Feeding Tube Management – What New Nurses Need to Know

Navigating the intricacies of feeding tube management is a crucial skill for nurses, especially for those new to the field. If you are seeking to deepen your knowledge in this area, this post will provide valuable insights into the comprehensive landscape of feeding tube management.

Why Feeding Tubes Are Used

Feeding tubes might be recommended for patients experiencing:

• Impaired swallowing abilities
• Chronic neurological conditions or decreased level of consciousness
• Intestinal failure
• Critical illness
• Oropharyngeal or esophageal obstruction
• Respiratory distress requiring mechanical ventilation
• Hypercatabolic states (like severe burns)

Nasal tubes are not appropriate for patients undergoing orofacial therapy to address potentially reversible dysphagia. The presence of a nasal tube significantly hinders the effectiveness of swallowing training.

Types of Feeding Tubes

Nasoenteric Feeding Tubes (NETs)

These are used for short-term feeding purposes (approximately 4-6 weeks in length) and are often inserted by the nurse at the bedside. 

Nasogastric feeding tubes: These are inserted through the nose and end in the stomach. The two main types are single lumen and double lumen.

• Single Lumen: It has one narrow channel (small bore) to deliver the medication and nutrition to the stomach. The two main types you’ll come across are the Levin and the Dobhoff. The Dobhoff has a weight at the end of the tubing.
• Double Lumen: This type is designed for suctioning. There are two channels: one for suctioning, and a narrower one with an air vent to alleviate pressure. The Salem Sump is one of the most common.

Nasojejunal (nj) feeding tubes: These are inserted through the nose and extend into the jejunum, a segment of the small intestine. They’re ideal for situations where gastric feeding is unfeasible, often due to gastric dysfunction or the need to bypass the stomach. Some institutions even use these for long-term enteral nutrition.

Percutaneous Endoscopic Feeding Tubes 

There are two types of percutaneous endoscopic feeding tubes, and they differ in where they terminate in the patient’s digestive tract. Both of these are inserted directly into the abdominal wall during a short surgical procedure completed by a gastroenterologist (or a general surgeon, ENT specialist, or radiologist).

• PEG feeding tube (Percutaneous Endoscopic Gastrostomy): Inserted directly into the stomach through the abdominal wall. Commonly employed for patients with prolonged difficulty swallowing or those requiring extended nutritional support.
• PEJ feeding tube (Percutaneous Endoscopic Jejunostomy): Alternatively used for patients requiring long-term nutritional support but who are facing medical conditions like delayed gastric emptying. In this case, a tube is inserted into the jejunum of the small intestine. This is used when administering enteral formula or medications into the stomach is not well-tolerated.

Assessing Feeding Tube Placement and Patency

Bedside nurses are responsible for the insertion of NET’s and it’s an important skill you will be responsible for. This is serious nurses! Incorrect placement of an enteral tube during feedings or medication administration can lead to life-threatening aspiration pneumonia. 

Typically, NET bedside placements are inserted without real-time knowledge of their position (blind method), leading to potential low-rate complications like pneumothorax. While guided placement with real-time position identification can help mitigate these issues, there is still a risk of undetected misplacements.

Methods for Assessing Tube Placement

1. X-ray is the gold standard for verifying position. It is performed after the placement to ensure that the tube has not been place down the trachea. The feeding tube should be labeled with adhesive tape and/or a permanent marker to indicate the location on the tube where it enters the nostrils or penetrates the abdominal wall. 
   
   The American Association of Critical‐Care Nursing suggests checking and documenting the position of a feeding tube every four hours and before administering enteral feedings or medications. This involves measuring the visible length of the tube and comparing it to the length documented during X-ray verification. Also to decrease the risk of aspiration maintain the head of the bed at 30°- 45° unless contraindicated.
2. Examining the pH of aspirated gastric contents. Gastric aspirate should register a pH of less than or equal to 5.5, determined using pH indicator paper specifically designed for human aspirate. 
   
   Keep in mind though, that aspiration of gastric content can contribute to tube clogging. But according to research it is not appropriate to stop enteral nutrition for a gastric residual volume of less than 500 mL in the absence of other signs of intolerance.
3. Bedside Ultrasound: Ultrasound can be used to visualize the nasogastric tube and confirm its placement in the stomach.
4. Capnography: Capnography measures the level of carbon dioxide (CO2) in exhaled air. It can be used to detect the presence of CO2 in the stomach, which suggests correct tube placement. However, it may not always be readily available at the bedside.

Some less reliable methods are the following:

• Auscultation: Air is injected into the NET using a syringe, and a stethoscope is positioned over the epigastrium. Confirmation of stomach placement is determined by the audible “whooshing” sound. The absence of sound or a muffled sound may suggest respiratory placement.
• Bubbles: The external end of the NET is submerged in water, and the presence of bubbles may suggest respiratory misplacement.
• Visual inspection of the aspirate: Looking at the color and consistency of the aspirate. The aspiration can be compared with a set of known location aspirates for visual characteristics (e.g., yellowness and cloudiness).

Nurse tip: Remember to withhold the enteral feeding and medication if the patient presents with symptoms related to potential aspiration. 

Assessing and Cleansing the Insertion Site

Pressure wounds can be formed in the area surrounding the fixation plate for PEG or PEJ or because of the adhesive used to secure the NET. Therefore, it is advised to assess the area daily, and clean it with a saline solution (or other prescribed solution) poured into a gauze. (Sometimes a barrier cream or a specific dressing can also be prescribed.)

Administering Tube Feeding

Tube feeding can be delivered through gravity for bolus feeding or via a pump for continuous or intermittent feeding. Pump-administered feedings are configured in mL/hr., with the rate determined by the healthcare provider’s prescription.

The nurse should examine enteral nutrition prescriptions for the following elements: the type of enteral nutrition formula, the quantity and frequency of free water flushes, the route of administration, the method of administration, and the rate.

Administering Medication

Administering medication through a feeding tube poses several challenges, such as potential access device obstruction and the risk of reduced medication bioavailability due to interactions, or delivery to an inappropriate segment of the gastrointestinal tract.

The Handbook of Drug Administration via Enteral Feeding Tubes is recommended to learn about this more in depth. For every drug, the information includes details about absorption sites following oral administration, interactions, health and safety data, alternative routes, recommendations, and step-by-step instructions for both intragastric and intrajejunal administration, if applicable.

Tube Irrigation

To maintain the patency, it is recommended to follow the hospital policy for tube irrigation. Generally, the necessary amount of water for irrigation is around 30ml in adults, 5m for infants, and between 10-30 for older kids, into a 60-mL syringe. 

Your hospital may have a policy that you must use sterile water to flush nasogastric tubes. However, that practice is possibly unnecessary. This is a great article that explains the issue well. When I worked at the bedside, we always used tap water (please note I worked in the US in an area with exceptionally high-quality drinking water). However, the policy change to require sterile water occurred in the early 2010s for critically ill and immunocompromised patients. The validity of this need is being scrutinized. Therefore, pay attention to whether or not your policy requires this.

Tips to prevent the tubes from clogging

Irrigate the tube frequently to prevent it from clogging by following these general tips:

1. Flush the tube immediately before and after feeding with at least 30 mL of water.
2. Never mix medicine with tube feeding.
3. Flush the tube with at least 30 mL of water before and after all medications.
4. Flush the tube with at least 5 mL of water between each medication if more than one is given.

Tube Suctioning

To achieve gastric decompression when needed, suctioning the gastric content (stomach pumping or gastric lavage) through the feeding tube might be needed.

This is most often done urgently in the Emergency Department when the need is identified. 

Once the NG tube is in place, the physician or healthcare provider uses a syringe or gastric lavage system to gently aspirate (withdraw) the stomach contents. This may involve flushing the stomach with small amounts of sterile saline solution, and suctioning it. The process is repeated until the aspirate appears clear.

The NG tube may be left in place to low-intermittent suction for a more extended period. The patient may come up to a med-surg unit or the ICU with the NG tube and an order for suction. 

Conditions that may necessitate suctioning from the feeding tube include:

1. Toxic ingestion (poisoning)
2. Gastroparesis or gastric outlet obstruction
3. Small bowel obstruction or pseudo-obstruction
4. Intractable nausea and vomiting
5. Upper GI bleeding
6. Gastrointestinal surgery
7. Postoperative patients who have not regained peristalsis

How to Manage Common Complications

Clogged Tubing

A major disruption to the flow in your shift can be a clogged tube. The tubes are small in diameter and medication or enteral feeding that is sitting in the tube can solidify and make it so the tube is unable to be flushed. 

Preventing a Clogged Tube

You can’t flush any meds or feedings through the tube if it’s clogged. Basically, we don’t want any enteral feeding material sitting in the tube unnecessarily if it can be avoided in the first place with a few simple good habits.

Quick definition: “Flushing” the tube means using 30-60 mL of tap or sterile water.

The best way to avoid this situation is with a few simple preventive measures:

• Always flush the tube before and after use if it is not continuously infusing. Any substance other than water can clog it, so we want to clear that out of the tubing every. single. time.
• Flush before you start continuous or intermittent infusing, and when it is complete.
• Request liquid medications if possible, rather than crushing and flushing pills (be aware that the liquid forms of some medications can cause diarrhea).
• If you must crush a pill, ensure it can be crushed first. Then, crush it into a fine powder with an appropriate device and flush with water before and after.

What if The Tube is Clogged Already?

Dealing with a clogged feeding tube is a pain, but it’s definitely doable. We don’t want to remove the tube and place a new one, as doing so is very uncomfortable for the patient. The first-line treatment is to try a de-clogging agent. Your hospital likely has a full policy on this process.

If the tube is obstructed, here are the general steps to address the problem:

1. Instill warm water with a 30-60 mL syringe
2. Apply a gentle back-and-forth motion to the plunger of the syringe until the clog loosens
3. If this does not resolve the problem, notify the practitioner. He or she may order a declogging enzyme or device (depending on your hospital’s resources). If this is ordered, you must follow the corresponding policy to complete the task.
4. If all that doesn’t work, the tube must be replaced.

(Citation: Wilkins, L.W. &. (2022). Lippincott Nursing Procedures (9th ed.). Wolters Kluwer Health. Page 292, https://online.vitalsource.com/books/9781975178611) 

As you can tell, this is a major headache. Don’t let it get this far. Preventing this will save you a TON of time!

Tube Misconnections

Tube misconnections can have disastrous consequences. If the NG tube becomes disconnected and someone accidentally connects that to a patient’s tracheostomy or ventilator, that can be fatal. It is a major goal of the nursing staff to prevent these kinds of events. Here’s a great article outlining the most common occurrences. 

Let’s go over a few tips to prevent this!

• Establish tubing connections in appropriate lighting conditions
• Avoid altering or adapting IV or feeding devices
• When reconnecting, systematically follow the lines back to their points of origin and verify their secure attachment
• As a component of the hand-off procedure, double-check connections and trace all tubes back to their sources
• Don’t force any fittings that don’t easily fit. Reexamine what you’re doing when you note resistance

Tube Feeding Intolerance 

Patients need daily monitoring for indications of tube feeding intolerance. Report to the provider if you notice something abnormal. Sometimes, intolerance signs indicate that the provider will need to change the formula, decrease the speed of administration, or decrease the volume of the bolus given. 

The symptoms to ask the patient about are the presence of abdominal bloating, nausea, vomiting, diarrhea, cramping, and constipation. 

Nurse tip: If cramping arises during bolus feedings, administering the enteral nutritional formula at room temperature can prevent it. 

Nasoenteric Tubes and Quality of Life

These tubes are frequently challenging for conscious patients as they can evoke a foreign body sensation in the pharynx, potentially leading to reflux esophagitis, pressure ulcers, and a propensity for dislocation.

Moreover, these tubes can contribute to psychological stress for patients, serving as a visible reminder of their illness. Geriatric patients experiencing an acute confusional state often exhibit poor tolerance to these tubes.

Living with feeding tube management at home can be exhausting for relatives to manage. The support of a home health nurse and agency would be wise to ensure appropriate care is provided. 

According to studies, gastrostomy tubes can improve quality of life for long-term use in certain conditions, such as when needing to relocate patients to a nursing home (closer to their family), establishing a method for administering medication (often for comfort care), and avoiding the drawbacks associated with long-term nasogastric tubes, which can be susceptible to malfunction.

Other issues patients with long-term tube feedings face include social isolation, missing the flavor of food and joy of eating, and not knowing when they feel satiated. Naturally, this is psychologically challenging, and patients often need emotional support and encouragement to cope effectively.

Final Thoughts on Tube Feeding Management

Taking care of patients who require tube feeding can seem like a lot of work, but with practice, you will feel like a pro in no time! My key take-home points as an experienced nurse are:

– Remember, this is scary and uncomfortable for patients. Be empathetic and understanding!

– Always make sure the tube is in the right place before using it (and verify it’s taped appropriately at the beginning of your shift)

– Continuously work to prevent clogs

– Look for clinical signs to discontinue as soon as appropriate, and notify the practitioner when this threshold has been met. This will allow you to remove the tube as soon as possible!

We also discuss this more in-depth in our course Nursing Skill Refresh if you’d like to delve deeper into this topic. More information on that course is below.

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