Nasogastric/Enteric Tubes/Feedings - Page 1 Revised: 9/86; 9/87; 8/88; 6/89; 6/93; 8/95; 12/97; 2/00; 8/01 10/04; 8/05;

9/07; 4/08 Reviewed: 9/90; 9/91

Nursing Policy: T-58 LSUHSC - Shreveport, LA _______

NASOGASTRIC/ENTERIC TUBES/FEEDINGS PURPOSE: To provide guidelines for nutritional care of the patient who cannot ingest food and/or medications orally or whose nutritional requirements must be supplemented by tube feedings. POLICY: 1. The physician's order shall include: a. type of nasogastric/enteric tube. b. feeding formula desired. c. rate at which the formula is to be administered. d. frequency and amount of formula to be administered, if bolus feeding. e. frequency and amount of flushes. f. instructions for evaluating residual volumes. g. nutritional assessment and consult by a registered dietician. Enteral feeding tubes shall be placed by the physician (ie., Nasoduodenal, Nasojejunal, Esophagostomy, Gastrostomy, Jejunostomy.) Nasogastric feeding tubes may be placed by a Registered Nurse. Licensed Practical Nurses are not permitted to place nasogastric feeding tubes. Nurses shall not insert nasogastric tubes in patients with the following: a. recent history of gastric surgery to include present admission, b. history of esophageal or nasal cancer, c. diagnosis of basilar skull fracture, cribriform fracture or indications that patient may possess such a fracture. (i.e., rhinorrhea, otorrhea, Raccoon eyes, bloody drainage from nose or ear). d. documented or suspected damage to the nasopharyngeal or esophageal tracts (i.e., gunshot wound(s) to the face or neck, multi-facial fractures). e. history of epistaxis. f. current diagnosis of esophageal varices. A nurse shall not instill anything via nasogastric/enteric tube on post gastric surgery patients unless specifically ordered. Verification Of Tube Placement a. Prior To Initiation of Feeding and/or Medication Administration 1. Enteral tube feedings shall be initiated only after tube placement in the duodenum is confirmed by X-ray. The physician is responsible for notifying the nursing staff of proper tube placement. 2. Nasogastric tube feedings and/or medication administration shall be initiated only after tube placement in the stomach is confirmed. This shall be done by aspiration of a small amount of gastric contents. Placement may also be verified by auscultation of air entering the stomach, while injecting 5-10cc of air into the tube. Sedated and Intubated patients should only have verification of placement done by X-ray. b. Subsequent Placement Verification 1. Nasogastric tube placement verification shall be done at least every shift for patient with continuous feedings. 2. Nasogastric tube placement shall be verified prior to each bolus feeding and/or medication administration.

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Nasogastric/Enteric Tubes/Feedings - Page 2 7. Patients receiving continuous nasogastric tube feedings shall have residuals checked as ordered by the M.D. and appropriately documented in the medical record. NOTE: This should not be done with enteric tubes since small lumen, flexible enteral tubes may collapse if aspiration of contents is attempted. Nurses shall not aspirate from enteral tubes. Patients with intermittent tube feedings shall have tubes flushed with 30 cc's of water prior to, and following each feeding unless otherwise ordered by the M.D. Patients shall have tubes flushed with 30 ccs of water prior to, and following medication administration unless otherwise ordered by the M.D. Patients with continuous feedings shall have tubes flushed with 30 cc's of water every four hours, unless otherwise ordered by the M.D. To administer medications to patients with tube feedings, stop the feeding, flush with 30cc's of water, administer the medication, and flush with 30cc's of water. Continue the feeding. NOTE: Medications should be liquid form whenever possible. If not, crush tablets thoroughly and dissolve in water. (DO NOT CRUSH ENTERIC COATED TABLETS.) Always check with the pharmacy prior to crushing a medication since some medications have the potential to produce an altered pharmacologic effect after such mechanical manipulation. Continuous tube feedings shall be administered via a controlled infusion feeding pump. Continuous nasogastric/enteric feeding bags, 60 cc syringes (used for boluses, checking for placement, etc), and tubing shall be labeled and changed at least every 24 hours with appropriate documentation in the medical record. Feeding bags used intermittently shall be flushed following each feeding and changed at least every 24 hours. Maximum hang time for formula/feeding is eight (8) hours. However, if the tube feeding contains protein powder. (i.e. Pro Mod), the maximum hang time is four (4) hours. Tube feedings, other than canned commercially prepared feedings, shall be refrigerated until administered. Amount of feeding to be used shall be taken out of refrigerator 30 minutes to 1 hour prior to administration. Opened tube feedings (plastic containers) not administered within 24 hours shall be discarded. Cans shall be one time use only and shall be discarded after being opened. Patients receiving tube feedings shall have their bed placed in reverse trendelenburg or the head of the bed elevated 30-45 degrees at all times, unless medically contraindicated. Patients receiving tube feedings shall have documented assessment of gastrointestinal function with intake and output recorded every eight(8) hours in the medical record. In addition, glucose checks should be performed every six hours in diabetics or glucose intolerant patients, unless otherwise ordered by the M.D. Daily weights should be done and documented in the medical record. Patients with nasogastric/enteral tubes shall have: a. Oral-pharyngeal hygiene at least every (8) hours. b. Daily insertion site care with visual inspection to prevent redness, excoriation or any other alteration in skin integrity. All orders for tube feedings are filled and distributed during hours of Nutritional Services operation from 0630 to 1700. Should a physician place an order for an enteral product after hours when Nutritional Services is closed, and the enteral product must be initiated immediately, the Administrative House Manager shall be contacted. The Administrative House Manager shall procure the enteral product from the nourishment kitchen. The order for enteral products shall be keyed in so that regular service can start the following day. An After Hours Enteral Products Retrieval Form shall be completed by the House Manager and placed to the left of the sink in the nourishment kitchen. The Administrative House Manager shall then transport the enteral product to the unit so it can be initiated.

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Nasogastric/Enteric Tubes/Feedings - Page 3

RESPONSIBLE PARTY I. INSERTION MD

ACTION

RATIONALE

1.

Writes order, which shall include: a. type of nasogastric/enteric tube; b. feeding formula desired; c. rate of administration; d. coloring of formula if desired; e. any instruction for residual volumes; f. frequency and amount of administration, for bolus feeding; and g. frequency and amount of water flushes (if different from that specified in policy). Gathers equipment: a. b. c. d. e. f. g. h. i. specified nasogastric/enteric tube, appropriate syringe to access placement, towel, tape, stethoscope, emesis basin, water-soluble lubricant, cup of ice water and straw (optional), and Gloves (non-sterile). 3. To decrease anxiety, increase cooperation, and provide the patient with an opportunity to voice concerns.

RN, RN Applicant

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MD, RN RN Applicant

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Explains procedure to patient.

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Washes hands with anti microbial soap and dons gloves. Positions patient in High Fowlers position unless medically contraindicated. 5. To decrease gag reflex and make swallowing easier, to close the trachea, and facilitate feeding passage into esophagus.

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Measures the feeding tube for length to be inserted (Nose- ear -xiphoid). For nasoduodenal placement, an additional length of tubing must be measured. Lubricates tip of tube with water - soluble lubricant. 7. Minimizes mucosal injury.

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Nasogastric/Enteric Tubes/Feedings - Page 4 8. Inserts the tube through a nares aiming down and back toward the ear, rotates the tube 180 degrees when nasopharynx is reached. MD, RN, RN Applicant 9. Advances tube firmly and steadily to desired length, as patient swallows (If permissible, sipping water may facilitate swallowing). Withdraws the tube immediately if any change in respiratory status is noted. Verifies tube placement by aspirating gastric contents of nasogastric tube or PEG. Assesses tube placement, using a syringe to inject a bolus of air, and auscultating as air enters the stomach; if sedated or ICU patient, verification should be done by Xray. Anchors feeding tube to nose and/or cheek. For enteric tube, leave some slack in tube so it will have extra length to migrate into duodenum. Assists patient to comfortable position. Disposes of equipment in appropriate containers. Removes gloves and washes hands with antimicrobial soap. Documents insertion of NG/enteral tube. type and size of tube, a. date/time of insertion; and b. patient's tolerance to procedure. c. 9. To help prevent accidental tracheal intubation.

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II. MANAGEMENT AND CARE OF THE PATIENT RECEIVING TUBE FEEDINGS RN, RN Applicant, LPN 1. Gathers feeding equipment and feeding formula (should be room temperature). Labels feeding container with patient's name and date/time. Checks the formula's expiration date and discards any expired formula. Orders a Nutrition Consult via Invision. 4. To assure adequate nutritional assessment of patients receiving enteral nutrition. 1. To prevent nausea and discomfort caused by temperature extremes.

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Nasogastric/Enteric Tubes/Feedings - Page 5 R.D. 5. Completes Nutrition Assessment within forty-eight hours of receipt of consult, assessing caloric, protein, and nutrient needs along with tolerance of tube feeding. RN, RN Applicant, LPN RN, RN Applicant, LPN 6. Washes hands with anti microbial soap.

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Assesses gastrointestinal function:

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Listens for bowel sounds. Checks for increased abdominal distention; c/o nausea; vomiting; cramps/diarrhea; constipation. Monitors weight; checks skin turgor, mucous membranes.

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Confirms position of nasogastic tube by: a. injecting 5-10cc of air while listening with a stethoscope. b. Aspirating a small amount of gastric fluid. Do not aspirate from enteral tubes. Checks gastric residual as indicated, following MD order for residual volumes. Residual may be: a. Discarded or b. Returned to stomach and ordered amount of tube feeding given. Maintains head of bed at 30-45 degrees or places into reverse trendelenburg, unless contraindicated. Instills 30 ml of water into feeding tube, unless otherwise ordered by the M.D., prior to and following bolus feeding and/or medication administration. 10. To prevent aspiration.

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To help ensure patency and prevent clogging of the tube.

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12. Begins tube feeding as ordered (Note: For a bolus tube feeding of 300 ml or less, a rate no greater than 50ml/min is recommended. For bolus tube feedings of greater than 300ml, a rate no greater than 30 ml/min is recommended. Bolus tube feedings should not exceed 500ml. Flushes tube following feeding with 30 ml of water. Assesses patient for: a. b. c. diarrhea, cramping T58-5 14.

Bolus Feeding is not recommended for tubes in the small bowel.

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To monitor for dehydration and electrolyte imbalance.

Nasogastric/Enteric Tubes/Feedings - Page 6 nausea/vomiting d. e. decreased bowel sounds f. abdominal distension g. bowel movements h. electrolyte abnormality, and nasogastric residual.

RN, RN Applicant, LPN

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Documents in medical record:

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type of feeding tube, method of administration, flow rate and amount, patients tolerance, patient/family teaching, intake and output, daily weight, and other pertinent observations.

Maintains tubes patency and placement. Performs mouth care; brushing teeth, gums and tongue twice daily. Applies lip moisturizer or petroleum jelly unless otherwise ordered. Discourages mouth breathing and uses measures to increase salivation such as chewing gum, sucking on hard candy or ice if permissible. 17. To prevent dry mouth, coated tongue, or cracked lips which could lead to parotitis (surgical mumps). To prevent skin irritation or excoriation.

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III. DISCONTINUING NG OR ENTERAL TUBE MD RN, RN Applicant, LPN 1. 2. Writes order for discontinuation. Assists patient to upright position.

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Places towel across chest.

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Washes hands with antimicrobial soap and dons non-sterile gloves. Removes anchoring tape. Rotates tube to be sure it moves freely. Flushes tube with small amount of irrigating solution. Instructs patient to take a deep breath and hold it. Clamps tube and removes slowly. Folds tube into towel out of patient's sight. T58-6

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Nasogastric/Enteric Tubes/Feedings - Page 7 11. Disposes of equipment into appropriate containers. 12. Removes gloves and washes hands with antimicrobial soap.

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Nasogastric/Enteric Tubes/Feedings - Page 8 RN, RN Applicant, LPN 13. Documents in medical record:

a. b. c. IV. MD

type and size of tube, date/time removed, and patient's tolerance

OBTAINING ENTERAL PRODUCTS AFTER HOURS 1. Orders enteral product that must be initiated after Nutritional Service is closed. (Note: Nutritional Service is closed from 1700 - 0630). Contacts the Administrative House Manager.

RN, RN Applicant, LPN House Manager

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Procures the enteral product from the Nourishment Kitchen. Completes "After Hours Enteral Products Retrieval Form", and places it on the board in the nourishment kitchen. Carries the enteral product to the unit so it can be initiated.

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House Manager/ Designee REFERENCES:

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Lewis, S., Heitkemper, M., and Dirksen, S. (2004) Medical Surgical Nursing: Assessment and Management of Clinical Problems (6th ed) Mosby Fundamentals of Nursing Made Incredibly Easy (2007) Lippincott, Williams, & Wilkins: Ambler, Pennsylvania. Swearingen, P. (2007). Manual of Medical Surgical Nursing Care: Nursing Interventions and Collaborative Management (6th ed.). Mosby-Elsevier. Bulechek, G., Butcher, H. and Dochterman, J. M. (2008) Nursing Interventions Classification (NIC). (5th ed.). Mosby-Elsevier.

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Nasogastric/Enteric Tubes/Feedings - Page 9

Nasogastric Tube Placement

Tube measured from nose to earlobe to xiphoid. Tube marked

Tube inserted to mark

Aspirate stomach contents

Gastric secretions: green, brown, tan, or offwhite Intestinal fluid: medium-deep golden brown or bile stained

Turn patient on to left side, if possible, and

No

Yes
Using 60cc catheter-tip syringe, inject 510cc of air through tube No (second attempt)

No
Air bubbling audible over epigastric area?

If tube position cannot be confirmed after repositioning notify physician to order abdominal X-ray

Yes Anchor tube to patient's nose and/or cheek

Is patient sedated or in ICU?

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Nasogastric/Enteric Tubes/Feedings - Page 10

Jamie Jett, MBA, RN Director, Patient Care Support/Medicine Services

_____________________________________ Signature

___________________ Date

Jean DiGrazia, MBA, RN Assistant Hospital Administrator and CNO Patient Care Services

_____________________________________ Signature

____________________ Date

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