Initiating Enteral Nutrition (Lippincott Procedures, 2022)

• Verify the order: route, feeding device, formula, administration method, volume, rate, and frequency of water flushes.
  • Compare the enteral feeding label with the order in the medical record.
  • Check the expiration date on the label.
  • Review the medical record to ensure the enteral tube placement has been confirmed via x-ray.
• Allow the enteral formula to warm to room temperature before administering as this can decrease the risk of diarrhea.
• Verify enteral tube placement by at least two of the following methods:
  • The marking on the enteral tube where it exits the patient’s nose should be noted once placement has been verified by x-ray. Check for tube migration (movement of the marking) prior to beginning tube feedings.
  • Check routine chest and abdominal x-ray reports.
  • Aspirate to confirm the presence of gastric contents with an enteral syringe.
    • Assess the aspirate. Fasting gastric secretions appear light green, brown, or clear and colorless.
    • Check for a change in volume of aspirate from the feeding tube. An inability to withdraw fluid may indicate the gastric tube slipped back into the esophagus.
    • Per your facility protocol, measure the pH of aspirate from the enteral feeding tube. Fasting gastric pH is 5 or less.
• If you think the enteral tube moved out of proper position, don’t start the feeding. Notify the practitioner immediately. An x-ray will be needed to verify tube location.
• Label the container and administration set with the date and time that it was first hung.
• Position the patient’s head of bed at 30 degrees to prevent aspiration.

Monitoring Enteral Nutrition Administration (Lippincott Procedures, 2022)

• If the feeding is ordered to run continuously, flush the feeding tube every 4 hours with 30 mL of water, as ordered and tolerated, to ensure patency and provide hydration.
• Assess for GI tolerance of enteral tube feedings every 4 hours.
  • Check for abdominal distention.
  • Monitor for abdominal pain.
  • Assess for passage of flatus and bowel movements.
• Measure gastric residual volume (GRV) per your facility policy and practitioner orders (Yasuda, et. al. 2019).
  • GRV is used to assess feeding intolerance (FI) and gastric emptying.
  • GRV is measured either by aspirating the enteral tube using a syringe, or by gravity drainage into a reservoir.
  • GRV may not be used routinely to monitor critical care patients receiving enteral nutrition.
  • In other patient care areas that monitor GRV, avoid holding the enteral tube feeding for a GRV less than 500 mL if there are no other signs of feeding intolerance.
• Monitor the patient’s weight, fluid, electrolyte, and metabolic status to assess the effectiveness of the enteral tube feedings.

Preventing Infection (Lippincott Procedures, 2022)​

• Change the enteral administration set per the manufacturer’s instructions to inhibit bacterial growth.
• If the feeding container used is not sterile, only pour a 4-hour volume of formula into the feeding bag to limit the risk of bacteria growth.
• Discard enteral formula that isn’t used within 24 hours.
• At home, patients should use a new enteral feeding bag each day.

Complications of Enteral Nutrition (Lippincott Procedures, 2022; Seres, 2023)

• Irritation, infection, or necrosis of the esophageal, tracheal, nasal, or oropharyngeal mucosa
• Abdominal bloating and distention
• Dehydration
• Diarrhea
• Vomiting
• Feeding intolerance (i.e., glycosuria, cramping)
• Aspiration
• Fluid and electrolyte imbalances
• Constipation
• Hyperglycemia
• Refeeding syndrome: potentially fatal condition marked by hypophosphatemia, cardiovascular collapse, respiratory failure, rhabdomyolysis, seizures, and delirium.

Documentation of Enteral Nutrition (Lippincott Procedures, 2022)

• Date and time of enteral feeding administration
• Type and volume of formula
• Volume of water given
• GI assessment
• Enteral tube exit site care
• GRV (if used)
• Verification of enteral tube placement
• Patient’s tolerance of feeding
• Hydration status
• Medications administered through enteral tube
• Date and time of enteral administration set changed
• Oral care
• Enteral tube feeding issues
• Patient and family education