5.18 – Enteral and Tube Feedings

Open Door provides care to individuals requiring enteral tube feedings.  In the ICF settings, tube feeds are administered only by a licensed nurse.  In Waiver settings, tube feedings may be delegated by a Registered Nurse to Certified DSP staff as per OAC 5123.  All tube feedings must have a specific written doctor’s order outlining dosage, frequency, route, time, flush orders, and type.  Tube feedings must be indicated in an individual’s care plan.  Skin integrity around the tube area should be monitored daily.

Types of Enteral Feeding Methods

Percutaneous Gastronomy Tubes (PEG):

• Can be placed with endoscopic or radiographic guidance.
  • GI consult for endoscopic placement, Interventional Radiology for radiographic placement. General Surgery will place PEG in OR but, only in combination with another procedure
• Post-placement may start enteral feeds between 6 and 24 hours.
  • Keep tube clamped until able to start enteral feeds. Recent studies support early enteral feeding with PEG tubes (6-12 hrs), however, many providers continue to support a 24 hour period of gravity drainage prior to feeding.
• The tube is secured to the skin by an outer flange that is carefully positioned during the procedure to prevent tube migration and keep the stomach opposed to the abdominal wall.
  • Do not manipulate this flange or place any gauze beneath it as this may loosen the approximation with the abdominal wall. The flange should be loosened after 5 days by physicians performing the procedure to prevent skin necrosis.
  • The PEG external bolster (skin disc) should be rotated every 8 hours for the first 24 hours. Do NOT loosen the bolster to rotate it! Check the measurement of PEG depth before and after rotation to ensure that it has not changed.
• The tube should also be secured to the skin with tape to avoid traction on the tube leading to dislodgment.
• Care of site:
  • Soap and water, gauze over the tube, and tape securely for 24 hours, as indicated.

Open Gastrostomy

• These are usually performed either in conjunction with a laparotomy for other reasons or for patients who cannot have percutaneous placement due to intra-abdominal adhesions.
• This procedure requires a general anesthetic.
• The stomach is tacked to the abdominal wall with sutures and an external suture is usually placed around the tube to prevent it from being dislodged.
• The tube should be left to gravity drainage for 24 hours and then can start enteral feeds.
• Can check residuals for tolerance
• The surgical incision should remain dressed for 24 hours and then left open to air if there is no drainage.

Transgastric Jejunostomy

• These tubes can be placed surgically, or with endoscopic or radiographic guidance.
• May contain a second port for gastric aspiration.
• Can be converted to gastrostomy later.
• Cannot monitor residuals to determine tolerance.
• Post-placement care is the same as PEG.

Surgical Jejunostomy

• Usually placed in conjunction with a laparotomy or for a patient who needs long term enteral access and cannot tolerate gastric feeds.
• These can be placed either via a laparoscopic or open approach and require a general anesthetic.
• A variety of tubes are used including red rubber catheters, Jackson Pratt drain tubing, and needle catheter jejunostomies.
• The jejunum is tacked to the abdominal wall with sutures and an external suture is usually placed around the tube to prevent it from being dislodged.
• Laparoscopically placed tubes will have suture bolsters around the skin exit site. These should not be manipulated by anyone other than the surgeon.
• Enteral feeds can begin 12 hours after surgery.

Notes/Caution

• NOTE: All tubes not being used for continuous enteral feeds should be flushed with 30cc (adults) or 5-10 cc (pediatric) tap water every 4 hrs to ensure patency.
• NOTE: All tubes should be marked at the skin entrance to allow monitoring for migration of the tube. Tube position should be monitored by the nursing staff q Shift.
• *Caution: If a PEG or surgically placed tube is dislodged from the abdominal wall this should be reported to the physician immediately. Place a 4×4 secure dressing over the site. Recently placed tubes (<7 days) will not have a well-formed fistula tract with the abdominal wall and so must be recannulated quickly to avoid closure of the tract. After the replacement of all tubes, a fluoroscopic exam should be ordered to confirm placement in the GI tract and rule out any leak prior to resuming enteral feeds.

Feeding Tube Obstruction

Causes of Clogged Feeding Tubes

• Improper flushing of tubes.
• Caloric dense formulations.
• Small-bore feeding tubes.
• Rate of flow that could allow gastric pH to clump the formula as well as cause a build-up
• on the sides of the feeding tube.
• While evaluating gastric residuals the low pH can cause formula coagulation.
• Medications that are not properly crushed. Bulk-forming medications (Psyllium).

Solutions

• Prevention
  • Frequent flushing with water is the easiest way to prevent clogging. Tubes should be flushed with 30 ml to 50 ml (adults) or 10cc (pediatrics) of water every 4-6 hours as a routine process as well as flushing pre and post medications can prevent most clogged feeding tubes. Flushing pre and post gastric residual checks can also prevent gastric acid accumulation and henceforth formula coagulation.
• Medications
  • Use liquid medications whenever possible. Some medications can be crushed after consultation with the pharmacy.
• Small-bore jejunostomy feeding tubes clog very easily.
  • Clarify medication administration guidelines from the physician before using these tubes for medication administration.

Unclogging

• Use a 30 to 60 cc syringe
  • Avoid small syringes due to high pressure.
• Flush with warm water.
• Flush with Carbonated beverage (approximately 5 ml).
• Liquid meat tenderizer (approximately 5 ml). Papain is probably beneficial. May repeat
• but avoid more than 2 doses. *
• 1 capsule Cotazym + 1 tab Sodium Bicarbonate with 10 ml warm water to the tube, clamp x 5
• minutes then flush. *
• 1-2 caps Cotazym in 6 ounces (180 ml) of warm water, draw up in catheter tip, clamp x 30
• minutes, then flush. *
  • Caution: Avoid eye contact when mixing.
• If these attempts to unclog the tube fail then the tube must be replaced

Feeding Protocol

Must be administered according to physician order and Medication Administration Record.

Contact physician to hold order when:

• 1/2 hour prior to procedures requiring the Trendelenberg position
• 6 hours prior to general anesthesia for non-intubated patients

Monitoring Tolerance and Complications of Enteral Feeding

Monitoring Tolerance

• Gastric feeds
  • Check gastric residual volumes once per shift and as needed.
  • Reinfuse the residual and recheck in 2 hours. Notify PHYSICIAN if residuals remain
  • Feeds should also be held for increasing abdominal distension and/or emesis. Notify PHYSICIAN.
• Jejunal feeds
  • Residual volumes are not helpful. Monitor abdomen for distension and bowel sounds once per shift and as needed. Hold feeds for emesis, abdominal pain, or distension.  Notify PHYSICIAN.

Last Revised: 6/6/22