Enteral Feeding and Tube Management

Around 40% of hospitalised patients in Australia are affected by malnutrition.

Without nutritional support, these patients may deteriorate, leading to poor outcomes such as prolonged hospital stays, infection and compromised recovery (DAA 2018).

What is Enteral Feeding?

Enteral feeding is the delivery of liquid nutritional support through a tube inserted into the gastrointestinal tract. It is used for patients who are unable to meet their nutritional requirements through oral intake. This may be because:

• Their oral intake is inadequate (e.g. poor appetite); or
• They are physically unable to intake orally in a safe way (e.g. dysphagia, reduced level of consciousness).

(DAA 2018)

Enteral feeding may complement oral intake or be used completely in place of oral intake (Dix 2018).

Enteral Feeding NDIS Quality Indicators

Enteral feeding is listed as a practice Standard under the High Intensity Daily Personal Activities Module outlined in the NDIS Practice Standards and Quality Indicators module for High Intensity Daily Personal Activities.

Under these standards, NDIS providers must meet the following quality indicators:

• Clients are enabled to participate in the assessment and development of an enteral feeding and management plan. This plan identifies possible risks, incidents and emergencies, and what actions need to be taken to manage these situations, including the escalation of care, if necessary. The client’s health status is reviewed regularly (with the patient’s consent).
• Staff members managing enteral feeding are informed by appropriate policies, procedures and training plans.
• Staff members managing enteral feeding have received all necessary training from a qualified health practitioner or another appropriately qualified individual.

(NDIS 2020)

Reasons for Enteral Feeding

Enteral feeding is considered for patients who:

• Are unable to meet their nutritional requirements through oral intake; and
• Have a functional and accessible GI tract.

(NHS 2015)

Generally, enteral feeding is needed if the patient is likely to have an inadequate oral intake for more than five to seven days (NHS 2015).

Patients with the following conditions may require enteral feeding:

• Stroke (may impair swallowing);
• Cancer (may cause loss of appetite);
• Critical illness or injury (may reduce energy or ability to eat);
• Failure to thrive or inability to eat in young children;
• Serious illness (places the body under stress and makes it difficult to intake adequate nutrition);
• Neurological or movement disorders (may make eating more physically difficult);
• GI dysfunction or disease;
• Swallowing disorders;
• Head injury;
• Cystic fibrosis; and
• Mental health conditions such as depression and eating disorders.

(Dix 2018; NHS 2015)

Contraindications for Enteral Feeding

If the patient’s gastrointestinal tract is compromised (e.g. gut failure or intestinal obstruction) or inaccessible via an enteral tube, they may require parenteral nutrition instead. This involves nutrients being inserted directly into the bloodstream via a central venous catheter (DAA 2018).

Older adults or patients receiving palliative or end-of-life care may not be suitable for enteral feeding. You should take into account quality of life, possible complications and expected outcomes when making a decision (DAA 2018).

Routes of Enteral Feeding

There are three sites on the body where an enteral feeding tube can be inserted, and several types of tubes that can be used, each taking a different route. This will depend on:

• The intended duration of the nutritional support;
• The patient’s condition; and
• Whether there is any trauma or obstruction that would impede access to a certain site.

(DAA 2018)

Site	Route Options
Gastric (stomach)	Naso-gastric tube Oro-gastric tube Trans-oesophageal tube Percutaneous endoscopic gastronomy tube Surgically or radiologically inserted gastronomy tube
Duodenum (small intestine)	Naso-duodenal tube
Jejunum (small intestine)	Oro-jejunal/naso-jejunal tube Surgical jejunostomy tube Percutaneous endoscopic jejunostomy tube Percutaneous endoscopic gastronomy and jejunal extension tube

(Adapted from WA Country Health Service 2019)

Enteral Tube Positioning

Before the commencement of feeding, you must ensure the tube is positioned correctly. Poor placement or tube migration can cause potentially life-threatening aspiration of feed (DAA 2018).

Placement must be confirmed through x-ray and by measuring the pH level of gastric aspirate (refer to your facility’s policies and procedures). A pH of less than 5.5 generally indicates that the tube is correctly positioned in the stomach (NHS 2016).

Other methods of confirming placement are not recommended as they are less accurate (DAA 2018).

Tube placement should be assessed:

• After the initial insertion;
• At least once per shift if the patient is on continuous feeding;
• Before administering feed, fluid or medication;
• If the patient complains of discomfort or feed reflux;
• After the patient vomits, retches or coughs;
• If the external tube length has changed;
• If the fixation tape has come loose; and
• If new, unexplained respiratory symptoms arise (e.g. breathlessness, wheezing, stridor), or oxygen saturation is reduced.

(NHS 2016)

Preventing Aspiration

In addition to ensuring the tube is correctly positioned, you can also minimise the risk of aspiration by:

• Elevating the head of the bed by 30 to 45 degrees during feeding and one hour afterwards.
• Checking for signs of intolerance (emesis, abdominal distension, constipation);
• Maintaining good airway management;
• Maintaining oral hygiene.

(Souza 2018; Canterbury District Health Board 2016)

Caring for Enteral Tubes

Caring for enteral tubes may include:

• Introducing food via the enteral tube according to the patient’s care plan;
• Monitoring the rate and flow of feeding, and adjusting this if necessary;
• Keeping the stoma area clean;
• Identifying and reporting any signs of infection;
• Ensuring the tube is positioned correctly;
• Flushing and aspirating the tube;
• Monitoring equipment;
• Following relevant procedures to address malfunctions such as blockage;
• Documenting a request to review the patient’s mealtime plan if required;
• Liaising with health practitioners to explain or demonstrate requirements; and
• Identifying and addressing symptoms that may require intervention (e.g. reflux, unexpected weight changes, dehydration, allergic reactions, poor chest health).

(NDIS 2018; WA Country Health Service 2019)

Monitoring Enteral Tubes

When caring for a patient with an enteral tube, it is important to regularly monitor the following:

• Food chart (if applicable);
• Nutritional intake;
• Fluid balance chart;
• Weight/BMI;
• Vital signs;
• Biochemistry;
• Urine output;
• Presence of oedema;
• Wound staging;
• Bowels;
• Capillary blood glucose;
• Medication;
• Nausea and vomiting;
• Tube position;
• Insertion site;
• Tube integrity;
• Gastronomy rotation;
• Gastronomy progression;
• Balloon water volume in balloon-retained tubes;
• General patient condition;
• Oral health;
• The goals of providing nutritional support; and
• The necessity of providing nutritional support.

(Bapen 2016; WA Country Health Service 2019)

Note: Refer to your facility’s policies and procedures for the frequency of monitoring.

Complications

Possible complications of enteral feeding include:

• Aspiration;
• Tube migration;
• Tube blockage;
• Tube leakage;
• Accidental dislodgement/removal of the tube;
• Candidiasis (may occur if the skin is exposed to tube leakage);
• Chemical dermatitis (may occur if the skin is exposed to gastric fluid leakage);
• Cellulitis;
• Infection;
• Overgranulation;
• Pressure necrosis;
• Haemorrhage;
• Mouth discomfort or infection;
• Reflux and vomiting;
• Abdominal pain or distension;
• Diarrhoea; and
• Constipation.

(Canterbury District Health Board 2016; Bapen 2016)

Generally, any of the following should be reported to medical staff or appropriate personnel:

• Elevated temperature;
• Redness, swelling, pain or leaking around the tube, which may indicate infection;
• Abdominal distension or hardness; and
• Migration of the tube.

(Canterbury District Health Board 2016)

Conclusion

Enteral feeding is important for providing nutritional support but can be dangerous if performed incorrectly. In order to avoid potentially life-threatening complications, correct and thorough care of the feeding tube is essential.

Note: This article is intended as a refresher and should not replace best-practice care. Always refer to your facility's policy on managing enteral feeding.

Additional Resources

• BAPEN, Enteral Nutrition
• Canterbury District Health Board, Adult Gastrostomy and Jejunostomy Feeding Tube Management
• DAA, Enteral Nutrition Manual for Adults in Health Care Facilities
• NDIS Practice Standards: Skills Descriptors
• NDIS Practice Standards: NDIS Practice Standards and Quality Indicators
• WA Country Health Service, Enteral Tubes and Feeding - Adults Clinical Practice Standard

References

• Bapen 2016, Enteral Feed Monitoring, Bapen, viewed 11 June 2020, https://www.bapen.org.uk/nutrition-support/enteral-nutrition/enteral-feed-monitoring
• Bapen 2016, Management of Enteral Feeding Complications, Bapen, viewed 12 June 2020, https://www.bapen.org.uk/nutrition-support/enteral-nutrition/complication-management
• Canterbury District Health Board 2016, Adult Gastrostomy and Jejunostomy Feeding Tube Management, Canterbury District Health Board, viewed 12 June 2020, http://edu.cdhb.health.nz/Hospitals-Services/Health-Professionals/CDHB-Policies/Nursing-Policies-Procedures/Documents/Adult%20Gastrostomy%20and%20Jejunostomy%20feeding%20tube%20management.pdf
• Dietitians Association of Australia Nutrition Support Interest Group 2018, Enteral Nutrition Manual for Adults in Health Care Facilities, Dietitians Association of Australia Nutrition Support Interest Group, viewed 11 June 2020, https://dietitiansaustralia.org.au/wp-content/uploads/2018/06/Enteral-nutrition-manual-june-2018-website.pdf
• Dix, M 2018, Enteral Feeding: How It Works and When It’s Used, Healthline, viewed 11 June 2020, https://www.healthline.com/health/enteral-feeding
• NDIS Quality and Safeguards Commission 2020, NDIS Practice Standards: NDIS Practice Standards and Quality Indicators, NDIS Quality and Safeguards Commission, viewed 11 June 2020, https://www.ndiscommission.gov.au/sites/default/files/documents/2019-12/ndis-practice-standards-and-quality-indicators.pdf
• NDIS Quality and Safeguards Commission 2018, NDIS Practice Standards: Skills Descriptors, NDIS Quality and Safeguards Commission, viewed 11 June 2020, https://www.ndiscommission.gov.au/sites/default/files/documents/2018-09/high-intensity-skills-descriptors.pdf
• NHS 2015, Guideline for the Care and Management of Enteral Feeding in Adults, NHS, viewed 11 June 2020, https://www.rdehospital.nhs.uk/docs/trust/foi/foi_responses/2015/december/Enteral_feeding_guideline~version_Jan_201411.pdf
• NHS 2016, Guidelines for the Insertion and Management of Enteral Feeding Tubes, NHS, viewed 12 June 2020, https://www.bsuh.nhs.uk/library/wp-content/uploads/sites/8/2019/06/Guidelines-for-the-Insertion-and-Management-of-Enteral-Tubes.pdf
• NHS 2016, Nasogastric Feeding Tube Insertion and Care Guidelines - Adult, NHS, viewed 11 June 2020, http://www2.worcsacute.nhs.uk/EasysiteWeb/getresource.axd?AssetID=11001&type=full&servicetype=Attachment
• Souza, J 2018, Nurses’ Guide to Tube Feeding, Shield Health Care, viewed 12 June 2020, http://www.shieldhealthcare.com/community/wp-content/uploads/2018/01/The-Complete-Nurses-Guide-to-Tube-Feeding-Slides.pdf
• Western Australia Country Health Service 2019, Enteral Tubes and Feeding - Adults Clinical Practice Standard, Western Australia Department of Health, viewed 11 June 2020, http://www.albanyhealthcampus.health.wa.gov.au/fileadmin/sections/policies/Managed/Enteral_Tubes_and_Feeding_Adults_Clinical_Practice_Standard_TS4KSNFPVEZQ_210_6774.pdf