Nasogastric
and Feeding Tubes
Proper nutrition in
hospitalized clients is necessary for wound healing, recovery, reduction in
morbidity, and consequent reductions in length of stay and mortality. The most
common nutritional deficiency in hospitalized clients is protein-energy
malnutrition. This type of malnutrition depletes body cell mass and impairs
tissue and organ function. When protein-energy malnutrition is left untreated,
the following client negative outcomes may occur:
·
Weakness
· Compromised
immunity
·
Decreased wound healing
·
Increased risk for
complications
Nutrition support is
prescribed for those clients at risk for protein-energy malnutrition. There are
two routes for delivery of nutrition support (NS) in adult clients: enteral nutrition (EN) and parenteral nutrition (PN). Enteral
nutrition includes both the ingestion of food orally and the delivery of
nutrients through a gastrointestinal tube.
Parenteral nutrition refers to nutrients bypassing the small intestine
and entering the blood directly. EN is preferred over PN because of decreased
bacterial translocation and reduced expense, and is usually delivered through a
feeding tube (Figure 38-14).
Critical indicators for determining
the feeding route and nutrition support formula include GI function, expected
duration of therapy, aspiration risk, and the potential for or the actual
development of organ dysfunction. For example, the decision to initiate PN or
EN support is based on evidence that the client is unable to meet his or her
own nutritional needs by oral intake and will therefore experience
malnutrition. Refer to Figure 38-15 for a clinical-decision algorithm that
outlines the selection process for choosing the route of nutritional support in
adult clients. The client’s nutrition support may be determined by a nutrition
support team (NST) in accord with the American Society for Parenteral and
Enteral Nutrition (ASPEN) guidelines.
Nutrition Support Teams
Since the early 1980s,
nutrition support teams (NSTs) were established to reduce the complications of
PN. To achieve the expertise required for a consulting service, the teams have
become multidisciplinary.
The nurse is seen as the vital
link between the client and other team members to include a physician, nurse,
pharmacist, and dietitian; see the accompanying display for the functions of
NSTs. The nurse’s role is critical, both for the implementation of nutritional
support and for ongoing assessment, because the nurse administers and monitors
nutritional therapies.
The nurse is also responsible
for eliciting the client’s or family’s continued
consent and collaboration with the therapy. The physician obtains the client’s
informed consent for starting the therapy. The nurse teaches the client and
family about the nutritional support to restore a sense of independence and
self-esteem. Many staff nurses are board-certified in nutrition support by
Providing Enteral Nutrition
Candidates for enteral tube
feeding are clients who have a functional GI tract and will not, should not, or
cannot eat. Therefore, tube feedings are used for clients who are (or may
become) malnourished and in whom oral feedings are insufficient to maintain
adequate nutritional status. Enteral tube feedings maintain the structural and
functional integrity of the GI tract, enhance the utilization of nutrients, and
provide a safe and economical method of feeding. Enteral tube feedings are
contraindicated in clients with the following:
·
Diffused peritonitis
· Intestinal
obstruction that prohibits normal bowel functioning
·
Intractable vomiting;
paralytic ileus
·
Severe diarrhea
Feeding
Tubes
Most feeding tubes are made of
silicone or polyurethane, which are durable and biocompatible with formulas.
They vary in diameter (8 to 12 French) and length in accord with the route and
formula. The physician selects the route (Figure 38-14) and type of feeding
tube on the basis of the anticipated duration of feeding, the condition of the
GI tract, and the potential for aspiration.
Insertion
of Enteral Feeding Tubes
Nasoenteral insertion of a
gastric feeding tube is the simplest and most often used method of tube
feeding. It is used as a temporary measure for clients who are expected to
resume oral feeding. Nasogastric intubation refers to insertion of a tube
through the nostril into the stomach; refer to Procedure 38-1. Nasoduodenal or
nasojejunal intubation allows nasal access to the duodenum and jejunum; it is
done with a longer tube and decreases the client’s risk of vomiting and
aspiration. Radiographic visualization is used to confirm tube placement prior
to feeding.
Enterostomy is the surgical
creation of an artificial fistula (gastrostomy, jejunostomy) in the intestines
by incision through the abdominal wall. Tube enterostomies can be placed at
various points along the GI tract and are performed when long-term tube feeding
is anticipated or when obstruction makes nasal intubation impossible.
Percutaneous endoscopic
gastrostomy (PEG) tube placement is usually performed by the physician at the
bedside or in the endoscopy room; insertion of a PEG tube does not require
surgery. Endoscopy nurses are often trained to assist with PEG placement. PEG
has become an accepted technique to provide enteral access for both children
and adults (
Enteral
Formulas
Nutrients administered through
tubes are liquefied so they can be easily digested and absorbed. Commercially
prepared formulas are available and used in most health care settings. There
are three basic types of formulas, which differ in osmolality, digestibility,
kilocalories, lactose content, viscosity, and fat content; see the accompanying
display.
Administration
of Enteral Feedings
Once the feeding tube’s
position has been radiographically verified, the formula can be administered as
prescribed; refer to Procedure 38-2. Most clients with a small-bore tube
receive continuous feeding with a formula pump to regulate the rate. One of the
advantages of continous feeding is that it keeps gastric volume small,
minimizing residual volume and reducing the risk of aspiration pneumonia; the
client is less likely to experience bloating, nausea, abdominal distention, and
diarrhea.
Safety
Considerations
Clients receiving EN through a
feeding tube are at risk for aspiration. The prevalence of tube placement
errors, as reported in the literature, varies from 1.3% to 50% in adults
(Cirgin & Marsha, 1997). Tube feeding aspiration can result from several
factors: displacement of the tube into the esophagus, large amounts of gastric residual, and lowered intestinal motility and delayed
gastric emptying, which may occur in clients who are on bed rest or receiving
narcotics for pain relief (Pratt & Tolbert, 1996). Auscultate for bowel
sounds to determine gastric motility. If the bowel sounds are hypoactive or
absent, stop or withhold additional feeding and notify the physician.
Always assess placement of the
feeding tube before administering any liquids. Clients who are receiving
continuous gastric feeding should be assessed every 4 hours for tube placement
and residual gastric contents. Aspirate gastric contents with a syringe. This
is done more easily with a large-bore tube than a small-bore tube. The lumen of
a small-bore tube collapses easily, making aspiration difficult and sometimes
impossible. Observe and check the pH of the aspirate as explained in Procedure
38-1; refer to the Research Focus. Replace stomach contents after checking the
residual to prevent fluid and electrolyte imbalance.
Another way of determining
tube placement is to visually examine the aspirate; refer to the accompanying
display. If the pleural aspirates contain blood, they will fail to show their
normal characteristics.
Client safety and comfort
require daily cleansing of the feeding tube’s exit site. Cleanse the skin with
a clean washcloth, soap, and water. Nasal feeding tubes require daily removal
of the tape from the nose, cleansing, and inspection of the skin for
irritation, inflammation, and infection and the nares for erosions, ulcers, or
abscesses.
Enterostomy tubes require
surgical asepsis of the exit site until the incision heals; rotate the tubes
within the stoma to promote healing. Report any observations of redness,
irritation, or gastric leakage at the site. Once the stoma has healed, the tube
can be removed and reinserted for each feeding. Between feedings, a prosthetic
device may be used to cover the ostomy opening.
PEG tubes require daily
rotation to relieve pressure on the skin. Notify the physician if you are
unable to rotate the PEG; it may be an indication of internal embedding of the
tube into the gastric wall. When the tube is internally embedded, it can cause
gastric acid reflux, which results in skin breakdown, sepsis, and cellulitis.
Care must be taken to avoid dislodgment of the tube. Keep it secured to the
client’s abdomen with tape, being careful not to use excessive tension. PEG
tubes require frequent flushing to prevent clogging. These tubes have small
lumens. If a tube becomes clogged, flush it with 60 ml of lukewarm tap water.
Potential
Complications
Clients receiving EN need to
be monitored closely to prevent complications. The nurse should perform the
following actions:
1. Assess the client for signs of gastric retention: nausea, vomiting, and
cramping. Palpate the abdomen for distention; auscultate for bowel sounds with
a stethoscope; and aspirate the gastric contents every 4 hours. If the aspirate
exceeds 100 ml in a 4-hour period or if bowel sounds are absent (indicating an
ileus), discontinue the feeding and notify the physician. Do not remove the
feeding tube.
2.
Monitor the feeding tube placement every 4 hours
by checking for any coils or kinks in the back of the throat and measuring the
length of tubing outside the body.
3.
Assess the client for
pulmonary aspiration by checking the gag reflex. If the reflex is absent,
suction the client. Discontinue the feeding and remove the tube if signs of
respiratory distress are present and notify the physician.
4.
Keep the client in a high
Fowler’s position to prevent aspiration if vomiting should occur. If vomiting
does occur, suction client immediately and assess the formula amount and rate
at which it was given.
5.
Dilute feedings to half
strength and slow the feeding time to prevent diarrhea.
6.
To maintain or achieve patency
of gastric and/or jejunostomy feeding tubes, a medical device called a
DeClogger may be used as prescribed by the client’s physician to maintain the
patency of these tubes.
Teach the client and caregiver
how to monitor for complications prior to discharge for home treatment. The
client and caregiver should be given the opportunity to practice these
assessment measures and demonstrate competency in performing the actual
procedures.
Removal
ofa Nasogastric Tube
When the physician determines
that the client’s nutritional status no longer warrants EN therapy or the need
to provide decompression of the gastric contents, the nasogastric tube is
removed; refer to the nursing checklist. If the client is connected to suction
for decompression, the physician may prescribe clamping the tubing for several
hours prior to removal, to ensure a functioning GI tract.
Providing Parenteral Nutrition
Parenteral nutrition is the
infusion of a solution directly into a vein to meet the client’s daily
nutritional requirements. Formerly called hyperalimentation, it is frequently
referred to as total parenteral nutrition (TPN), the intravenous infusion of a
solution containing dextrose, amino acids, fats, essential fatty acids,
vitamins, and minerals. Other terms used interchangeably with TPN are 3 in 1 (dextrose,
amino acids, and fats) and total nutrient admixtures (TNA).
PN is used to treat
malnourished clients or clients who have the potential for becoming
malnourished and who are not candidates for enteral support. PN can be
prescribed for either short-term or long-term use, as previously discussed in
the decision algorithm (Figure 38-15).
The type of device used for
the PN therapy is determined by the duration of the therapy and the osmolality
of the solution. Peripheral parenteral nutrition (PPN) is used for short-term
treatment to deliver isotonic or mildly hypertonic solutions into a peripheral
vein; the volume is usually limited to between 2,000 and 3,000 ml/day,
providing a caloric value of about 2,000 kcal/day.
Central parenteral nutrition
(CPN) is used for longterm therapy to infuse highly hypertonic solutions directly
into the superior vena cava. The delivery of highly hypertonic solutions into
peripheral veins can cause sclerosis, phlebitis, or swelling complications.
Specific client populations that benefit from PPN or TPN are described in the
accompanying display.
Components
of Parenteral Nutrition
PN solutions are predigested
or chemically prepared nutrients that can be administered singly or as
admixtures. The basic components of PN are:
1. Carbohydrates, primarily in the form of monohydrous glucose, ranging
from 5% solution for PPN to 50% to 70% hypertonic solution for CPN; provides
the client with 60% to 70% of caloric (energy) needs.
2.
Amino acids, in the form of synthetic
crystalline amino acid solutions; provides 5% to 15% of the total calories (CPN
solutions contain sufficient amino acids for tissue synthesis).
3.
Lipid (fat emulsions),
prepared from safflower and soybean oil with egg phospholipids; supply up to
30% of the client’s caloric (energy) intake; additional lipid emulsions and
glucose or amino acids provide for a TNA isotonic solution.
Other ingredients, called
admixtures, provide for the client’s biochemical needs (electrolytes, vitamins,
and trace elements such as zinc, selenium, chromium, magnesium, iodine, copper,
iron, and molybdenum). Medications, such as heparin, may also be added to the
TPN solution. Heparin is commonly added to reduce the buildup of a fibrinous
clot at the catheter’s tip. When the TPN catheter is the only available venous
access, TPN may be used to deliver antibiotics. The TPN solution should be
prepared only by a pharmacist using sterile technique and a laminar flow hood
to reduce the risk of contamination.
Administering Medication through a Feeding Tube
Refer to agency protocol
regarding medication administration and contraindications. Feeding tubes with a
double lumen have two separate ports; read the manufacturer’s instructions to
determine which port to use to administer the medication. Administering medications
through the wrong port may cause the tube to clog.
Check for tube placement,
clear the tubing of formula, and check the patency of the tube by flushing it
with water before administering the medication. It is advisable to use the
liquid form of any medications when possible. After administering each
medication, flush the port to prevent clogging. Measure the aspirates removed,
all liquids instilled into the tube, and the water used for flushing and
medications, and record them on the client’s intake and output record.
Complementary Therapy
Holistic nursing recognizes
wellness as a state of harmony among mind, body, and spirit. To nourish means
to provide that which is necessary for life, health, and growth; to nourish
also means to cherish, to strengthen, and to promote (
1.
2. Traditional Chinese
Medicine, one of the oldest systems of healing, incorporates acupuncture,
Chinese herbs, massage, food therapy, exercise, and lifestyle changes into
prevention and treatment.
3. Chiropractic Medicine, an
American heritage, relies on a sound nutritional program as adjunct therapy to
support the body’s inherent ability to heal itself by reestablishing an
unobstructed flow of nerve impulses between the brain and the rest of the body.
4. Naturopathic Medicine, an
ancient form of healing that was formalized in
5. Osteopathic Medicine,
founded by Dr. Andrew Taylor Still, a medical surgeon for the Union Army during
the Civil War, integrates into conventional medicine nutritional
recommendations for prevention. For example, to prevent coronary heart disease,
a diet low in saturated fats is combined with antioxidants (vitamins C, A, and
E) to help prevent free radical formation, thus preventing tissue breakdown as
well as the accumulation of plaque in the arteries.
6. Herbal Medicine recognizes
food as medicine, ensuring that the unique healing properties of specific herbs
have a direct effect upon tissue. The healing effect is through direct contact
with the tissue and the effects caused by the metabolism and absorption of the
chemicals present in the various plants. Based on a holistic context, herbal
medicine recognizes that true healing must involve all dimensions of the person
to change whatever dietary indiscretions exist as well as to make other
adjustments in one’s lifestyle.
Many herbal products are
available in various forms such as teas, extracts, capsules, and tablets to
provide nutrients that nourish our bodies and relieve digestive symptoms. The
following discussion addresses the digestive and nondigestive actions of
certain herbs: bitters, chamomile, dandelion, peppermint, rosemary, and
slippery elm. Bitters is a term used to describe a
group of herbs that have a bitter taste. The taste of bitterness on the tongue
sends a message to the brain through the nervous system to stimulate the
secretion and activity of the esophagus, and the secretions of the stomach,
duodenum, and gallbladder, and to stimulate the production of insulin by the
pancreas. The bitterness promotes appetite and in a complex way aids digestion.
Bitter herbs are considered digestive stimulants because they stimulate various
parts of the digestive system to increase or improve digestive activity. The
most valuable bitter herbs are barberry, centaury, gentian root, golden seal,
mugwort, white horehound, and wormwood (Hoffmann, 1998).
Chamomile contains calcium,
essential oils, iron, magnesium, manganese, potassium, tannic acid, vitamin A,
apigenin (a sedative compound), and other nutritive ingredients. Chamomile
possesses the following actions: anti-inflammatory, appetite stimulant,
digestive aid, diuretic, nerve tonic, and sleep aid. Traditionally, Chamomile
is used for stress and anxiety, indigestion, and insomnia, and it is often used
to treat colitis, diverticulosis, fever, headaches, and pain. It is effective
as a gargle or mouthwash for treating gingivitis. Caution: This herb should not be taken over
long periods of time, as it may lead to a ragweed allergy; it should not be
used by those who are allergic to ragweed (Balch & Balch, 1997).
Dandelion leaves and roots are
high in iron, manganese, phosphorus, protein, aluminum, and vitamin A with
trace amounts of calcium, chromium, niacin, riboflavin, silicon, zinc, and
vitamin C. It is a potent digestive tonic that may be used in conditions that
affect the gastrointestinal tract such as heartburn, gas, gastroesophageal
reflux, and constipation. Dandelion has a toning effect on the liver,
gallbladder, and pancreas, providing relief from gallstones or gallbladder
attacks, as well as diabetes and hypoglycemia. Dandelion is considered safe and
may be taken as often as needed. Caution: Due to its laxative effects, large
sudden intake may result in diarrhea; start with smaller doses and gradually
increase over time.
Peppermint contains essential
oils, tannic acid, vitamin C, and other ingredients. It is one of the best
carminative agents (stimulates and soothes the digestive system, removes gas),
and it enhances digestion by increasing stomach acidity. It is often
recommended for chills, colic, diarrhea, headache, heart trouble, indigestion,
nausea, poor appetite, rheumatism, and spasms. Caution: This herb may interfere
with iron absorption.
Rosemary is often used as a
natural food preservative because of its chemical and nutritive content. It is
considered a circulatory and digestive bitter; it fights bacteria, relaxes the
stomach and acts as a decongestant; it also helps prevent liver toxicity, and
has anticancer and antitumor properties. It relieves intestinal colic,
flatulent dyspepsia, headaches, high and low blood pressure, circulatory
problems, and menstrual cramps, and it is used to treat ulcerative colitis,
Crohn’s disease, and fevers, especially colds and influenza (Hoffmann, 1998;
Balch & Balch, 1998).
Slippery elm bark contains
calcium, phosphorus, polysaccharides, starch, tannins, and vitamin K. It
soothes inflamed mucous membranes of the stomach, bowels, and urinary tract. It
may be used to treat gastritis, gastric or duodenal ulcer, enteritis, colitis,
diarrhea, and colds, flu, and sore throat.
EVALUATION
Evaluation of nutritional
therapy is ongoing. The nurse uses current data to measure the achievement of
goals and outcomes; once they are achieved, the plan of care is revised
accordingly. If goals are not met, the nurse should determine whether the nursing
diagnosis was accurate or whether the nursing interventions were appropriate
and the outcomes achievable.
The plan of care should be
modified to maximize the client’s response to therapy. For example, if the home
health client states compliance with diet therapy to maintain the HDL, LDL, and
cholesterol levels within normal limits, but the values are
not within normal limits, institute a food record to monitor cholesterol and
fat intake for three consecutive days. Visit the client on the fourth day and review
the record. Provide teaching as necessary to assist the client in changing
eating patterns.
