Policies and Procedures
Title:
ENTERAL TUBE FEEDING
I.D. Number: 1020
Authorization:
[x ] SHR Nursing Practice
Committee
Source: Nursing
Date Revised: October 2006
Date Effective: September 2000
Scope: SHR Acute Care
Any PRINTED version of this document is only accurate up to the date of printing 24-Nov-15. Saskatoon Health Region (SHR)
cannot guarantee the currency or accuracy of any printed policy. Always refer to the Policies and Procedures site for the
most current versions of documents in effect. SHR accepts no responsibility for use of this material by any person or
organization not associated with SHR. No part of this document may be reproduced in any form for publication without
permission of SHR.
1. PURPOSE
1.1 To minimize complications associated with enteral tube feeding.
2. POLICY
Physician Order
Required
 To start or discontinue tube feeding, for solution type, volume, flow rate
and blood work as appropriate.
Consult
 Dietician
Special
Considerations
 Keep the head of the patient’s bed elevated at least 30-45 degrees unless
contraindicated.
 Hold feeds for 30minutes to 1 hour prior to placing patient in a supine
position. (Pediatrics: holding tube feed requires a physician order)
 Monitor patients for intolerance of tube feeding (abdominal distention,
nausea, vomiting, diarrhea, abdominal pain, large residual).
 Monitor patient blood work results.
 Administer tube feed at room temp. (infants-may warm slightly)
 Continuous feeds are recommended for duodenal/jejunal tubes.
 Do not use a stopcock with tube feed tubing.
 Medications: do not give any sublingual, enteric coated or sustained
release medication through the feeding tube.
Infection
Control




Rinse top of formula can with water before opening.
Cover, label and refrigerate remaining formula and use within 24hrs.
Wash hands and wear non-sterile gloves when accessing tube feed.
Solutions will be suspended for no longer than 4 hours. (Peds: for low
volumes <10ml/hr use syringe pump with special enteral tubing so feed is
used in 4 hrs)
 Avoid adding new formula to that remaining in container from previous
feed.
 Change administration sets every 24 hours. (NICU: every 4 hours)
 Use sterile water as a flush or for diluting tube feed.
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Policies & Procedures: Enteral Tube Feeding
I.D. # 1020
Confirm
Correct
placement of
Feeding Tube
Nasogastric (NG) or Orogastric(OG) Feeding Tubes:
 Assess for correct placement of feeding tube prior to each intermittent
feed, medication administration and at least every 4 hours when patient
is receiving a continuous feed.
Methods to check tube placement- (Use at least 2 or more) of the following
methods):
1. Check external length of feeding tube (tube must be marked with
permanent marker or tape at insertion site).
2. Aspirate gastric contents.
3. Test pH of gastric contents (pH of 5.5 or below indicates correct
placement in most pts).
Note: patients taking acid reducing drugs (e.g. Pantaloc,Ranitidine) may
have an altered pH (see pH testing procedure pg. 806-Nursing Skills
Text).
4. Inject 10-20 mls of air for adult (Pediatrics: 5-10 mls of air) and auscultate
with stethoscope over stomach area for swoosh sound (this method alone
is not considered a reliable test for tube placement).
5. Assess client for signs & symptoms of inadvertent respiratory migration of
tube: coughing, choking or cyanosis.
 If the correct placement of feeding tube cannot be verified by these
methods, obtain an order for Medical Imaging to confirm
placement.
 Peds: if gastric placement not confirmed, remove and replace tube.
Nasoduodenal/Nasojejunal (ND,NJ) Feeding Tubes
 Confirm correct placement by measuring external length of tube and
compare to length documented in nursing care plan.
Gastrostomy Tubes (PEG)
 Confirm correct placement by measuring external length of tube and
compare to length documented in nursing care plan.
Jejunostomy (PGJ)
 Confirm correct placement by measuring external length of tube and
compare to length documented in the nursing care plan.
 Check for any discoloration of tube shaft. If discoloration is less than 3
inches from insertion site an X-ray should be done to confirm
placement. If discoloration of the tube is greater than 3 inches consult
Interventional Radiology for tube check and repositioning as required.
If tube was initially inserted by Surgeon/Attending Physician they
should be notified.
Assess
tolerance of
Tube Feed
Nasogastric(NG) or Orogastric(OG) Feeding Tubes
 Check gastric residual volumes every 4hrs X 24hrs post initiation of new
feeds or when rate or volume orders change. For established gastric
feeds, check residual prn and when client exhibits signs of gastric
intolerance (abdominal distention, nausea, vomiting, and diarrhea).
Pediatrics: check residual volumes prior to every bolus feed.
 Notify physician if residual is 2X hourly rate (continuous) or greater
than 50% feed volume (intermittent).
 Re-feed residual according to physician orders.
Buttons: do not aspirate, check patient for abdomen distention and vent
tube prn.
Flush Feeding
Tubes
All types (NG,OG, ND,NJ, PGJ, PEG, Buttons)
 Every 4 hours (continuous feed).
 Before and after each feed (intermittent).
Page 2 of 4
Policies & Procedures: Enteral Tube Feeding
I.D. # 1020
Before and after checking residuals.
Before and after each medication (never mix medication with tube
feed).
Amount of Flush: Adults: 20-30 mls sterile water (Nasoduodenal/Nasojejunal40mls sterile water); Pediatrics: 5-20 mls, or as ordered, NICU: 0.5 mls sterile
water or air, PICU: air only, or as ordered.
 Flush with a pause/push technique to decrease clogging of tube.


Insertion Site
Care
PGJ, PEG, Button
 Follow post insertion orders.
 Observe & assess PGJ/PEG/Button insertion site every shift – assess skin
condition, notify physician of redness greater than 1 cm, swelling,
drainage or leaking of gastric contents or tube feed.
 Clean insertion site q12 hrs and prn with saline. Apply gauze dressing if
required (change dressing prn).
 Check security of PGJ/PEG anchoring device (e.g. flexi-trak)
frequently to prevent dislodging.
 Rotate Buttons 360 degrees once daily. Button should turn freely.
NG, OG, ND and NJ
 Observe skin at nares (NG tubes), lips and oral mucosa for any
redness or breakdown every shift.
 Alternate nares with re-insertion of NG tube if possible.
Occlusion of
Feeding Tube
Note: if tube occlusion occurs do not force irrigation.
Attempt to irrigate with 50mls warm water using a gentle back and
forth motion.
 Pediatrics: use 10-20mls, if continues to be plugged, remove tube and
re-insert unless contraindicated.
 If above is unsuccessful, obtain Dr. order for pancreatic enzyme
mixture:
Recommended adult mixture: 1 tab Cotazyme (lipancreatin) and 1 tab
sodium bicarbonate (500mg) with 5 mls water. (Note: for safety reasons wear
gown and mask when preparing this mixture)
 Infuse gently into feeding tube and leave for 5 minutes.
 Attempt to irrigate with sterile warm water. If still occluded repeat
pancreatic enzyme and sodium bicarbonate solution as above.
Attempt to flush.
 Notify physician if occlusion persists.


Documentation




Record formula type and strength, hourly intake, flush volume,
aspirate volume
Symptoms of feeding intolerance: vomiting, diarrhea, abdominal
distention and/or pain, large residual.
Document insertion site assessment and care.
Document feeding system changes on appropriate record.
3. PROCEDURE
3.1 Refer to Nursing Interventions and Clinical Skills – 3rd Ed.
3.1.1
Verifying Tube Placement for a Large –bore or Small –bore Feeding Tube: pages: 805807.
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Policies & Procedures: Enteral Tube Feeding
I.D. # 1020
3.1.2
Administering Tube Feedings: pages: 808-814.
3.1.3
Administering Medication through a Feeding Tube: pages 814-818.
4. REFERENCES
Elkin, M, Perry, A &Potter, P. (2004) Nursing Interventions & Clinical Skills –3rd Edition. Philadelphia,
PA: Mosby: Chapter 33-Enteral Nutrition.
Khair, J. (2005) Guidelines for testing the placing of nasogastric tubes. Nursing Times; Volume 20,
pages 26-27.
Methany, N & M. Schallom, S. Edwards. (2004) Effect of gastrointestinal motility and feeding tube
site on aspiration risk in critically ill patients: A review. Heart & Lung- The Journal of Acute and
Critical Care. Volume 33(3), pages 131-145.
Nursing Council-Calgary Health Region, Enteral Tubes: Assessment of Placement.-2005. Regional
Nursing Policy & Procedure Manual. Calgary Health Region
Regina Nursing, Feeding Tube - Occlusion. Health Services. Oct. 2004. Regina Qu’Appelle Health
Region.
Padula, C & C. Planchon & C. Lamoureux (2004) Enteral Feedings: What the Evidence Says.
American Journal of Nursing, Volume 104, No. 7, pages 62-69.
Sanko, J. (2004) Aspiration Assessment and Prevention in Critically Ill Enterally Fed patients:
Evidence –Based Recommendations for Practice. Gastroenterology Nursing. Vo. 27(6), pages
279-285.
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