GASTRIC DRAINAGE AND ENTERAL FEEDING STANDARDS OF NURSING CARE (SONC)
Insert Oral/Nasal Gastric Tube Promote Safe NG Drainage Promote Safe Enteral Feeding Promote Early Enteral Feeding Administer Dietary Supplements Document Dietary Supplements		Maintain Tube Patency Monitor Feeds Monitor Residuals Change Feeding Tubing Maintain Bowel Routine Routine Lab Work When to Hold Feeds for OR
STANDARD OF NURSING CARE		RATIONALE FOR STANDARD
Ensure 4 moments of hand hygiene are met when performing assessments and/or managing monitoring equipment. Perform risk assessment and select appropriate PPE based on patient diagnosis and procedure being performed.
1.	Insert Oral/Nasal Gastric Tube Nurses in CCTC may insert nasal or oral gastric tubes in patients who are intubated and ventilated. Contraindications to ORAL or NASAL tube placement by nurse: Esophageal varices (contact GI) Esophageal surgery, e.g., esophagectomy (contact surgical team) Recent ear nose and throat or gastric surgery (contact surgical team) Recent GI bleeding (contact GI or surgical team) Contraindications to NASAL tube placement: Nasal fractures Anterior basal skull fracture Sinusitis Epistaxis If INR > 2.0, review with physician to consider appropriateness of correcting INR to facilitate nasal insertion. If INR is prolonged and there is no contraindication to oral tube placement (above), use oral route for tube insertion (nurse may insert orally).	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 NG drainage tube with sterile sodium chloride solution (in bottles). Record net volume drained on fluid balance record. If NG loss is > 125 ml per shift, review intravenous replacement therapy with physician.	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 Maintain HOB > 30 degrees if patient has an endotracheal tube OR if patient is being enterally fed 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 backrest angle 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 tubes. Feeding should only be initiated via surgical 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). Flush feeding tube before and after medication 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 or tubing that is compatible with intravenous therapy MUST NOT BE USED WITH ENTERAL PRODUCTS.	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 small bowel feeding tube placed intraoperatively for feeding purposes. Flushing is important to maintain tube patency. Products used for enteral feeding must have a different connection than those used for IV administration to reduce the risk for accidental parenteral administration of enteral products. This is a Health Canada standard that was introduced after numerous reported adverse events due to inadvertent administration of enteral products via intravenous routes.
4.	Promote Early Feeding Feeding should be initiated within 24 hours of admission, unless contraindicated. Enteral feeding can be initiated using a gastric drainage tube if prompt feeding tube placement cannot be achieved, however, gastric drainage tubes should be replaced with a small bore feeding tube within 24 hours. Small bowel placement is the preferred method for feeding tube insertion and should be the goal during the initial attempt. If you are unable to get into the small bowel bowel, feeding may be initiated by gastric placement. Monitor for tolerance and consider reattempting small bowel feeding tube if feeds are not tolerated. If a patient who has previously tolerated gastric feeding requires reinsertion of a feeding tube (e.g., removed by patient or feeding tube is clogged), reinsert the tube into the gastric placement. See Procedure for Oral or Nasal Insertion of a Small Bowel Feeding Tube.	4.	NG tubes are larger and stiffer and intended for drainage only. The incidence of sinusitis is lower when feeding tubes are used. 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 as a powder. Mixing is best achieved by shaking the powder after addition to water. Add powder and 20-30 ml of steril water to a sterile specimen container. Apply cap and shake vigorously to mix. 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. Flush well after administration. If a dose of supplement is not given for any reason, document in the AI record and follow-up with the dietitian.	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.
6.	Document Dietary Supplements Transcribe the supplement order to the Kardex. Document that administration of glutamine or protein boluses on the fluid balance record (codes as "P" or "G"). 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 enteral medication administration and q 6 h and prn using 30 ml STERILE water. Oral meds and free water administration is done using sterile water (250-500 ml bottles). Document medication and flush volumes on the fluid balance record. Replace cap on syringe when not in use and flush with sterile water after use to remove residual medication. Change syringes Q 12 H and prn. Blocked tubes may be flushed with pancreatic enzymes dissolved in sodium bicarbonate. If tube blockage cannot be relieved, change feeding tube promptly to prevent nutrition disruption.	7.	Flushing is needed to reduce the incidence of tube obstruction. Sterile water is used to prevent contamination. 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 feeding orders in HUGO at the start of each shift and ensure Kardex is accurate. Monitor bowel sounds and bowel elimination status 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, notify the physician and change nasal tubes to oral (if patient has an endotracheal tube). Percutaneous tube placement may be considered for some patients.	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 Do not check residual volumes when feeding tube location is small bowel. For gastric tube placement only, check Gastric Residual Volumes (GRV) Q12H until patient has tolerated the final feeding rate for 24 hours, then discontinue routine GRV assessments. If the GRV is < 300 ml, return the aspirated GRV to the patient via the feeding tube. Discard the GRV if > 300 ml. Recheck GRV PRN if indicated based on clinical findings (e.g., abdominal distention, nausea or vomiting, suspected aspiration). Protocol for Increased Gastric Residual Volumes (GRV): 1. If GRV is > 300 and < 500 ml: Notify physician Obtain an order to initiate a prokinetic agent Reposition patient to promote gastric emptying (HOB elevated, right side positioning). Check for impaction Initiate bowel routine per protocol Continue feeding at the defined rate as long as GRV is not greater than 500 ml and there are no clinical signs of intolerance. Recheck in 12 hours (or PRN if clinical concerns identified). 2. If GRV is > 500 ml: Stop feeds Notify the physician and dietitian for instructions Attempt small bowel feeding tube placement. 3. If patient vomits or enteral feeding is present/suspected in tracheal aspirate: Stop feeds Notify physician and dietitian for instructions Consider small bowel feeding tube placement.	9.	Residual volumes are difficult to obtain from a small bowel feeding tube and measurement is unnecessary. Gastric emptying may be impaired during critical illness. Shock, trauma, sympathomimetics and narcotics are examples of causes for impaired GI motility. Return GRV back to the patient to prevent loss of enteral nutrition. If > 300 ml, the focus should be placed on improving gastric emptying. The stomach empties into the duodenum towards the right. Right lateral positioning may promote emptying of gastric contents into duodenum. Constipation is an important cause for feeding intolerance.
10.	Change Feeding Tubing Enteral feeding solution bags and feeding tube sets used for enteral formulas are changed every 48 hours when a closed system is being used. Change enteral feeding tube bags and tubing that are used for free water administration Q 24 H. Use sterile water (250 and 500 mL bottles) for free water administration (not tap water). 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.	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. Patients with acute spinal cord injury require regular dose laxatives and suppositories (to promote bowel evacuation at least once every two days).	11.	Inadequate bowel routine can interfere with feeding and promote inadequate nutrition. Delayed feeding is associated with negative patient outcomes. Inadequate bowel routine can contribute to patient discomfort and agitation, and can impair ventilation. Spinal cord injured patients are unable to defecate with assistance; fecal retention can lead to autonomic dysreflexia.
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.
13.	Holding Feeds for the OR (Endorsed by Department of Anaeesthesia and Perioperative Medicine) Critical Care Program LHSC (June 2014) Guideline for Enteral Feeds and Surgical Procedures This guideline is meant to assist with the management of enteral feeding in critically ill patients that are going to the operating room for a procedure. Although it addresses most situations it does not replace clinical judgment. The treating team may make a decision that reflects the best care of an individual patient given specific circumstances. 1. For intubated patients with a post pyloric feeding tube, enteral feedings should continue up to the time that the patient is called for transport to the OR. Feeds should then be held for the procedure. 2. For intubated patients with an orogastric tube or nasogastric tube, feeds should continue up to 1-2 hours prior to transfer and residual gastric contents should be aspirated and discarded on call to the OR. 3. For intubated patients scheduled for surgical manipulation of the airway (eg. rigid bronchoscopy, laryngectomy, tracheostomy), feeds should be held 6-8 hours prior to the procedure at the direction of the anesthetist and/or surgical team. 4. On return from the OR from non-abdominal surgery, feeds are to be resumed at the pre-operative rate. 5. On return from the OR for patients undergoing step-wise closure of an open abdomen, feeds are to be resumed at the pre-operative rate. 6. Following bowel surgery, do not resume feeds until the surgical team and ICU have discussed the feeding plan. There may be circumstances when the surgical team may direct that enteral feeding be held (eg. ischemic bowel, fistula, bowel not in continuity). 7. Non-intubated patients who are either on an oral diet or receiving tube feeds should be fasting for a minimum of 8 hours prior to any elective surgical procedure. These patients can receive their medications with sips of water.