Managing feeding by an enteral tube

Process Map

Related Items

• Enteral Feed Management (PEG)

Process - Step by Step

• Enteral feeding is the delivery of a nutritionally complete feed containing protein, carbohydrate, fat, water minerals and vitamins into the stomach, duodenum or jejunum.
• Decisions on tube route, content and nutritional management are best made by the client’s multidisciplinary care team and put into place only by skilled medical professionals with consent from the client, their family, carer, and/or guardian.
• Procedures for administering enteral feeding should be outlined in a standard protocol available from health care personnel. 
• Delivery options include continuous infusion by pump, intermittent by gravity, intermittent bolus by syringe and cyclic feeding by infusion pump. Individuals of any age may require tube feeding so care should be tailored according to the client (e.g. infant or adult).
• Paediatric enteral feeding/nutritional support requirements can differ from adult needs. The clinical indications for children requiring enteral feeding can include but are not limited to cerebral palsy, premature infants, ventilated clients and those who suffer cancer, cystic fibrosis, or Crohn's disease.
• Children will need special infant formulas and high-energy feeds in order to cater adequately for their particular growth and nutritional needs.

• Enteral tube feeding is usually considered for a person who is malnourished or at risk of malnutrition and has:
  • an inadequate or unsafe oral intake and
  • a functional, accessible gastrointestinal tract.
• This can be due to a range of conditions:
  • anomalies of the throat, oesophagus or bowel
  • anorexia
  • impaired swallowing capacity
  • orofacial deformities/fractures
  • neurological or psychiatric conditions
  • severe debilitation
  • respiratory distress.

• NOTE: It is VITAL that only skilled and trained personnel manage and care for those who require enteral tube feeding.
• HWH's key managers must ensure that care workers can set up pump feeds and administer bolus feeds correctly. 
• Failure to do so may result in the incorrect volume of feed being delivered and microbial contamination of feed. CCMs must identify workers who require training and organise specialised education accordingly.

• Care considerations for all types of enteral tube feeding:
  • If the client is confused/disoriented or physically restless, get help from another worker
  •  Clients with enteral feeds may experience disturbed body image and require positive reassurance and support of family members and friends
• Insertion Site
  • Assess insertion site every shift, assess skin condition and check for abnormalities
  • Monitor drainage or leaking of gastric contents
  • Apply gauze dressing if there is drainage (if the dressing is used, change it as required)
  • Gently rotate the tube 360 degrees (unless advised otherwise by a medical specialist).
  • Remember that clients need water which may be administered by bolus
• Tubing and Tape
  • Beware of an allergy to tape used for anchoring tubing—record and document as required.
  • Check tube is anchored, looped and securely taped (should not be hanging freely)
  • Check tube length using the tube markers to ensure the tube is in the correct position and not displaced

• Daily care for a person with NG tube:
  • maintain hand hygiene and wear disposable gloves
  • Provide privacy for the client
  • inspect the condition of nostrils and, oral cavity, mucosa and note down
  • Elevate the head to 30 degrees
  • Checking the length of tubing is recommended once per shift to reduce the risk of aspiration due to tube migration
  • Clamp tubing when not being used
• PEG Stoma Care and Advancing the Tube 
  • The PEG stoma site will require cleaning each day. The feeding connector requires rotating once a day.
• Stoma Cleaning Equipment:
  • PPE - gloves
  • A small bowl of cool boiled water 
  • Soft gauze swabs 
  • Alcohol wipes
  • A bowl to discard used swabs and alcohol wipes
• Stoma Cleaning and Rotating the Feeding Tube: 
  1. Hand Hygiene and PPE
  2. Use cold boiled water and soft gauze to clean the stoma site, wash all around the stoma site and surrounding area, and clean in one direction only - clockwise.
  3. Discard the used swabs in a bowl.
  4. Rotate the tube once a day - one turn in a clockwise direction so the tube moves freely. 
• Advancing the Feeding Tube 
  1. PPE - change gloves
  2. Sanitise the first 10 cms of the feeding with an alcohol wipe.
  3. Undo the tube clip
  4. Advance the feeding tube into the stoma (5 cms) and return to the usual position. 
  5. never advance tubing where there is resistance
  6. Leave a finger-wide space between the stoma and the tube clip and secure the tube clip. 
• Syringe Cleaning Method:
  1. Pull apart the plunger from the barrel
  2. Place the plunger and the barrel in a bowl with mild detergent and wash by shaking the water through the syringe parts, replace plunger into the barrel and draw soapy water into the syringe and push through syringe Luer lock to clean.
  3. Repeat step 2 in cool boiled water to rinse syringe barrel and plunger
  4. Allow to air dry on a paper towel
  5. Store clean syringe parts in a clean airtight container.

• Flush Equipment
  • Hand Hygiene - PPE
  • 60 ml syringe
  • Jug of cool boiled water
  • A clean container 
• Flush Method 
  1. Draw up 60 mls cool boiled water in the syringe and place in a clean container
  2. Remove feeding tube from Statlock or Hyperfix in position
  3. Close the clamp on the feeding tube
  4. Remove the stopper from the feeding port
  5. Push a syringe of water into the feeding tube port and twist
  6. Open the clamp on the feeding tube
  7. Flush the water into the feeding tube using a push-pause technique
  8. Close the tube clamp on the feeding tube
  9. Remove the syringe from the port
  10. replace stopper on feeding port
  11. Replace tube on to Statlock or Hyperfix in position

• Equipment 
  • Hand Hygiene - PPE
  • 60 ml syringe
  • Jug of cool boiled water
  • A clean container
  • specifically prepared and measured food or feed according to the client's needs
  • giving set if required
• Guidelines
  • Prime feeding tube with 100 mls of cool boiled water before food administration
  • Foods are to be given through the feeding port of the feeding tube
  • Foods should be in liquid form 
  • Flush the feeding tube after feeding. Use a 60ml syringe with 30mls of water (every 4-6 hours for continuous feeds)
  • Infection control: wipe the top of the formula with an alcohol swab before opening—No feed should be hung for more than 8 hours—do not add a new formula to the old
  • dispose of used materials correctly to prevent the spread of microorganisms
  • positioning of the syringe prevents the introduction of air into the tubing
  • never force solutions
  • If feeding intermittently, feed volume is usually 200-500 mls per feed
• If you have any concerns about feeding progress, cease administration by TURNING OFF the infusion pump or clamping or kinking the feeding tube.
• To administer foods
  1. Hand hygiene and PPE
  2. Firstly, ensure the feeding tube has been flushed
  3. Close the tube clamp on the feeding tube
  4. Ensure the person is positioned at 30 degrees for feeding
  5. Check that the feeding tube is positioned correctly and not kinked
  6. Check the expiry date of the feed/shake bag or bottle
  7. Measure liquified prepared food and draw it up into a syringe OR select purchased prepared food container 
  8. Remove the stopper from the feeding port
  9. Push the syringe into the feeding tube port and twist to secure Luer lock OR use an aseptic technique and hang the bag on a drip stand and prime giving set or with a bolus, connect the syringe to a feeding tube.
  10. Open the tube clamp.
  11. Administer the food using a push-pause technique on the syringe plunger OR connect the giving set to the feeding tube and set the feeding rate on the pump or use gravity to allow the feed to flow
  12. To complete the feed flush the feeding tube with 100 mls cool boiled water
  13. Close the port and close the tube clamp
  14. Replace tube onto Statlock or Hyperfix in position
  15. monitor for mishaps, i.e. allergy, reflux, diarrhoea and maintain physical comfort
  16. record details.

• Equipment:
  • Hand Hygiene - PPE
  • 60 ml syringe
  • Jug of cool boiled water
  • Tablet crusher
  • Medications
  • Medication cup
  • Spoon 
  • A clean container
• Guidelines:
  • If in any doubt about efficacy and administration, consult and confirm with the pharmacist
  • Liquid medication or soluble tablets are advised
  • mortar and pestle can be used to crush some tablets
  • Give each medication separately and make sure the tubing has been flushed of residue before and after dispensing
  • monitor for any adverse reaction to the new medication.
• To administer medications - 
  1. Hand hygiene and PPE
  2. Firstly, ensure the medication tube has been flushed
  3. Close the tube clamp on the feeding tube
  4. check medication order
  5. Measure liquid medications into a medicine cup and dilute with cool boiled water OR Crush tablets with a pill crusher and mix with 20ml cool boiled water.
  6. Draw up the diluted medication in the syringe
  7. Remove the stopper from the medication port
  8. Push the syringe into the medication tube port and twist
  9. Open the tube clamp
  10. Flush the water into the medication tube using a push-pause technique
  11. If more water is required to flush the tube repeat the procedure
  12. Close the port and close the tube clamp 
  13. Replace tube onto Statlock or Hyperfix in position
• Repeat the steps for each medication and remember to administer each medication separately.

• Keeping good records is advised to maintain quality care for those dependent on enteral feeding.
• Shift notes are important to track what, when and how care has been given.
• A client checklist might include details such as
  • date of insertion
  • Skin condition around the access site
  • Client age, medical history/physiological state
  • weight and body mass index
  • nutritional goals and hydration needs
  • date of dietician/clinical review
  • type of feed, equipment and tube gauge in use
  • daily monitoring essentials
  • fluid balance chart and bowel movement chart
  • emergency actions, contact phone numbers for family, doctor, and hospital.
• Please report any concerns to the relevant CCM

• Oral hygiene is important for all clients, even without oral intake. 

• No - Step 8 -
• Yes - Step 9 -

• Oral hygiene is still important for clients who receive all nutrition and fluid needs via enteral tube feeding. Daily oral hygiene includes:
  • gentle brushing of teeth, gums, tongue and palate with a soft toothbrush and mild toothpaste (suction devices and suction toothbrushes may be necessary for some participants with difficulty swallowing)
  • mouthwash (if recommended by a medical specialist) taking care to avoid aspiration. May require a specific non-alcoholic mouthwash to avoid drying out.
  • Maintain moisture in the mouth if required with swabs and lip moisturiser

• A qualified health professional decides when to remove an enteral feeding tube. 

• Yes - Step 10
• No - Step 11

• Regarding tube removal:
  • When to remove a feeding tube is decided by a qualified health professional
  • If a balloon held gastrostomy tube has been pulled out or has fallen out it needs to be replaced by a competent worker before the stoma closes
  • Always verify the order to discontinue tube feeding
  • Paediatric removal might require sedation of an individual in the hospital
  • Only a clinical nurse or other health professionals can remove a feeding tube.
  • Consent should be obtained before the removal of the tube
  • Care workers need knowledge of the risks and complications of removing enteral feeding tubes
  • escalate care as appropriate.

• When to seek medical advice can differ between individuals and the type of enteral tube being used.

• Yes - for gastronomy tube or device (PEG) - Step 12
• Yes - for nasogastric tube (NGT) - Step 13 
• No - Step 12

• Inadvertent removal of the tube
  • If the stoma is immature (less than 6 weeks), the stoma will close within 2-4 hours. If this happens, a new procedure would be required. Call an ambulance or take the person to the nearest emergency department immediately.
  • If the stoma is mature (6 weeks or more):
    • contact the client's medical specialist, local gastroenterology unit or emergency department
    • The client may require an immediate radiology contrast study/endoscopy procedure to reposition the tube
• Other potential gastrostomy feeding problems
  • When to call the CCM:
    • If there is hyper granulation of the stoma site
    • excoriation or breakdown of skin around the access site
    • infection—monitor for fever, redness greater than 1 cm around the insertion site or swelling
    • nausea, vomiting or regurgitation—this might indicate improper placement of tube or aspiration into the lungs
    • respiratory difficulty
    • a sore throat or irritated pharynx
    • abdominal pain or distention, diarrhoea or constipation
    • signs of malnutrition, organise fluid and electrolyte pathology testing.
    • There is drainage or leaking of gastric fluid or contents or tube feed
    • the tube becomes displaced.

• Seek medical advice when supporting a person with a nasogastric tube if:
  • There is redness and swelling around both nostrils
  • The tube is blocked, and you can’t unblock it
  • The patient gags. Check the pharynx with a torch and tongue blade
  • there it is suspected that the tube has moved, e.g. poor tolerance to feed, reflux of feed into the throat, discomfort in the throat, change in tube length is suspected
  • The tube falls out, and you are unable to replace it
  • The tube needs to be replaced
  • If you have any concerns about feeding progress, cease administration by TURNING OFF the infusion pump or clamping or kinking the feeding tube.