + carbs have highest osmotic effect (are small molecules)
• Proteins (large) have less osmotic effect
• Lipids have no osmotic effect
• Electrolytes have big effect on osmolality and thus big influence on pt ability to tolerate a soln


How does dumping syndrome occur as a result of tube feed with high osm?

• High osm soln taken → H20 moves into stomach + intestines → pt has fullness, nausea, diarrhea → dehydration, hoTN, tachycardia = dumping syndrome


Does diluting a solution help to dec risks intolerance?
Who are particularly intolerant of high osm feeds?

• May help to dilute soln at first…not clear evidence for this
• Those who are debilitated not as tolerant


What sort of factors/components of tube feed are considered when deciding on type of tube feed?

• Depends on GI tract and nutritional needs
• Consider chemical composition of nutrient source (protein, carbs, fat), caloric density, osmolality, residue, bacteriologic safety, vitamins, minerals, cost

• Have disease specific formulas


• Polymeric formulas = ?

high molecular weight; composed of proteins, fat, and carbs in high-molecular-weight form (ex: Ensure,Isosource, Osmolite)


• Chemically defined formulas =

(go into jejunostomy)


What are modular formulas?

= contains only one nutrient (ex: Beneprotein = just protein) → sometimes use a combo of these in patients who can’t tolerate certain components of other prepared solutions…then just add the other constituents, nutrients, etc.


What is sometimes added to the formula for those at risk of diarrhea?



Are NG + nasoenteric tube feedings generally well tolerated?

Many don’t tolerate NG + nasoenteric tube feedings well


Different tube feed methods? (bolus, etc.)

• Can be given as intermitten bolus feedings, intermittent gravity drip, continuous infusion, cyclic feeding


How frequently is Intermittent bolus given into stomach (usually by gastrostomy tube) typically?

4-8x day


Intermittent gravity into stomach used when? Over what time period is it typically admin'd?

when pt at home – admin over 30 mins at scheduled intervals


Continuous infusions...
When is this used?
Pros and cons?

- Continuous infusion used when admin into small intestine; preferred for pt at risk of aspiration + those who tolerate tube feedings poorly;
given at constant rate w pump
PROs: dec’s abd distension, gastric residuals
CONs: less pt flexibility, pump is expensive


WHen is cyclic feeding used? How?

infusion given over 8-12hrs, can be done at night; may be appropriate for pt being weaned from tube feedings, as supplements for those who can’t eat enough + those at home that need daytime hours free from pump


What nursing assessments need to be done with those pt's on tube feeds?

• Nutritional status
• Existing chronic illnesses or factors that inc metb rate (sx, fever)?
• Hydration status
• GI tract functioning?
• Kidney fx? Electrolyte levels?
• Any meds that affect nutritional intake and fx of GI tract?
• Does dietary prescription fulfill client needs?

o Tube placement, pt position (HOB at 30-45 degrees), formula flow rate
o Pt tolerance: fullness, bloating, distension, urticaria, N+V, stool pattern + character?
o Clinical responses (BUN, serum protein, prealbumin, lytes, renal fx, Hb, HCt)
o Dehydration?
o Report elevated BG, dec urinary output, sudden weight gain, periorbital or dependent edema
o Residual vol before each feeding or q4hrs if continuous – return aspirate to stomach
o I/O
o Weight twice weekly
o Consult dietician regularly


What sort of outcomes need to be reported?

Report elevated BG, dec urinary output, sudden weight gain, periorbital or dependent edema


How often is open system formula replaced? Tube feeding containers + tubes?

Open systems formula replaced q4hrs
o Tube feeding container + tubes change q24-72 hrs


How often should pt be weighed when on tube feed?

Med surg says 2x weekly

P+P say 3X weekly (at first daily until full established rate for 24hrs)


Pt diagnoses for tube feed?

• Imbalanced nutrition r/t inadequate intake
• Risk for diarrhea r/t dumping syndrome or tube feed intolerance
• Risk for ineffective airway clearance r/t aspiration from tube feeding


Planning and goals for pt on tube feed?

• Nutritional balance
• Usual bowel pattern
• Reduced risk of aspiration
• Adequate hydration
• Prevention of complications
• Knowledge + skill in self-care


Ensure Gravity feeds placed...

above level of stomach


Bolus feedings. What vol + how often typically?

300-400mL q4-6hrs


o Continuous feed rates depend on?

caloric density of formula + energy needs of pt


What is the goal for tube feeding regarding weight and Nitrogen balance? Without producing?

o Want positive N balance and weight maintanence/inc w/t producing abd cramps + diarrhea


Intermittent feeds. How much given usualyl and over how long?

200-350mL given over 10-15mins


Advantage of pump for tube feed?

allows admin of viscous fluid through small tube


Residual gastric content measured when? How often during continuous feeds?

before each intermittent feeding + q4-8hrs during continuous feeding


What residual vol (GRV) warrants concern?

o Res vol of 200mL or greater = concern for those at high risk of aspiration…if this occurs twice, nurse to notify physician (med-surg)

P+P says >250mL twice or 500mL once


WHen is flushing done on tube feed?

• Before + after each dose of med + tube feeding
• After checking for gastric residuals + gastric pH
• Q4-6hrs with continuous feedings
• If tube disconnected or interrupted for any reason
• When tube not being used, done twice daily
• Record in fluid intake!


Why flushing?

With how much?

o Maintain patency, reduce risk of bacterial growth, crusting and occlusion



What to do if med to be given through tube feed is not liquid?

Can you mix meds to be given and/or mix them with tf formula?

o If not liquid, must be crushed to fine powder first + dissolved
o Do NOT mix meds with each other or tube feeding formula
o Each med given separately as bolus according to med’s preparation


How big should syringe be when administering into tube feed?

o When small-bore tube for continuou infusion used, use 30mL syringe or larger so don’t rupture tube


Consideration for giving meds into post-pyloric tb?

o Giving meds into post-pyloric tubes may adversely affect absorption…avoid if possible


What to do with enteric coated and timed-release meds when giving in tf?

o Enteric coated and timed-release tablets can’t be crushed – need to get alternativ formulation
o Some timed-release capsules or sustained-release capsules can be opened and contents added to tube feed formulas – ALWAYS check with pharmacy first!


o Feeding container + tubing change how often?



how is formula given to admin into open system?

Open = liquid or powder to be dissolved in H20


amount in bag should never exceed what will be infused in __hour period? Why?

o To avoid bacterial growth, amount in bag should never exceed what will be infused in 4 hour period


What is a closed system for tf and how long can it be hung for?

o Closed = prefilled, sterile container spiked with enteral tubing; can be hung safely for 24-48hrs


What are possible causes of diarrhea with tube feed that need to be ruled out?

• Dumping syndrome
• Contaminated formula
• Malnutrition (dec in intestinal absoption)
• Medication therapy – abx, digoxin, antiarrhythmics found to inc diarrhea
• C. Dif infection


What is diarrhea defined as?
What kind of BMs are expected in those on tf?

o Those with enteric feeding often have diarrhea (watery stools 3 or more times in 24hrs)
o Pasty, unformed stool expected (because formula has little to no residue)


Cause of dumping syndrome?


o Dumping syndrome results from rapid distension of jejunum when hypertonic soln admin fast (20-30mins)
o Preventing symptoms of dumping syndrome: (chart 37-2 p. 1098)
• Slow instillation to provide time for carbs + electrolytes to be diluted
• Fluids at room temp (temp extremes cause peristalsis)
• Admin by continuous drip
• Advice pt to remain in semi-fowler for 1 hr after feeding


When does aspiration occur with tf?

o Occurs with regurgitation or when feedings instilled improperly into pharynx or trachea


What nursing measures need to be taken to prevent aspiration of tf?

o Nurse must verify correct tube placement before q feeding, each time med admin’d + once a shift if continuous
o Pt should be in semi-fowlers for NG feeding + one hour after
o Monitor residual volume – if excessive stop feeding + notify physician


Nursing measures to maintain adeqaute hydration for pt on tf?

o Pt may not be able to communicate need for H2O
o H2O given q4-6hrs + after feedings to prevent hypertonic dehydration
o Monitor signs of dehydration, admin water routinely, I/O, residual vol + fluid balance


What can nurse do to promote coping ability of pt on tf?

o If pt having difficulty adjusting, nurse to encourage self-care (recording own I/O); encourage by pointing out signs of progress


o Criteria for tube feeding at home:

edically stable + can tolerate 70% of tube feeds, capable of self-care or has caregiver, has access to supplies + interest in learning how to administer tube feeds at home


Causes of N+V in tf pt?

Change in formula or rate
Hyperosmolar formula
Inadequate gastric empting


Tx of diarrhea as complication of TF?

Assess fluid balance + electrolyte levels
Implement changes in tube feeding formula + rate


Possible cause of Gas/Bloating/cramping in tf pt?


Air in tube
- Ensure air doesn't enter
Notify physician if persistent


Tx and prevention of dumping syndrome?

Check fibre + water content
Rate + temp of formula

Avoid rapid infusion of feeding, admin at room temp


Complications of tf

- Diarrhea (most common)
- N+V
- Gas/Bloating/cramping
- Dumping syndrome
- Constipation
- Aspiration pneumonia
- Tube displacement
- Tube obstruction
- Residue
- Nasopharyngeal irritation
- Hyperglycemia
- Dehydration and azotemia


Possible causes of constipation in pt on tf?


High milk (lactose content)
Lack of fibre
Opioid use

Ensure fibre + water content Admin adequate H2O as flushes


Causes of aspiration pneumonia as complication of tf?


Improper tube placement
V + aspiration of tube feeding
Flat in bed
Use of large tube

Assess resp status
Measure length of tube to check placement
HOB at 30degrees


Causes of tube displacement?


Excessive coughing, vom
Tracheal suctioning
Airway intubation

Stop feeding + notify physician Check tube placement before admin


Nasopharyngeal irritation


Tube position/improper taping
Use of large tubes

Assess nasopharyngeal mucous membranes q4hrs
Tape tube to prevent pressure on nares


Hyperglycemia as complicaion of tf


Glucose intolerance
High cab content of the feeding

Check BGM
Request dietary consult to re-eval choice of feeding product


Dedydration as complciation of tf


Hyperosmolar feedings with insufficient fluid intake

Report signs and symptoms of dehydration
Implement changes in tube feeding formula, rate or ratio to water Provide adequate hydration through flushes


Who is gastronomy better for?

for long term + for comatose pt’s (aspiration less likely occur because gastroesophageal sphincter remains intact)


Different types of gastronomy tubes + which are temp or perm?

o Stamm = temporary or permanent
o Janeway = permanent
o PEG (percutaneous endoscopic gastrostomy) = temporary

• Stamm requires sutures to hold in place


Where do gastronomy tubes exit abdomen?

Left upper adb


Alternative to PEG is?

LPDG = low-profile gastrostomy device → put in 3-6months after gastrostomy tube insertion. Is flush with skin, has one way valve to prevent gastric reflux; downside is cannot access residual vol (b/d one way valve) – more details p. 1100


Nursing assessments for gastronomy tube insertion?

• Preop: can pt adjust to body image + self care?
• Pt should be fully aware of implications of sx, whether permanent or not, etc
• Prep skin assessment – is there any reason for delay in healing (DM, ascites, CA)
• Post op: fluid + nutritional needs met? Proper maintenance of tube + site assess for infection


Nursing diagnoses for pt with gastronomy

• Imbalanced nutrition r/t enteral feeding problems
• Risk for impaired skin integrity at tube insertion site
• Ineffective coping r/t inability to eat normally
• Disturbed body image r/t presence of tube


Collaborate Problems - Potential Complications of gastronomy?

• Wound infection, cellulitis, leakage, abdominal wall abscess
• GI bleeding
• Premature removal of the tube
• Aspiration
• Constipation or diarrhea


When/what fluids are given after initial gastronomy insertion + when do normal fluids start being infused?

o First fluid nourishment given shortly after insertion – usually tap water + 10% dextrose (30-60mL at a time at first, then 180-240 at a time by day 2..as long as tolerated and no leakage)
o Water + enteral feeding can be infused after 24hrs for permanent


Can blenderized foods be given into gastronomy? Advantages of this?

o Blenderized foods can be added gradually to clear fluids until full diet is achieved - those who get blenderized tube feeds usually don’t need to give up usual food routine (more easily adjust to this), also maintains close to normal bowel fx


Nursing care for gastronomy tube + preventing infection

What needs to be assessed/done daily to prevent skin breakdown?

o Small dressing can be applied to protect skin around incision from seepage
o Nurse to verify tube placement, assess residuals and gentle manipulate tube or stabilizing disk once daily to prevent skin breakdown
o If has anchoring balloon, need to check integrity of it by deflating + inflating once weekly


Most common complication of gastronomy tubes?

wound infection + other wound problems (cellulitis) and abscesses in abdominal wall → many will be compromised nutritional status already


What should the nurse do if bleeding from insertion site of gastronomy tube?
Premature removal?

o Bleeding from insertion site + stomach → assess vital signs, drainage from operative site, vom + stool for blood
o Premature removal: cleanse + apply sterile dressing, call doctor (will close in 4-6hrs)


Pt teaching for home + community care of gastronomy tube?

o Pt shown how to check for residual gastric contents before feeding
o Learns to check + maintain patency by admin of room temp water before + after feeding
o Told to maintain in semi-fowler for 1hr following to prevent aspiration
o Told to flush with 30-50mL H2O after each med + feeding + daily to keep patent
o Told to monitor tube length


Should pt who can take oral meds but has tube feed take them orally or not?

• Oral meds are still route of choice as long as pt can swallow and retain the drug in the stomach


What to do with drugs that aren't liquid to admin in tf?
How much does it need to be dissolved in?
What to do with capsule?

1) Always check with pharm to see if med come in liquid form → less likely cause tube obstruction
2) If no liquid form, check to see if can be crushed
3) Read med labels carefully before opening capsule. Open capsules + mix with water ONLY if ok’d by pharm → some capsules can just be poured down tube as is (as long as not crushed)
4) Crush tablet into fine powder + dissolve in at least 30mL warm wateri (some may need to be dissolved in NS)


crushing enteric-coated, sustained-action, enzyme-specific, buccal, and sublingual tablets does what?

affects pharmacokinetsics or causes gastric irritation


If bulk forming laxatives prescribed for pt with tf, what to do?

consult appropriate hc team member for alternate prescription → these meds form semisolid mass and can occlude the tube


WHy is it bad to add a med to high res vol in stomach?

may have ineffective peristalsis + adding med to it will affect absorption


Why is important to pinch tube when preparing to admin med? What to do with syringe?

remove plunger from syringe + connect to pinched or kinked tube → pinching tube prevents excess air from entering stomach + causing distension


How much water goes into syringe before administering med (adults + chidren)
How to instill?

Put 15-30mL (5-10mL for children) water into syringe barrel to flush before administering first med. Raise or lower barrel of syringe to adjust the flow as needed. Pinch or clamp tubing before all water is instilled → flushing ensures med does not come in contact with other substance; clamping prevents excess air from entering

Pour liquid or dissolved meds into syringe barrel + allow to flow by graviy into enteral tube → helps avoid traua to intestinal mucosa


Guideline for giving more than one med through tf?

If giving several meds, give each separately + flush with 15-30mL (5Ml for children) of tap water between to avoid drug

When all meds have been administered, flush again with 15-30 (5-10mL for children) warm water to ensure whole dose given + tube doesn’t occlude


If tube connected to suction, how long should you wait after giving a med to restart the suctioning?

IF tube connected to suction, disconnect + keep tube clamped for 20-30mins after giving med. Some agencies recommend 1-2hrs → ensures med is absorbed rather than suctioned out of stomach


If drug is incompatible with tube feed solution and pt on continuous infusion, wat to do?

• Must ensure med is compatible with feeding solution → if not and pt on continuous feeds, need to consider alternate route or feed must be held for 1-2hrs before + after drug admin


When does clogging of tube feed occur?

Preventative measures?

• Can occur if runs dry, meds mixed with feeding formulas, or med not adequately crushed
• Aspirating to check for residual vol also inc risk of clogging (but should be done)

• Flush liberally, using 60mL piston syringe


Other strategies for unclogging tube?

reposition pt (to straighten kinks), flush + aspirate with water, instilling meat tenderizer, carbonated beverages, cranberry juice or flushing with small barrel syringes with or without digestive enzymes
(p+p specifically say not to use pop or juice)


Assessments before irrigating tube feed?

• Gastric aspirate: vol, colour, character
• Bowel sounds – is peristalsis occuring?
• Monitor vol admin’d and compare with order
• See protocol for routine irrigaions (usually q 4-12hrs)


Procedure for flushing tube feed?

1. Position pt in high fowler (if tolerated) or semi
2. ID pt
3. Hand hygiene + gloves
4. Verify tube placement if fluid can be aspirated for pH testing
5. Irrigate before, between, and after final meds + before intermittent feeding admin’d
6. Draw 30mL water from pt’s own solution bottle (don’t use from other patients) – alt flushing soln’s such as cola + fruit juice cause clogging d/t acidity
7. Change irrigation bottle q24hrs to ensure solution stays sterile (or tap water may be ok in some places)
8. Kink feeding tube while disconnecting from administration tubing or while removing plug at end of tubing
9. Insert tip of syringe into end of feeding tube. Release king + slowly instill soln
10. If unable to instill, position pt on left side + try again (tip of tube may be against stomach wall)
11. Remove syringe. Reinstitute tube feeding or give med



o Feeding not safe d/t risk of aspiration r/t altered LOC, swallowing disorders, impaired gag reflex, dependence on mechanical vent, esophageal situations + delayed gastric emptying
o Conditions that interfere with normal ingestions or absorption of nutrients or create hypermetabolic states: surgical resection of oropharynx, proximal intestinal obstruction or fistula, pancreatitis, burns, severe pressure ulcers
o Conditions in which disease or tx-related symptoms reduce oral intake: anorexia, N, pain, fatigue, SOB, depression


Assessments before tube feeds?

• Clinical status for need for enteral nutrition: dec LOC, nutritional deficits, head or neck sx, etc
• Food allergies?
• Abdomen, incl bowel sounds
• Baseline weight + review lytes + fluid status, metb abnormalities


Procedure for giving tube feed

See written notes (too long!) Bits and pieces of it in next few cards...

1. ID pt X2
2. HH + gloves
3. Get formula – check expiry, ensure is at room temp
4. Prep formula
5. Open roller clamp + allow tubing to fill. Clamp off and hang on IV pole
6. Place pt in high fowler
7. Verify tube placement – observe aspirate + take pH
8. Check gastric residual vol (GRV) before each intermittent + bolus feeding + q4-6hrs for continuous feedings
9. Before attaching feeding admin set to feeding tube, trace tube to point of origin. Label admin set “Tube Feeding Only”
10. start intermittent or continous drip
12. Advance rate of tube feed gradually, as ordered
13. Flush tubing w 30mL water q 4hrs during continuous infusion. Have dietician recommend total free water requirement per day


How to prep formula for tube feed?

a. Use aseptic technique while manipulating components of feeding system
b. Shake formula well; clean top of canned formula with alcohol
c. For closed system, connect admin tubing to container; for open, poor into admin bag


How should pt be positioned during tube feed?

If a pt needs to be positioned supine, how to position for tube feed?

Place pt in high fowler (or elevate HOB to at least 30 degrees…preferably 45)

place in reverse trendel


Procedure for checking GRV?

What results indicate should not instill more formula/med?

a. Draw up 10-30mL air + connect to feeding tube
b. Inject air into tube. Pull back slowly + aspirate total gastric contents
c. Return contents to stomach unless >250mL (check agency policy)
d. DO NOT ADMIN when single GRV measurement exceeds 500mL or when two measurements taken 1 hr apart exceed 250mL
e. Flush feeding tube with 30mL H2O


Procedure for setting up intermittent gravity drip

a. Pinch proximal end of tube + remove cap. Connect distal end of admin set to feeding tube + release tubing
b. Set rate by adjusting roller clamp on tubing or attach tubing to feeding pump. Allow bag to empty gradually over 30-45mins. Label bag w tube feeding type, strength, amount. Include date, time, initials.
c. Change bag q 24hrs


What to do whenever feedings are interrupted?
How often to use new admin set?

Rinse bag + tubing with water water whenever feedings are interrupted. Use new admin set q24hrs – cleans out old tube feed formula + reduced bacteria


Evaluation during/after tube feed?

• Measure GRV per policy (usually 4-6hrs) + ask if N or cramping present
• Monitor I/O at least q8hrs + calculate daily totals q24hrs
• Weight pt daily until max admin rate is reached + maintained for 24 hrs, then 3x/wk
• Monitor lab values
• Observe pt resp status
• Auscultate for bowel sounds
• For tubes through abdominal wall, inspect for skin integrity


What to do if feeding tube clogged?

Attempt to flush w water
Do not use soda + juice – are products for unclogging
Hold feeding + notify dr
Maintain pt in semi-fowler position


What to do GRV exceeds 250mL or cutoff per agency protocol

Recheck residual 1 hr later
Notif hc provider if GRV remains high (typically hold feeding if residual >250mL in 2x checks)


What to do if pt aspirates formula?

Report changes to hc provider; if no recent CXR, suggest one
Position pt on side
Suction nasotracheally + ototracheally
Possible abx


What to do:
Pt develops large amount of diarrhea (more than 3 loose stools in 24hrs)

Notify hc provider. Consult dietician about need to change formula
Consider C. Diff or bacterial contam of feeding
Provide perianal skin care after each stool
Determin if pt meds could be cause


What might it indicate if patient on tf has nausea + vom?

paralytic ileus


What to do
Pt develops N+V

Withhold tube feed + notify hc provider
Be sure tube is patent, aspirate for residual


What to do:
Fluid withdrawn from tube has foul odour or unusual appearance

Notify hc provider
Do not return aspirated material


What to record/report following tube feeding?

• Amount + tube of tube feeding, method of infusion, pt response (GRV, camping), patency of tube, condition of skin at tube site
• Record vol of fomula + any additional H2O intake
• Report type of feeding, state of feeding tube, pt tolerance + adverse outcomes


Pt teaching for tube feed at home?

• Stay upright for 1hr after if possible
• Pt or family should not reconnect lines if become disconnected
• Pt may express feelings of fullness, inc gas, belching or diarrhea
• How to determine correct placement of tube


What is particularly important for gerantologic pt's on tf?

delayed gastric emptying common – GRV esp important with this pop


Gastronomy tubes AKA?

• Gastronomy tubes aka G Tubes, or PEG tubes (which describes those inserted endocscopically)


Gauge or gastronomy tubes?

16-28 Fr gauge


WHat are combination tubes

opening to both SI and stomach; allow simult gastric decompression + intestinal feeding of pts with impaired gastric emptying or upper GI CA)

• PEJ (precut endoscopic jejunostomy) can be placed through existing PEG


Procedure for

• Determine if exist site is left open to air or dressing indicated
• ID pt X2
• HH + gloves
• Remove old dressing, discard with gloves
• Clean skin around site with warm H2O + mild soap or NS suing 4/4 gauze
• Dry site
• Apply thin layer protective skin barrier to site if indicated (excoriated)
• If drsg ordered, place drain gauze dressing over external bar or disc (do not place under external bar as can cause gastric tissue erosion or internal abdominal wall P)
• Secure dressing w tape
• Place date, time + initials on dressing
• Remove gloves + dispose of gloves + HH
• Document