GASTRIC DRAINAGE AND ENTERAL FEEDING
STANDARDS OF NURSING CARE (SONC)

1. Insert Oral/Nasal Gastric Tube
2. Promote Safe NG Drainage
3. Promote Safe Enteral Feeding
4. Promote Early Enteral Feeding
5. Administer Dietary Supplements
6. Document Dietary Supplements
   

7. Maintain Tube Patency
8. Monitor Feeds
9. Monitor Residuals
10. Change Feeding Tubing
11. Maintain Bowel Routine
12. Routine Lab Work
    

STANDARD OF NURSING CARE

 1.

Insert Oral/Nasal Gastric Tube

Clinical Nurses in CCTC may insert nasal or oral gastric tubes in patients who are intubated and ventilated. Clinical Nurses must successfully insert 2 nasal/oral gastric tubes under the guidance of an experienced Clinical Nurse before independently performing the skill.

Contraindications to Nasal Insertion:

• Head injury
• Epistaxis
• Nasal surgery

Contraindications to Oral/Nasal Insertion:

• Esophageal varices
• Esophageal surgery (e.g., esophagectomy)
• Recent ear nose and throat or gastric surgery
• GI bleeding
• Facial fractures
• Severe coagulopathies

 1.

It is easier to obtain residuals from NG tubes versus feeding tubes, however, NG tubes are larger and more traumatic to the mucosa. While they provide a suitable method for initiating feeding that avoids delays, once a patient is tolerating enteral feeds, a feeding tube should be inserted to replace the OG/NG drainage tube.

Tube advancement could induce bleeding in patients with coagulopathies or varicosities.

Esophageal or gastric incisions may be perforated by tube advancement. Patients should never be fed via a tube situated above the incision.

All patients with head trauma should be presumed to have a possible basal skull fracture. CT and skull xrays cannot conclusively rule out basal skull fractures. Anterior basal skull fractures may provide a communication between the nasal cavity and meninges that can increase the risk for meningitis. In severe facial and basal skull trauma, feeding tubes could be inadvertently advanced into the cranial cavity. Oral insertion is a safer route for patients with a head injury.

 2.

Promote Safe NG Drainage

Connect NG tube to low, intermittent wall suction. Utilize six foot drainage tubing with a "Y" connector. Set intermittent suction at no greater than 90 mmHg.

Irrigate the NG tube q 6 h and prn using sterile 0.9 % sodium chloride solution. Record irrigate used and volume drained on intake and output record.

If NG loss is > 125 ml per shift, obtain an order to replace volume losses ml/ml with 0.9 % sodium chloride with potassium added.

 2.

To reduce the risk for aspiration.

Normal saline solution is used to maintain electrolyte concentration during irrigations.

Excessive HCl removal can cause hypokalemia and/or hypochloremia with metabolic alkalosis. Replacement of NG losses with 0.9% sodium chloride with potassium can prevent these disturbances.

 3.

Promote Safe Enteral Feeding

All patients with ETT's or enteral feeding tubes via nasal or oral insertion routes are maintained with HOB > 30 degrees unless contraindicated. The degree of elevation is documented in the graphic record. If the HOB cannot be elevated, the reason is documented in the AI record.

If HOB cannot be elevated (e.g., spinal precautions, obesity), consider using reverse trendelenburg.

DO NOT FEED patients who have undergone esophageal or gastric surgery via gastric drainage tubes. Feeding should be initiated via percutaneous jejunal tubes. The surgical team must document in the clinical record that feeding may be initiated, and identify where feeding should be delivered (i.e., identify the feeding tube).

3.

To reduce the risk for aspiration and Ventilator Associated Pneumonia (VAP).

Reverse trendelenburg positioning maintains HOB elevation without flexing the spinal column.

Feeding above the incision line is contraindicated due to the risk for perforation, leak or infection. Following esophageal or gastric surgery, feeding is initiated only upon the order of the surgeon who knows the surgical procedure. Patients will usually have a percutaneous small bowel feeding tube placed intraoperatively for feeding purposes.

 4.

Promote Early Feeding

Enteral feeding may be initiated via NG tube. An NG tube should be replaced with a feeding tube once the patient is tolerating the feeds.

Feeding should be initiated within 24 hours of admission, unless contraindicated. Enteral feeding is the preferred route. If feeding has been delayed, the reason should be documented in the AI record.

Enteral nutrition is usually ordered full strength and initiated at a rate below the patient's final goal rate. Orders are written to increase the feeds as tolerated, until the final goal is achieved.

Small bowel placement is the preferred method for feeding tube insertion. Currently, only CCTC residents and small number of approved Clinical Nurses may insert feeding tubes into the small bowel. Feeding should not be delayed if small bowel placement cannot be established at admission. See Procedure for Oral or Nasal Insertion of a Small Bowel Feeding Tube.

 4.

NG tubes are easier to obtain residuals but are larger and more traumatic to the nasal pharynx.

Early feeding is associated with improved patient outcomes. Feeding post pylorus reduces gastric residuals, promotes movement of feeds into the small bowel, reduces risk for gastric regurgitation and aspiration and promotes more effective feeding.

 5.

Administer Dietary Supplements

When ordered, administer protein and/or glutamine supplements via the side port of the Y-Site feeding tube extension set.

Supplements are provided by dietary and should be allowed to sit at room temperature for 15-30 minutes prior to administration. Shake syringe prior to administration.

Flush feeding tube before and after administration with 30 ml of STERILE water. Sterile saline flushes may be ordered if the patient is hyponatremic.

Catheter tip syringes must be used for enteral administration. Luer lock syringes should not be used.

 5.

Protein supplementation may be required for patients with volume limitations (e.g., renal failure) or who have high protein requirements (e.g., catabolic patients, burns, traumas).

Glutamine supplementation has important immune properties that may be beneficial to burned or trauma patients.

Administration of cold supplements may induce cramping. Free water administration may worsen hyponatremia. Flushing is important to maintain tube patency.

Products used for enteral feeding must be different than those used for IV administration to reduce the risk for accidental administration of enteral products parentally.

 6.

Document Dietary Supplements

Transcribe the supplement order on the Kardex.

Transcribe the Protein and/or Glutamine supplement on the MAR. Document the dose and time. Initial following administration of each dose.

You must manually recopy each supplement order at the 2400 hr MAR to MAR check. They will not appear as typed entries when new MARs are printed.

Record the volume given on the intake and output record.

 6.

Dietary supplements do not have a Drug Information Number, therefore, they are not considered medications. They will not be entered by pharmacy.

 7.

Maintain Tube Patency

Feeding tubes are flushed before and after meds and q 6 h and prn using 30 ml STERILE water. Oral meds and free water administration is done using sterile water. Oral meds and flushes are documented on the intake and output record. Recap syringes after tubing is flushed. Replace syringes after use for medications.

If a dose of supplement is not given for any reason, document on the MAR and make a notation in the AI record to indicate the reason.

Blocked tubes may be flushed with pancreatic enzymes dissolved in sodium bicarbonate.

If tube blockage cannot be relieved, change feeding tube promptly.

 7.

To reduce the incidence of tube obstruction. Because bacteria have been found to grow in tap water, syringes may become a source for bacterial growth and critically ill patients may be more susceptible to translocation of bacteria from the bowel to the blood stream, sterile water and aseptic techniques should be used.

Pancreatic enzymes may digest proteins, fats and carbohydrates, relieving obstructions due to feeds.

To avoid interruption in nutrition. Early and adequate feeding is associated with better patient outcomes.

8.

Monitor Feeding

Review Kardex daily for orders. During initiation of feeds, orders are written to increase feeds q X hrs until a final rate is achieved. Once final rate is tolerated, additives such as protein or glutamine may be ordered. Orders are transcribed to the Kardex. Additives are documented in the Enteral Feeding section of the graphic record.

Monitor bowel sounds and bowel movements q shift. Document in the daily assessment record and on the graphic record. Review bowel routine orders daily and administer medications as ordered to ensure regular bowel function.

Inspect bucal/nasal cavity q shift for evidence of skin breakdown. If mucosal injury is noted, change tube position or placement. Inspect bridge of nose q shift for signs of skin breakdown.

If nasal tube is in place, monitor q shift for evidence of nasal discharge, increased white count or fever that could suggest sinusitis. If sinusitis is suspected, nasal tubes must be removed and positioned orally or percutaneously. Report findings to physician.

8.

Early feeding is associated with improved patient outcomes. Feeding post pylorus may reduce potential for gastric residuals, promote movement of feeds into the small bowel, reduces risk for gastric regurgitation and aspiration, and promote more effective feeding.

Significant mucosal injury can be induced by feeding tubes. If damage extends to include the cartilage of the nose, spontaneous repair may not occur.

Sinusitis is an important complication associated with nasal feeding tubes. Feeding tubes must be removed if infection is suspected, even if antibiotics are ordered, as they provide an ongoing source for colonization of bacteria. If clinical signs of infection are not identified, the patient may be treated with nasal decongestants, saline spray and tube removal.

 9.

Monitor Residuals

Residual volumes are checked q 12 h. If volume is > 3 hours feeding volume, obtain an order to initiate prokinetics and decrease enteral feeding rate by 50%. Recheck residual in 4 hours. Document residual volumes in graphic record.

Stop feeds if patient vomits. Notify physician and document in the AI record.

Right lateral positioning may promote emptying of gastric contents into duodenum.

Do not hold feeds unless necessary. Patients who are going to the OR who are already intubated do not require feeds to be stopped for surgery unless GI surgery is being performed. Review feeding goals/OR plans during morning rounds prior to surgery.

 9.

Gastric emptying may be impaired during critical illness. Shock, trauma, sympathomimetics and narcotics are examples of causes for impaired GI motility.

Aspiration of gastric contents can lead to VAP.

The stomach empties into the duodenum towards the right.

Vomiting and aspiration risk is increased during intubation due to gagging in the presence of gastric contents. Feeds do not need to be held to deliver anaesthesia alone. Feeds are only held if other reasons exist. Withholding feeds without a reason contributes to inadequate nutrition.

 10.

Change Feeding Tubing

Enteral feeding solution bags and feeding tube sets are changed every 24-hours when a closed 24-hour system is being used. For all other delivery systems, enteral feeding bags and tubing sets are changed q 4 hours.

Document when a new bag has been hung by placing an upright arrow in the enteral feeding intake column on the fluid balance record. Document in the graphic record when tubing changes are made.

10.

To reduce the risk of promoting bacterial growth. During critical illness, increased gut permeability may increase the risk for bacterial translocation from the GI tract to the blood stream.

 11.

Maintain Bowel Routine

Obtain order to initiate bowel routine preprinted orders when patients are enterally fed.

 11.

Inadequate bowel routine can interfere with feeding and promote inadequate nutrition. Delayed feed is associated with negative patient outcomes.

Inadequate bowel routine can contribute to patient discomfort and agitation, and can impair ventilation.

 12.

Routine Lab Work

Obtain a 24-hour urine collection for creatinine clearance, creatinine, urea, electrolytes and osmolality once per week for all patients being enterally or parenterally fed. Collect urine from 0600 Monday morning until 0600 Tuesday morning.

Measure prealbumin upon initiation of nutritional support and every Monday.

 12.

To monitor adequacy of nutrition.