SDE: Clinical Guidelines Ch7J

Clinical Procedure Guidelines for Connecticut School NursesPrintable version | Back to Contents
7
Specialized Health Care Procedures

J. Enteral Tube Feedings

Definitions

Delivering a liquid nutrient formula directly to the stomach, duodenum, or jejunum.

  • Enteral Nutrition: Nutrition administered in the gastrointestinal tract.
  • Tube Feedings: Enteral nutrition delivered via a tube, catheter, or stoma.
  • Stoma: A stoma is a surgical bypass of a natural conduit.
  • Gastrostomy: A stoma that bypasses the upper digestive tract and directly enters the stomach.
  • Jejunostomy: Surgical creation of an opening to the middle portion of the small intestine (jejunum), through the abdominal wall.
  1. (American Society for Parenteral and Enteral Nutrition, 2011).

Methods

Bolus feeding is the administration of liquid into a feeding tube using gravity to determine the rate the liquid passes through the tube. The liquid is either poured into a 60 cc syringe or a tube-feeding bag and held (or hung) at a height above the stomach that allows for the most desirable and tolerated rate of administration, typically over 15–30 minutes. Pushing the liquid in with the syringe is sometimes used to augment a bolus feeding (Altman GB, ed., 2003).

Tube feeding pump is a mechanical device that uses a matching tube-feeding bag and tubing. A set rate to administer a set volume over a specific period of time is programmed into the pump. Pumps vary in size and battery power potential. Tube feedings using pumps can be continuous (i.e., 30 cc/hr.) or intermittent (i.e., 240 cc over one hour). The school nurse needs to be competent using the specific type of pump for an individual student.

Types of Feeding Tubes

Feeding tubes use an abbreviation system that indicates the point where it enters the body and the point where it ends (and the liquid is infused).

  1. NGT (Naso Gastric Tube): These can either be inserted for each feeding or remain in place for a set period of time.
  2. GT (Gastrostomy Tube): These are surgically inserted through the stomach wall, leaving one end accessible on the abdomen and the other in the stomach. The most common type used in children is the low-profile brand “Mic-Key” (also referred to as a “button”). An extension tube is connected and locks in place when used for feedings, hydration, or medications. When not in use this device caps off to remain relatively flush with the abdominal wall.
  3. G-JT (Gastro-Jejunostomy Tube): Also surgically inserted through the stomach wall, entering the stomach, passing through the pylorus, and ending in the jejunal segment of the small intestine. These tubes are generally indicated for children who cannot tolerate food in their stomach. They may have a lumen that ends in the stomach and another lumen that ends in the jejunum, so the nurse needs to be clear if one lumen is for medication and the other is for feeding (it is helpful to label the two lumens).
  4. JT (Jejunostomy Tube): Similar to the GT, except it is surgically inserted through the abdominal wall directly into the jejunal section of the small intestine (Rosewell Park Cancer Institute, n.d.).

Purpose

To provide a safe method of feeding a student who cannot tolerate oral feeding or requires supplementation to oral feeding in order to ensure adequate nutritional intake. Also, to provide continuity with the health care plans that students follow at home.

Equipment

Per provider’s order and individual health care plan.

Procedure

Tube Feeding

  • Prepare formula or liquid to be administered (normally room temperature).
  • Ensure feeding tube is intact and in the correct anatomical position.
  • Prime the feeding tube to minimize the amount of excess enteral air.
  • Clamp or pinch-off feeding tube prior to opening to air (to avoid reflux of gastric contents out of tube).
  • Attach syringe and administer fluids.
  • Unclamp feeding tube.
  • Administer feeding as directed.
  • When feeding is complete, flush tube with prescribed amount of water.
  • Cap or disconnect tube as indicated.

Medication Administration

  • Prepare medication as prescribed.
  • If administering a pill or capsule, ensure that solid particles are adequately dissolved or mixed in water.
  • Clamp or pinch-off feeding tube prior to opening to air (to avoid reflux of gastric contents out of tube).
  • Attach syringe and administer medication.
  • Clamp or pinch-off feeding tube prior to disconnecting syringe in order to avoid reflux (and loss) of medication back out of tube.
  • Flush with sufficient water to ensure that no medication is left in tube.
  • If administering medication immediately before tube feeding, tube feeding may be used to flush through the medication.

Delegation Considerations

Initiating tube feeding or tube medication administration: RN, LPN

Monitoring of feeding: RN, LPN, physical therapist, occupational therapist, speech pathologist, teacher, school health aide, other certified personnel.

Select Nursing Considerations

  1. Administration of any tube feeding in school requires a nurse to be present in the building.
  2. Tube feedings in school require a procedure authorization order and plan signed by a prescribing health care provider and parent/guardian, including: the type of formula; amount; infusion type and rate; frequency of administration; and amount of water used to flush the tube.
  3. The most significant risk with tube feedings is aspiration of liquid nutrition into the lungs.
  4. Keys to preventing aspiration include:
    1. Ensuring tube placement is appropriate.
    2. Proper positioning.
    3. Monitoring during feedings:
      1. Stop feeding immediately for gagging, vomiting, coughing, change in skin color, or difficulty breathing. An immediate nursing assessment would then be indicated.
  5. Additional considerations include:
    1. Any specific method for securing a feeding tube.
    2. Storage and preparation of the formula.
    3. Caring for the insertion site:
      1. Rashes tend to occur as a result of leaking around a GT stoma site.
      2. Management may include using a barrier ointment and frequent dry dressing application.
      3. Granulation tissue usually forms as a result of excess friction between the tube and the stoma site.
      4. Daily monitoring of the insertion site to ensure healthy skin integrity at the insertion site is essential.
  6. Mic-Key tube considerations:
    1. Mic-Key tubes should be level with the skin, able to rotate 360 degrees, and use a water-filled balloon in the stomach side of the stoma to maintain it in place.
    2. The balloon is usually filled with 5 cc of sterile or distilled water and should routinely be checked once a week (at home), and more often if it appears loose or leaking (Kimberley Clarke, 2010) .
    3. A balloon that is leaking and unable to hold water is an indication for Mic-Key tube replacement.
    4. A spare Mic-Key should be maintained at school and the nurse needs to be trained in inserting a new one if it falls out:
      1. Prompt reinsertion of a Mic-Key tube is vital to maintain the opening of the stoma site.
      2. If the nurse is unable to reinsert the Mic-Key, prompt medical attention is indicated.
  7. NGT insertion in school is a relatively unique procedure that goes beyond the scope of this manual. Specific procedures and training needs for the school nurse should be obtained on a case-by-case basis. Once an NGT is properly inserted, the procedural steps listed above for feeding and medications can be applied.
  8. Medication and nutrition administered into the jejunum require careful consideration since bypassing the stomach can affect absorption rates and tolerance.

References

Altman GB, ed. Feeding and medicating via a gastrostomy tube. Delmar’s Fundamental and Advanced Nursing Skills. 2nd Ed. Albany, NY: Delmar Thomson Learning; 2003: 742-749. Per Medlineplus.

Altman GB, ed. Feeding and medicating via a gastrostomy tube. Delmar’s Fundamental and Advanced Nursing Skills. 2nd Ed. Albany, NY: Delmar Thomson Learning; 2003: 742-749. Per Medlineplus

Americal Society for Parenteral and Enteral Nutrition. (2011). What is enteral nutrition? Retrieved January 17, 2012.

Bowden, V.R., and Greenberg, C.S. (2008). Pediatric Nursing Procedures, 2nd edition. Philadelphia, PA: Lippincott Williams and Wilkins.

Guenter, P. and Silkroski, M. (2001). Tube feeding: practical guidelines and nursing protocols. Gaitherberg, MD: Aspen Publications, Inc.

http://www.mic-key.com/

http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000165.htm

Kimberley Clarke (2010) MIC-KEY care and usage guide. Retrieved January 19, 2012.

Rosewe Park Cancer Institute. (n.d.). Jejunostomy tube. Retrieved January 17, 2012.

Wilson, D. and Hockenberry, MJ (2007). Wong’s clinical manual of pediatric nursing (7th ed.). Denver, CO: CV Mosby

Resource

Bankhead R., Boullata J., Brantley S., Corkins M., Guenter P., Krenitsky J., Lyman B., Metheny N.A., Mueller C., Robbins S., Wessel J.(2009) Enteral nutrition administration. In: A.S.P.E.N. enteral nutrition practice recommendations. JPEN Journal of Parenteral and Enteral Nutrition; 33, 149-58. Retrieved January 17, 2012.





Content Last Modified on 8/30/2012 1:39:32 PM