Nursing management of enteral tube feedings

Oral medications administration through enteral feeding tube: Clinical pharmacist-led educational intervention to improve knowledge of Intensive care units' nurses at Jordan University Hospital

Introduction

Medication administration through enteral feeding tubes is a practice that is commonly encountered in hospital settings, particularly in critically ill patients. This study aims to evaluate the knowledge of intensive care unit nurses regarding enteral medication administration and evaluate the effect of an educational intervention led by a clinical pharmacist that would improve nurses’ knowledge regarding the subject.

Methods

A pre/post interventional study was conducted. Improvement in nurses’ knowledge regarding medication administration through an enteral feeding tube was assessed using a validated questionnaire.

Results

Data were coded, entered, and analyzed using the Statistical Package for Social Sciences (IBM SPSS statistics 22). Independent samples t-test and paired t-test were used to detect any statistically significant differences in the mean total knowledge scores both between and within each group respectively. A P-value of <0.05 was considered statistically significant. The mean total knowledge score for nurses in the intervention and control group at the pre-interventional phase of the study was inadequate. There was a statistically significant improvement in the mean total knowledge score for the interventional group at the post-interventional phase of the study, while that of the control group remained inadequate (Intervention group total mean knowledge score at baseline 12.11 ± 3.75, post-intervention 21.50 ± 2.36, p-value <0.001; Control group total mean knowledge score at baseline 12.05 ± 3.12, post-intervention 12.60 ± 3.76, p-value 0.96).

Conclusion

Incorrect drug preparation and administration for patients with feeding tubes can affect patients. The knowledge of nurses regarding the subject can be improved significantly via an educational intervention. The activation of clinical pharmacists’ role and collaboration between pharmacists, physicians, and nurses is highly recommended in this clinical setting.

Enteral Medication for the Tube-Fed Patient: Making This Route Safe and Effective

The administration of medication through an enteral access device requires important forethought. Meeting a patient's therapeutic needs requires achieving expected drug bioavailability without increasing the risk for toxicity, therapeutic failure, or feeding tube occlusion. Superimposing gut dysfunction, critical illness, or enteral nutrition-drug interaction further increases the need for a systematic approach to prescribing, evaluating, and preparing a drug for administration through an enteral access device. This review will explain the fundamental factors involved in drug bioavailability through the gut, address the influencing considerations for the enterally fed patient, and describe best practices for enteral drug preparation and administration.

A Nationwide Survey of Long-Term Care Facilities to Determine the Characteristics of Medication Administration through Enteral Feeding Catheters

Previous data clearly showed profound differences in nursing practices and techniques within the state of Texas regarding the administration of medications through enteral feeding catheters (EFCs) between long-term care (LTC) facilities that predominantly serve a rural vs an urban population. This study aims to determine the incidence and characteristics of medication administration through EFCs in the LTC setting in the United States with particular emphasis on the delineation between practices in facilities that predominantly serve a rural vs an urban population. A 36-item validated survey was mailed to the Directors of Nursing of the 16,400 LTC facilities registered with the U.S. Medicare LTC facility database registry. In all, 1278 (7.8%) surveys were included in this analysis. The majority of nurses responding were RNs (93%), with extensive years of experience (19 years), working in facilities predominantly serving a rural area (58%). There were significant differences between rural and urban facilities with regard to the percent of patients receiving medications through EFCs (6.6% vs 9.0%, p < .0001), number of oral medications/day (8.3 vs 9.4, p = .0003), amount of flush before and after administering medications (64 mL vs 59 mL, p = .0127), those attending a seminar/in-service on medication administration through EFCs (45% vs 56%, p < .0001), and medication obstruction rate (6.4% vs 3.9%, p = .0227). Medication obstruction rate was significantly increased when nurses used 3 or more inappropriate techniques (8.1% vs 4.8%, p = .0171), particularly crushing enteric-coated (8.9% vs 4.6%, p = .0003) and sustained-release dosage forms (8.5% vs 4.7%, p < .0001). Medication obstruction through EFCs is significantly increased when 3 or more inappropriate techniques are utilized. Techniques, complications, and sources of information vary significantly from rural to urban facilities and various parts of the country. A universal set of guidelines to administer medications through EFCs should be adopted and widely disseminated particularly to LTC facilities in rural areas.

A UK and Irish survey of enteral nutrition practices in paediatric intensive care units

The aim of the present study was to describe the present knowledge of healthcare professionals and the practices surrounding enteral feeding in the UK and Irish paediatric intensive care unit (PICU) and propose recommendations for practice and research. A cross-sectional (thirty-four item) survey was sent to all PICU listed in the Paediatric Intensive Care Audit Network (PICANET) database (http://www.picanet.org.uk) in November 2010. The overall PICU response rate was 90 % (27/30 PICU; 108 individual responses in total). The overall breakdown of the professional groups was 59 % nursing staff (most were children's nurses), 27 % medical staff, 13 % dietitians and 1 % physician assistants. Most units (96 %) had some written guidance (although brief and generic) on enteral nutrition (EN); 85 % of staff, across all professional groups (P= 0.672), thought that guidelines helped to improve energy delivery in the PICU. Factors contributing to reduced energy delivery included: fluid-restrictive policies (60 %), the child just being 'too ill' to feed (17 %), surgical post-operative orders (16 %), nursing staff being too slow in starting feeds (7 %), frequent procedures requiring fasting (7 %) and haemodynamic instability (7 %). What constituted an 'acceptable' level of gastric residual volume (GRV) varied markedly across respondents, but GRV featured prominently in the decision to both stop EN and to determine feed tolerance and was similar for all professional groups. There was considerable variation across respondents about which procedures required fasting and the duration of this fasting. The present survey has highlighted the variability of the present enteral feeding practices across the UK and Ireland, particularly with regard to the use of GRV and fasting for procedures. The present study highlights a number of recommendations for both practice and research.

Safe practices for enteral nutrition in critically ill patients

Promoting patient safety in the enterally fed critically ill patient is dependent on nursing surveillance and recognition of potential areas of patient harm and medical errors. Identifying areas for potential human error, administrative and organizational conditions that are conducive to error, and the patient's own tolerance to EN need to be recognized by the critical care nurse if the risk for EN complications is to be minimized.

To return or to discard? Randomised trial on gastric residual volume management

BACKGROUND

The control of gastric residual volume (GRV) is a common nursing intervention in intensive care; however the literature shows a wide variation in clinical practice regarding the management of GRV, potentially affecting patients' clinical outcomes. The aim of this study is to determine the effect of returning or discarding GRV, on gastric emptying delays and feeding, electrolyte and comfort outcomes in critically ill patients.

METHOD

A randomised, prospective, clinical trial design was used to study 125 critically ill patients, assigned to the return or the discard group. Main outcome measure was delayed gastric emptying. Feeding outcomes were determined measuring intolerance indicators, feeding delays and feeding potential complications. Fluid and electrolyte measures included serum potassium, glycaemia control and fluid balance. Discomfort was identified by significant changes in vital signs.

RESULTS

Patients in both groups presented similar mean GRV with no significant differences found (p=0.111), but participants in the intervention arm showed a lower incidence and severity of delayed gastric emptying episodes (p=0.001). No significant differences were found for the rest of outcome measurements, except for hyperglycaemia.

CONCLUSIONS

The results of this study support the recommendation to reintroduce gastric content aspirated to improve GRV management without increasing the risk for potential complications.

Development and evaluation of standardized protocol to prevent nasoenteral tube obstruction in cardiac patients requiring enteral nutrition with restricted fluid volumes

AIMS AND OBJECTIVES

This study sought to assess the impact of a standardized protocol to maintain nasoenteral tube (NET) patency in patients requiring fluid restriction and identify factors associated with tube patency.

BACKGROUND

Nasoenteral tube obstruction may interrupt nutritional support and prohibit drug administration. Balancing NET patency in the context of fluid restriction can be a challenge.

DESIGN AND METHODS

The impact of the standardized protocol was assessed by using a quasi-experimental design and an historical control.

RESULTS

Sixty patients receiving nasoenteral feeding as part of their clinical management were enrolled in the study. Nasoenteral obstruction was 8.3%, showing a reduction from the 17.4% observed in the baseline data collection. A key factor associated with tube obstruction was sounding of an infusion pump alarm reflecting the tube patency issues.

CONCLUSIONS

While mindful of the limitations of probability sampling, the implementation of a standardized protocol accompanied by staff training reduced the rates of NET obstruction.

RELEVANCE TO CLINICAL PRACTICE

On the basis of these findings, we conclude that it is possible to maintain the patency of small bore tubes, even in the presence of fluid restriction, with a standardized protocol to guide clinical management.

[Measurement of residual gastric volume: in search of better evidence]

INTRODUCTION

Measurement of residual gastric volume is a frequent practice in chronic patients, but there is lack of consensus on the convenience of reintroducing or discarding aspirated gastric content (AGC).

OBJECTIVE

Determine the grade of scientific evidence on the efficacy of two interventions -reintroduction/rejection- of AGC in chronic patients.

MATERIAL AND METHODS

Systematic review of the evidence available on the convenience of reintroducing or discarding ACG.

PROCEDURE

a) establishment of inclusion/exclusion criteria; b) determination of the search strategy (keywords and itineraries); c) dumping of databases: MEDLINE, CINAHL, CUIDEN, IME, SCIELO and COCHRANE. Search for indirect method and manual dumping of indexes; d) independent and contrasted critical reading, using the CASPe template; and e) contrast of critical analysis results.

RESULTS

Search itineraries generate more than 800 references that once purged make it possible to select 54. After reading them, only 4 really focused on the questions related with the reintroduction/rejection of AGC: 2 revisions, 1 observational study and a random clinical trial with a small sample. Meta-analysis techniques could not be used due to the heterogeneity of these studies. Thus, the results of the study were analyzed separately. Using this procedure, a final result was obtained that showed a low grade of scientific evidence.

CONCLUSIONS

There is limited scientific evidence on the convenience, safety and benefits of both interventions. It is difficult to establish a care protocol, so that we suggest performing an experimental study to establish the indications and contraindications of both interventions.

Percutaneous endoscopic gastrostomies: the burden of treatment from a patient perspective

AIM

This paper reports a study of patients' experiences of this relatively new technology, and explores possible strategies for defining, delineating and addressing patients' concerns, problems and needs.

BACKGROUND

The number of patients in the community relying on percutaneous endoscopic gastrostomy for their nutritional needs is increasing, but percutaneous endoscopic gastrostomy feeding is not problem-free. However, few studies report on its impact from a patient perspective.

METHODS

Twenty adults with long-term percutaneous endoscopic gastrostomies were interviewed in their own homes, using both semi-structured and structured approaches. Qualitative data were analysed thematically and related to a symptom checklist and an established quality of life measure, the Short Form-12.

FINDINGS

Most participants felt that insertion of a percutaneous endoscopic gastrostomy had been life-saving, but found that percutaneous endoscopic gastrostomy feeding came to dominate their lives and was associated with an appreciable "burden of treatment". Some, but not all, of the problems recounted were unavoidable: percutaneous endoscopic gastrostomy feeding inevitably imposed physical restrictions on mobility; 17/20 participants had experienced serious technical problems with their percutaneous endoscopic gastrostomy tubes. On structured questioning, all interviewees had some, potentially treatable, gastrointestinal symptoms, and eight had continuous problems. In some cases, the burden of treatment was exaggerated by being unanticipated and, for 13 patients, difficulties with care provided by non-specialist services. Describing this "burden of treatment" for each patient required both a narrative and a structured approach: without the symptom checklists, some important and treatable problems were missed. Both physical and mental health Short Form-12 scores were low, and mental health scores were congruent with the interview data.

CONCLUSIONS

It might be possible to reduce the "burden of treatment" identified by incorporating a structured approach to patient monitoring and by reviewing the occupational territories of specialist and non-specialist practitioners. Further research with larger numbers of participants is needed to explore the integration of narrative and quantitative data when determining patients' clinical needs.

Enteral nutrition in intensive care

The aims of this descriptive study were to examine (1) nurses' perceptions of responsibility, knowledge and documentation focusing on enteral nutrition and (2) nursing practice regarding enteral feeding in the intensive care unit. Forty-four nurses in three intensive care units responded to a questionnaire (response rate 70%) and 40 bedside observations were performed. The nurses' primary source of knowledge was consultation with colleagues. Regarding responsibility, knowledge and documentation, the focus was more on planning, implementation and prevention than on the assessing phase of the nursing process. Gastric residual volumes were almost never checked, and none of the tubes were labelled. Seven out of 40 bedside observations revealed a backrest elevation of 30 degrees or more. Mean backrest elevation was 20.7 degrees. Comparisons between nurses in the three hospitals revealed significant differences. This study indicates that enteral nutritional nursing care within intensive care has its strength in planning, implementation and prevention of complications. Regarding nutritional assessment, the registered nurses (RNs) scored low. There are gaps between recommended nursing care and nursing practice regarding enteral nutrition. Knowledge and awareness of responsibilities in combination with a systematic documentation could increase the optimal nutritional care of the intensive care patient.

Validation the use of refractometer and mathematic equations to measure dietary formula contents for clinical application

BACKGROUND AND AIMS

Gastric residual volumes are widely used to evaluate gastric emptying for patients receiving enteral feeding, but controversy exists about what constitutes gastric residual volume. We have developed a method by using refractometer and derived mathematical equations to calculate the formula concentration, total residual volume (TRV), and formula volume. In this study, we like to validate these mathematical equations before they can be implemented for clinical patient care.

METHODS

Four dietary formulas were evaluated in two consecutive validation experiments. Firstly, dietary formula volume of 50, 100, 200, and 400 ml were diluted with 50 ml water, and then the Brix value (BV) was measured by the refractometer. Secondly, 50 ml of water, then 100 ml of dietary formula were infused into a beaker, and followed by the BV measurement. After this, 50 ml of water was infused and followed by the second BV measurement. The entire procedure of infusing of dietary formula (100 ml) and waster (50 ml) was repeated twice and followed by the BV measurement.

RESULTS

The formula contents (formula concentration, TRV, and formula volume) were calculated by mathematical equations. The calculated formula concentrations, TRVs, and formula volumes measured from mathematic equations were strongly close to the true values in the first and second validation experiments (R2>0.98, P<0.001).

CONCLUSIONS

Refractometer and the derived mathematical equations may be used to accurately measure the formula concentration, TRV, and formula volume and served as a tool to monitor gastric emptying for patients receiving enteral feeding.

Gastric residual volumes in critically ill paediatric patients: a comparison of feeding regimens

This study examined the effect of gastric feeding regimens, either continuous or intermittent, on fourth hourly gastric residual volumes (GRV) in a group of critically ill paediatric patients where delayed gastric emptying is defined as a GRV greater than 5ml/kg. A randomised controlled trial was conducted in a tertiary paediatric intensive care unit (PICU), with 45 participants being randomly assigned to either the continuous (n=22) or intermittent (n=23) gastric feeding groups. Participants remained in the assigned group for the duration of the study and, fourth hourly, GRV were assessed to monitor the incidence of delayed gastric emptying. Both groups were similar in age, weight, gender, diagnosis, paediatric index mortality (PIM) score, and usage of pharmacological agents known to affect the gastrointestinal tract. No differences emerged in study duration or the volume of administered enteral formula (ml/kg/day). The intermittent feeding group commenced enteral feeding earlier in the PICU admission (13.0 hours versus 18.5 hrs, p=0.05). Repeated measures analysis revealed no overall difference in median GRV/kg values between treatment groups over the 72 hour study period. Additionally, the incidence of fourth hourly GRV, greater than 5ml/kg, was not different between the continuous and intermittent feeding groups. The provision of enteral nutrition via the gastric route is a common treatment in the PICU, and GRV are frequently used as a measure of gastric tolerance. The result of this analysis provides some support for the theoretical definition of delayed gastric emptying being >5ml/kg. However, further work is required to confirm this finding and to determine its relevance when providing enteral nutrition to the critically ill paediatric patient.

Effect of gastrointestinal motility and feeding tube site on aspiration risk in critically ill patients: a review

OBJECTIVE

The purpose of this literature review is to examine the effect of the interaction between gastrointestinal motility and feeding site on the aspiration risk in critically ill, tube-fed patients.

METHODS AND RESULTS

A single answer to the question of the preferred feeding site is not likely to be found because the degree of aspiration risk varies significantly according to individual variations in gastrointestinal motility and multiple pre-existing and treatment-related risk factors. However, regardless of the feeding site, it is ultimately regurgitated gastric contents that are aspirated into the lungs. For this reason, the clinical assessment of greatest interest is the evaluation of gastric emptying, usually monitored clinically by measuring gastric residual volumes.

CONCLUSION

Current recommendations for monitoring residual volumes and preventing aspiration are provided.

Nutritional intake in the critically ill: Improving practice through research

Enteral feeding is the preferred method of nutritional support in the critically ill; however, evidence suggests that many critically ill patients do not meet their nutritional goals. The implementation of enteral feeding protocols has improved nutritional delivery, although protocols can be widely variable. Similarly, enteral feeding related nursing practice is also inconsistent within and between intensive care units (ICUs). These variations in enteral feeding practice can be linked to the shortage of reliable and valid research into the many issues associated with the effective delivery of enteral nutrition. In the absence of a strong research tradition and practice, rituals are embraced and rarely challenged, further contributing to the wide variations in enteral feeding practice. Of particular importance are practice issues related to the commencement of enteral feeding and the assessment of feeding tolerance. This article seeks to review the literature related to commencing enteral feeding, with particular reference to the suitability of enteral nutrition, methods of enteral feeding and adjustment of enteral feeding rates. Issues relating to feeding intolerance, including the assessment of gastric residual volume and the development of diarrhoea, will also be explored.

Continuous nasogastric tube feeding: monitoring by combined use of refractometry and traditional gastric residual volumes

BACKGROUND & AIMS

Traditional use of gastric residual volumes (GRVs) is insensitive and cannot distinguish retained enteral formula from the large volume of endogenous secretions. We designed this prospective study to determine whether refractometry and Brix value (BV) measurements could be used to monitor gastric emptying and tolerance in patients receiving continuous enteral feeding.

METHODS

Thirty-six patients on continuous nasogastric tube feeding were divided into two groups; patients with lower GRVs (<75 ml) in Group 1, patients with higher GRVs (>75 ml) in Group 2. Upon entry, all gastric contents were aspirated, the volume was recorded (Asp GRV), BV measurements were made by refractometry, and then the contents were reinstilled but diluted with 30 ml additional water. Finally, a small amount was reaspirated and repeat BV measurements were made. Three hours later, the entire procedure was repeated a second time. The BV ratio, calculated (Cal) GRV, and volume of formula remaining were calculated by derived equations.

RESULTS

Mean BV ratios were significantly higher for those patients in Group 2 compared to those in Group 1. All but one of the 22 patients (95%) in Group 1 had a volume of formula remaining in the stomach estimated on both measurements to be less than the hourly infusion rate (all these patients had BV ratios <70%). In contrast, six of the 14 patients in Group 2 (43%) on both measurements were estimated to have volumes of formula remaining that were greater than the hourly infusion rate (all these patients had BV ratios >70%). Three of the Group 2 patients (21%) whose initial measurement showed evidence for retention of formula, improved on repeat follow-up measurement assuring adequate gastric emptying. The remaining five patients from Group 2 (35%) had a volume of formula remaining that was less than the hourly infusion rate on both measurements. The pattern of Asp GRVs and serial pre- and post-dilution BVs failed to differentiate these patients in Group 2 with potential emptying problems from those with sufficient gastric emptying.

CONCLUSIONS

Refractometry and measurement of the BV may improve the clinical utilization of GRVs, by its ability to identify the component of formula within gastric contents and track changes in that component related to gastric emptying.

Intolerance to intragastric enteral nutrition in critically ill patients: complications and management

Compared with parenteral nutrition, early administration of enteral nutrition (EN) to critically ill patients improves clinical outcomes and reduces infection rates. Intragastric EN often is complicated by intolerance, as indicated by elevated volumes of aspirated gastric residuals. Conflicting data are available for the volume of residual that represents intolerance, but most clinicians use 150-200 ml to signify gastrointestinal motility dysfunction. Intolerance is associated with mortality. Data support an association between intragastric EN and aspiration pneumonia, but little information is available regarding the contributory effect of intolerance. Transpyloric migration of the feeding tube may facilitate tolerance but does not reduce the likelihood of aspiration pneumonia. Prokinetic agents (cisapride, erythromycin, metoclopramide) promote gastric emptying. Results of most studies are limited because patients did not receive or tolerated intragastric EN. Metoclopramide is the agent of choice for treating intolerance. Further studies are necessary before prokinetic drugs can be recommended for preventing intragastric EN-associated aspiration pneumonia.

Esophageal cancer: therapeutic approaches and nursing care

OBJECTIVES

To review the various treatment approaches, complications, and nursing management of patients with esophageal cancer.

DATA SOURCES

Review articles, staging manual, textbook chapters, and research studies.

CONCLUSIONS

The diagnosis and treatment of esophageal cancer is a complicated process. Combined multimodal therapy with chemotherapy, radiotherapy, and surgery is showing promising results. However, each treatment approach has complications and side effects that must be managed.

IMPLICATIONS FOR NURSING PRACTICE

Nursing care is complicated and requires coordinating various support services, patient and family education, clinical assessment, nutritional management, management of side effects, and palliative care.

Aspiration in a patient receiving enteral nutrition

This case was selected to illustrate the advantages of an interdisciplinary team approach when the aspiration risks of enteral tube feeding are examined for patients with multisystem involvement. The case reviews a 79-year-old widowed woman with a cervical 6 to 7 spinal cord injury requiring mechanical ventilation and enteral feeding. The patient had multiple complications that prolonged her hospital course and required interdisciplinary involvement of medical, nutrition, nursing, respiratory, and speech pathology services. After an initial stay at another hospital, she was admitted to Providence Saint Joseph Medical Center (PSJMC) Acute Rehabilitation and Intensive Care Units. The patient was transferred home with PSJMC Home Health Services, and her case was part of a continuous quality improvement (CQI) project population group of ventilator-dependent patients. The purpose of the interdisciplinary CQI team was to enhance nutrition intervention, improve patient outcomes, and reduce costs. This teaching case has added to the body of information being evaluated by the CQI team on nutrition intervention of ventilator-dependent patients.