Feeds can be administered via syringe, gravity feeding set or feeding pump. The method selected is dependent of the nature of the feed and clinical status of the child. There is limited evidence available to support one method of feeding over the other. Do not administer feeds through enteral tubes that are being used for aspiration or are on free drainage.
An enteral feeding pump can be used intermittent, bolus or continuous administration of feeds, but is best suited for continuous feeding when tolerance to rate of feeding is an issue. Infinity pumps are now in use throughout RCH and the giving set can be primed by pushing the fill set button.
For further information regarding the use of the infinity pump please see the manufactures instructions. Please note: in most situations an IV syringe pump is not recommended for administration of enteral feeds and should not be used on the ward.
If very small rates are required, consider using frequent syringe bolus feeding techniques as an alternative. For older children feeds given as a bolus should be removed from the fridge minutes before administration to bring them to room temperature.
Feeds given as a bolus may be warmed in an approved bottle warmer. This would be appropriate for all infants and older children who experience discomfort with cooler feeds. Continuous feeds should NOT be warmed. They may be removed from the fridge minutes prior to administration to bring it to room temperature and should not hung for longer than 4 hours — use the dose limit function on the feed pump to ensure this occurs.
Caution should be taken if titrating feeds up and down in patients with a metabolic condition. The decision for which type of enteral feed a child should receive should be made in consultation with the dietician, medical team, nursing staff and family, taking into account the nutritional needs, clinical status and tolerance of feeds of the child. Enteral feeds can be ordered from the RCH formula room. The family should be offered a dietician review while they are an inpatient to ensure the current feeding regime meets the ongoing nutritional needs of the child.
Nurses who are preparing and administrating medication via an enteral tube must adhere to the Medication Management Procedure. Consult your ward pharmacist or call Medicines Information ext: for advice on how to prepare a drug for enteral administration.
Flushing is the single most effective action that prolongs the life of nasogastric tubes. Nurses should consider titrating feeds down or ceasing feeds for a short period of time depending on the clinical status and nutritional needs of the child. High acuity and intensive care patients may require management of Gastric Residual Volumes GRV to assist in management of gastric emptying delays, feeding intolerance, electrolyte balance and patient comfort. Patients who have a non-functioning GIT i.
Please remember to read the disclaimer. Published December The Royal Children's Hospital Melbourne. Enteral feeding and medication administration.
Enteral feeding and medication administration Note: This guideline in currently under review. Aim This guideline aims to support nurses in administering feeds and medications via a nasogastric, orogastric or gastrostomy tube in a safe and appropriate manner. Gastrostomy tube - a feeding tube which is inserted endoscopically or surgically through the abdominal wall and directly into the stomach.
Once removed it may be returned to the patient or discarded. Trans-Anastomotic Tube TAT tube - Utilised after surgery to repair oesophageal atresia inserted by surgeons in the Neonatal patient population. The position of the tube must be checked: Prior to each feed Before each medication Before putting anything down the tube If the child has vomited 4 hourly if receiving continuous feeds Nursing staff should perform the following observations and obtain a gastric aspirate to establish tube position.
Utilising pH indicator strips a reading of between should be obtained and documented. Small-bore tubes can be difficult to aspirate therefore the following are suggested techniques to try enhance the ability to obtain aspirate: Turn the patient onto their side. This may move the tube away from the wall of the stomach. It will also clear the tube of any residual fluid. If a child belches immediately following air insufflation, the tip of the tube may be in the oesophagus Wait for minutes.
This will allow fluid to accumulate in the stomach and try aspirating again. If it is safe to do so and the child is able to tolerate oral intake consider providing them with a drink and attempt aspirate in minutes If no aspirate obtained, advance the tube by cm and try aspirating again If aspirate not obtained discuss with senior nursing staff or medical staff and consider removing the tube or checking position by x-ray.
Gastrostomy tube Correct placement of the tube should be confirmed prior to administration of an enteral feed by checking insertion site at the abdominal wall and observing the child for abdominal pain or discomfort. The position of the tube needs to be checked 4 hourly with change of feeds It is recommended that the feed be ceased, withdraw aspirate and test pH.
If reading greater than 5, cease the feed for 30 minutes, aspirate and test pH Should there be any dispute as to the position of the tube, do not recommence feeds.
Discuss with senior nursing staff or medical staff. The following needs to be checked 2 hourly during the feed: Taping Marker on NGT Observe child for signs of respiratory distress. How are they cared for? This article provides a practical guide to those that are most commonly used, both in hospital and in the community. This feeding tube can also be used:. If enteral tube feeding is likely to be needed only for a short time less than four weeks , a feeding tube is usually inserted into the stomach through the nose nasogastric tube, Fig 1 ; for longer periods gastrostomy feeding should to be considered National Institute for Health and Care Excellence, Serious complications after gastrostomy tube insertion are uncommon.
However, in , the National Patient Safety Agency NPSA issued a rapid response report following several patient deaths that occurred after gastrostomy insertion Box 1. Between October and January , the National Patient Safety Agency received 11 reports of deaths and 11 of severe harm describing delay in recognising and acting on signs of complications in the 72 hours after gastrostomy insertion.
Source: National Patient Safety Agency If enteral feed or medication cannot be administered into the stomach for example, if there is delayed gastric emptying or pyloric obstruction , there is the option of post-pyloric feeding.
In this procedure, enteral feed is administered into the small intestine — usually into the jejunum, more rarely into the duodenum. For short-term post-pyloric feeding, the nasal route can be used; for long-term post-pyloric feeding, a jejunostomy surgical opening from the skin into the jejunum may be considered. Alternatively, an existing gastrostomy can be used to insert a longer tube into the small intestine. A nasogastric tube NGT is passed through the nostril along the nasopharynx and oesophagus into the stomach.
Depending on the type Table 1 , NGTs are used for: gastric aspiration; gastric decompression; or administering enteral feed, fluid or medication. The smaller the gauge the higher the risk of blockage, while tubes over 12Fg are more likely to cause discomfort.
The NGT is secured externally at the nose or cheek by adhesive tape or a fixation device. The area should be checked daily for signs of pressure damage and to ensure the fixture device is intact NICE, One of the two recommended methods of checking the position of a nasogastric tube is to look at it on X-ray and check the following:. An orogastric tube is passed through the mouth, throat and oesophagus, into the stomach. It is an alternative to an NGT when using the nasogastric route is not possible.
Orogastric tubes are used primarily in neonates; they are usually avoided in all other patients due to the risk of being bitten or displaced by the tongue NHS Improvement, Their position needs to be checked using the same methods as for NGTs. A percutaneous endoscopic gastrostomy PEG is created under endoscopic guidance. A PEG tube Fig 3 is the long-term enteral gastric feeding tube of choice for patients with an uncompromised airway but accessible gastric region, who are able to undergo an endoscopic procedure.
It can be used for administering enteral feed, fluid or medication, starting four hours after placement NICE, This happens when the piece securing the tube in the stomach the bumper becomes embedded in gastric mucosa once the gastrostomy tract has fully developed.
The first advance and rotate is carried out days after placement Dowman et al, Frequencies and timings vary, depending on local policy. A radiologically inserted gastrostomy RIG is placed under X-ray guidance. The type of tube used varies — a balloon gastrostomy tube BGT, Fig 4 is the more common option. A RIG can be used:. In a RIG, the gastrostomy tract is created via gastropexy and secured by skin fasteners or sutures on the abdomen. Gastropexy is a surgical procedure in which the stomach is sutured to the abdominal wall to provide a safe tract through which a gastrostomy tube is placed.
The number of gastropexy fasteners or sutures varies from one to four Lowe et al, The length of time for which gastropexy fasteners remain in place varies from days Lowe et al, If they are removed too soon, the formation of the tract could be compromised. Once the gastrostomy tract has healed and fasteners have been removed, care of the RIG tube depends on the type of tube inserted during the procedure.
A BGT is held in place in the abdomen by a water-filled balloon. It can be inserted radiologically or surgically or, if replacing a PEG through an established gastrostomy tract, percutaneously NNNG, b. BGTs can be used:. Factors including gastric pH, frequency of tube use and fungal infection may affect the longevity of the balloon NNNG, b.
BGTs need to be replaced every three to nine months depending on the manufacturer. Replacement can be undertaken in secondary or primary care Ojo, If a BGT is to be changed in the community, the procedure should, where possible, be undertaken during office hours so support and advice is available if there are any problems NNNG, b.
The size of the balloon varies between devices. It is normal for the balloon to lose some water but the amount is individual to each person and the size of the BGT in situ. To monitor water loss, you will need to document how much water is removed from a balloon and how much is used to inflate it each time it is changed. If there is significant water loss or no water can be withdrawn, expert advice should be sought to consider replacing the tube. This can sometimes be referred to as a percutaneous endoscopic gastrostomy, PEG or a Button gastrostomy.
A gastrostomy tube can also be inserted under radiological guidance, often referred to as a RIG Radiologically Inserted Gastrostomy. This is used in the same way as the PEG or Button outlined above, it is only the insertion method which is often different. Your healthcare team will ultimately use the method of insertion which is most appropriate for you, taking in to account of a number of factors, such as your medical condition.
Jejunostomy Feeding. This can sometimes be referred to as a percutaneous endoscopic jejunostomy PEJ. Gastrostomy with Jejunal Adapter. To avoid a second surgical procedure this can be achieved without performing a Jejunostomy, through the replacement of the existing gastrostomy with a transgastric-Jejunal feeding tube.
Essential the tube enters the stomach through the abdominal wall as a gastrostomy and held by a fixation device to the inside of the stomach wall. The tube is then advanced into the jejunum, thus bypassing the stomach when feeding. This can sometimes be referred to as a percutaneous endoscopic gastrostomy-jejunostomy, PEG-J.
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