What should you monitor during enteral feeding?
What is enteral feeding?Enteral feeding refers to the delivery of a nutritionally complete feed, containing protein, carbohydrate, fat, water, minerals and vitamins, directly into the stomach, duodenum or jejunum[1]. Show
Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction and in patients who are critically ill[2, 3]. Supplemental parenteral nutrition is used in a step-up approach when full enteral support is contra-indicated or fails to reach the required intake targets[4]. Patient selection for enteral feedingThe use of home enteral feeding is increasing worldwide[5]. Multidisciplinary primary care teams focused on home enteral nutrition can provide cost-effective care[6]. Enteral feeding should be considered for malnourished patients or in those at risk of malnutrition who have a functional gastrointestinal tract but are unable to maintain an adequate or safe oral intake[1, 7]. Enteral nutrition is often used for children as well as for adults[8]. Children may require enteral feeding for a wide range of underlying conditions, such as for malnutrition, for increased energy requirement (eg, cystic fibrosis), for metabolic disorders and also for children with neuromuscular disorders. Although it is often a life-saving manoeuvre, the patient's quality of life may be adversely affected[9]. Enteral feeding is particularly beneficial for:
Low-flow enteral feeding may also be useful in combination with parenteral nutrition to maintain gut function and reduce the likelihood of cholestasis[14]. AccessShort-term access is usually achieved using nasogastric (NG) or nasojejunal (NJ) tubes. Opinions vary as to the initial continuous feeding rate. Traditionally the recommendation has been 30 ml per hour[14]. However, the evidence on which this rate is based has been challenged, and ranges upwards of 40 ml per hour have been suggested[15]. Percutaneous endoscopic gastrotomy (PEG) or jejunostomy placement should be considered if feeding is planned for longer than one month[11]:
Feed preparationsVarious nutritionally complete pre-packaged feeds are available:
Nutrients such as glutamine, arginine and essential omega-3 fatty acids are able to modulate immune function. Enteral immunonutrition may decrease major infectious complications and length of hospital stay in surgical and some critically ill patients. Further research is ongoing[18]. Complications of enteral feeding[19]General complications of feedingSee the separate article Nutritional Support in Primary Care. Tube complications
Infection
Gastro-oesophageal reflux and aspiration
Gastrointestinal symptoms
Re-feeding syndrome[2]
MonitoringMonitoring should include the general observations and laboratory schedule recommended for all forms of nutritional support, particularly if the patient is at high risk of re-feeding syndrome[1]. Consideration should also be given to:
Home therapy[22]The number of patients receiving home enteral feeding has increased considerably in recent years. It is now estimated that more than twice as many patients receive enteral nutrition in the community compared with those in hospital.
Ethical considerationsThe provision of clinically assisted nutrition and hydration may be a relatively straightforward management decision. However, there are occasions, particularly towards the end of life, when the process of taking such a decision may become an ethical and medicolegal minefield. The GMC reminds us that enteral feeding is a form of treatment, and as such should be subject to the normal discussion with the patient and or/their family or representatives about risks and benefits[25]. Consideration should also be given to the legal framework regarding consent to treatment published by the Department of Health[26]. Particular scenarios which often prove challenging from a ethical and/or medicolegal perspective include:
What are important assessments to consider when administering enteral feeding?When beginning enteral feedings, monitor the patient for feeding tolerance. Assess the abdomen by auscultating for bowel sounds and palpating for rigidity, distention, and tenderness. Know that patients who complain of fullness or nausea after a feeding starts may have higher a GRV.
What safety measures have to be maintained while the patient is receiving an enteral tube feeding?Wear gloves when handling feeding tubes and avoid touching can tops, container openings, spikes and spike ports. Label equipment: Labels should include the patient's name and room number, the formula type and rate, the date and time of administration and the nurse's initials.
What complications can occur during enteral feeding?Possible complications associated a feeding tube include:. Constipation.. Dehydration.. Diarrhea.. Skin Issues (around the site of your tube). Unintentional tears in your intestines (perforation). Infection in your abdomen (peritonitis). Which assessments should be made for a patient receiving tube feedings?Objective assessments for patients with enteral tubes include assessing skin integrity, tube placement, gastrointestinal function, and for signs of complications: Assess the tube insertion site daily for signs of pressure injury and skin breakdown. Cleanse and protect the area as indicated.
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