Introduction

Welcome to the Enteral Feeding for the Caregivers course, designed to empower nursing professionals with the knowledge and skills to educate caregivers on safe, effective, and compassionate enteral feeding practices. We will develop an understanding of when and why enteral feeds are indicated, followed by detailed guidance on preparation, including patient positioning, formula selection, and equipment setup. We will also address essential topics such as monitoring for complications, post-feeding protocols, and emergency response procedures to enhance patient safety.

Indications 

Enteral feeding provides a safe and nutritious alternative for individuals who cannot safely or comfortably take food by mouth. [1,2,3] Given directly into the stomach or small intestines via a temporarily or permanently placed gastric (G) or gastrojejunal (GJ) tube, these feeds can be given for numerous indications and to an individual of any age. Some of the most common indications include patients with: [2] 

• Decreased level of consciousness  
• Neuromuscular conditions which make it unsafe to eat orally (Parkinson’s or multiple sclerosis) 
• Severe dysphagia or anorexia (undergoing chemotherapy or history of radiation) 
• Esophageal stricture or obstruction 
• Cystic fibrosis 

Another common indication is the temporary use of a nasogastric (NG) tube for newborns who need supplemental nutrition but are otherwise stable to go home. This applies to babies who spent time in the neonatal care unit due to prematurity or other complications. [4] 

Description of Enteral Feeding  

Enteral feedings consist of a medical-grade formula made up of carbohydrates, fats, and proteins, in addition to vitamins and minerals. [5] There are both “real food” formulas and lab-made formulas, and they range from over-the-counter (ex., Boost or Ensure) to prescription. The healthcare team will decide on the appropriate formula before discharge. This formula will be administered via a syringe, gravity, or pump at prescribed intervals. Medications may also be given through the tube if necessary. [1,2] 

Caregivers need to be knowledgeable of the procedure for administering the enteral feed safely and aware of the extra steps entailed.  

These include: 

• Mixing and preparing formula 
• Ensuring that equipment is available and functioning properly (syringes, feeding pumps, bags, feeding tube) 
• Positioning of the one receiving enteral feeds 
• Verifying that there is no residual feed left in the stomach 
• Monitoring for complications (and seeking care when needed) 

While the nurse may do the initial caregiver education, it may also be done by another specialized clinician. In this case, the nurse will reinforce the procedural education. [2] A thorough assessment of caregiver competence and access to all necessary resources (such as clean water, sanitary living conditions, and consistent electricity) should be conducted as soon as the patient is cleared for home enteral feeding. [1] 

Preparation 

Preparation is an essential element of the teaching plan. 

Supplies 

There are numerous supplies required for enteral feeding. Some supplies are required regardless of the method used, and others are unnecessary in certain cases. The feeding tube will be surgically implanted, but the caregiver must maintain the insertion site, including any supplies to protect the skin or hold the tube in place. [3] 

Formula 

The prescribed or over-the-counter formula should be kept in the original container until it is ready. Some require refrigeration, while others should be stored in the freezer. The formula should be removed before feeding to allow it to come to room temperature. The nurse should instruct the caregiver to follow the label instructions carefully. [6] 

Feeding Tube 

This will have been surgically placed before bringing the patient home for enteral nutrition. However, the site should be assessed. This includes verifying the placement of the tube by measurement in the case of an NG or G tube. Drawing back on the tube to determine if stomach contents or residual feeding are present and auscultation to determine if air is heard over the stomach are no longer considered to be reliable or safe methods. [7,8] 

Other Supplies 

Other supplies are necessary to administer the actual feeding. Regardless of the method and equipment used, a large (60 mL) syringe and room temperature water will be required to flush the feeding tube before and after the feeding is instilled. 

Supplies that are specific to the various set-ups are listed below. Feeding bags and tubing sets must be changed daily to minimize the risk of infection or contamination. [6] 

Hand hygiene 

As with all medical procedures, good hand hygiene is imperative. Before handling the feeding equipment and formula, hands should be washed with soap and hot water for 20 seconds. [6] This is critical to prevent infection at the tube site or contamination of the formula. 

Equipment 

As mentioned above, there are numerous supplies for administering enteral feeding. While most supplies are disposable and can easily be replaced, all should be cleaned and inspected for proper functioning before each use. In the case of an electronic pump, the caregiver will work with a vendor to obtain new supplies and troubleshoot their equipment. 

Feeding Procedures

Position 

Before receiving an enteral feed, the caregiver should assist the individual in moving to a seated recumbent position. Ideally, the head of the bed or chair should be at least 30 degrees, but the general recommendation is between 30 and 45 degrees. [1,2] Lower elevations correlate with an increased risk for aspiration and reflux. [1]

Tube placement 

Ensuring that the tube is properly placed is critical to prevent complications. Previously, auscultation of air over the stomach was used to determine if the tube was in the stomach versus the airway. However, this method is no longer considered effective or safe. [7,8] Aspirating gastric contents were also relied upon to determine tube placement; however, that has also proved unreliable since the color of a gastric aspirate could be confused with those of the airways. Similarly, gastric pH was unreliable due to the pH of the formula and other concurrent medications. Even reviewing markings on the tube itself is not always accurate since tubes can migrate internally while still appearing correct on an outer visualization. [7,8]

Upon initial placement, an x-ray will be used to identify that the tube is correctly positioned in the stomach, and this is the only reliable method of confirming placement. However, this is not feasible for someone receiving enteral feeds at home. Currently, the best methods for assessing placement at home are looking at the measurements on the tube and/or measuring from the exposed portion of the tube to the tip and checking the pH. [9,10] Placement should be checked with every feed or daily if on continuous feeds.

Prepare the Formula 

Each formula will have different storage instructions. Formulas requiring refrigeration or freezing must be brought to room temperature before administering. [6] First and foremost, the expiration date should be reviewed, and the formula should be discarded if it is past the date. [11] Opened containers should be used or discarded within 24 hours. While some formulas come as a ready-made liquid, others may be in a powder formulation and should be mixed with water as per the package instructions.

Administer the Formula 

Three methods are available for providing tube feedings: feeding via a syringe, gravity bag, or an electronic pump and bag set-up. When initiating enteral feedings, the feeding volume typically should start low and increase slowly as the stomach adjusts and feeding tolerance is confirmed. [1] The feeding method is selected based on feeding volume and patient tolerance. All methods start with flushing the tube and checking for appropriate tube placement, positioning the patient, and preparing the formula.

The amount of time that formula can be left in the system depends on whether the system is open or closed. An open system is defined as a formula that comes ready-made in a can or is mixed from a powdered formulation and dumped into a syringe or bag set-up; a closed system is defined as a pre-filled bag that is connected to a tubing set-up. In an open system, ready-made formula can hang for eight hours, while mixed formula is only good for four. In a closed system, the formula is good for 24-48 hours. [11]

Syringe 

To administer a syringe feeding, these steps should be followed: [1] 

• Draw the formula into the syringe
• Attach the syringe tip to the clamped feeding tube
• Unclamp the feeding tube
• Slowly push the plunger
• Disconnect the bag and tubing after infusing the feed and flush the feeding with about 30ml (one ounce)
• Close the system and clean supplies

Syringe feeds are typically given over 15-30 minutes [1]. Feeding via a syringe increases the risk of aspiration due to the pressure applied to push the feeding into the tube. [2]

Gravity 

To administer feedings via gravity, the following should be done: [1,12] 

• Pour the formula into the bag and tubing set-up (open system) or attach a tubing set to a pre-filled bag (closed system)
• Hang from an IV pole or wall hook at least 18 inches above the patient
• Fill the drip chamber about half full
• Adjust the roller clamp to ensure the correct administration rate
• Disconnect the bag and tubing after infusing the feed and flush the tube with about 30ml (one ounce)
• Close the system and clean supplies

Gravity feeds are usually administered over 15-30 minutes.

Feeding Pump 

To administer feedings with a pump, the following should be done: [1,12] 

• Pour the formula into the bag and tubing set-up (open system) or attach a tubing set to a pre-filled bag (closed system)
• Insert feed tubing into the pump per manufacturer instructions (calibrate as required)
• Attach the feeding set-up to the feeding tube
• Open the roller clamp
• Start the pump
• Rinse the bag and tubing after eight hours (pre-made formula) or four hours (mixed formula) and only refill with enough formula for four to eight hours
• Disconnect the bag and tubing after infusing the feed and flush the tube with about 30ml (one ounce)
• Close the system and clean supplies

Feedings given on a pump can be intermittent or continuous. They can be used for gastric feedings but are required for small intestine feedings. [1]

Flushing the Tube 

Maintaining an open tube is as important as verifying placement, administering feeds, and caring for the site. After feeding, the tube should be flushed with water to ensure it remains clear and to provide hydration. Typically, 30ml (one ounce) is sufficient. A flush should be given after every bolus feed or medication administration. If on continuous feeds, the tube should be flushed every four hours. [1] The volume of tube flush may be adjusted based on the specific patient’s needs and tolerance.

If the tube becomes occluded, there are other options to clear the tube. These should never be given without a doctor’s authorization. They include: [1]

• Cola or other carbonated beverages
• Pancreatic enzymes

Post-Feeding Care

Position 

The seated inclined position should be maintained for at least 30 minutes after the feeding is completed to minimize the risk of reflux or aspiration. Ideally, staying upright for a few hours after feeding is the most protective. [3]

Clean up 

After the feeding is completed, all single-use supplies, such as formula cartons, should be disposed of. If an open set-up is used, syringes and bag/tube set-ups should be rinsed every four to eight hours. In both open and closed systems, the syringes and bag/tube setups should be discarded after 24 hours. [11] Any leakage should be cleaned up around the tube site, and hands should be cleaned. If any remaining formula is given after the appropriate window of time, it should be thrown away.

Monitor for Complications 

There are several potential complications when administering tube feedings. Some can be easily addressed by slowing the feeding down, while others require more urgent and intense intervention. Many gastrointestinal complications can indicate a feeding intolerance or the feeding being administered too quickly.

Complications include: [1] 

• Increased satiety
• Gas/bloating
• Vomiting/ nausea
• Reflux
• Diarrhea
• Constipation
• Increased coughing could indicate aspiration

Generally, if any of these symptoms occur, feeding can be slowed down, positioning can be optimized, formulas can be changed, blenderized foods can be used instead of liquid formulas, or more water or fiber can be added to the diet. [1] However, all of these symptoms warrant a physician evaluation. In the case of increased coughing, which may indicate that the feeding tube is in the airways and not the stomach, feeding should be stopped, and urgent help should be obtained. [1] Suctioning of the mouth and upper airways may also be useful in this case. [13]

Emergency Contact Information 

Phone numbers for emergency care (including physicians, pharmacists, and supply vendors) should be kept in an easily accessible location like the refrigerator. Being familiar with what hospital will be used in the event of an emergency is also critical to patient safety. [14]

Troubleshooting

This section will delve into some of the more common problems that may arise when utilizing a feeding tube.

Occluded Tube 

One of the most common complications is a blocked tube. This could be related to many factors, including lumen size, rate of feeding, thickness of the formula, or any other additional foods or medications given through the tube. [1] The tube must be opened before feeding, and regular water flushes can help prevent this; flushing with warm water may be especially helpful. [15] Carbonated drinks should not be used to unclog the tube. [15]

Displaced Tube 

In the case of a new tube being dislodged, emergency care should be obtained as soon as possible. [3] If the feeding tube becomes partially or completely dislodged, the feeding should be stopped immediately if it is in progress. The tube should be left in place and securely covered before seeking urgent treatment at an emergency room, urgent care, or physician’s office. Prevention is key because tube replacement must happen quickly to prevent the stoma from closing entirely. [16]

Skin Irritation 

The skin condition at the insertion site, whether nasal or abdominal, is important to maintain and monitor closely. Any skin breakdown can increase the risk of infection. Leaked feedings, friction, and poor skin care contribute to skin breakdown. [2,3,12] The skin should be evaluated at every feeding, and the tube site should be cleaned daily.

Additional Tips

Daily Care 

Tube sites require daily monitoring and hygiene to remain healthy. [5] The site should be cleaned at least once a day but may require intermittent cleansing as needed to remove leaked feedings or other drainage.

While the care for tube sites is somewhat individualized based on whether they are nasal or abdominal, there are some common guidelines for site care. These include:

• Monitoring the site daily for erythema, drainage, skin breakdown, or bleeding [1,17]
• Removing any crust or drainage from the site (with warm water) and maintaining dry skin (especially with g-tubes or buttons)- can help reduce the risk of skin breakdown and infection [3]
• Abstaining from the use of skin lotions or creams unless specifically prescribed (such as barrier creams like zinc oxide) [17]

Typically, dressings are not required beyond the initial healing phase; however, the site should be maintained as directed. [12]

Peristomal infections are one of the main complications (5-30% of patients) and can become serious. They are more likely to occur in individuals with other significant medical conditions such as cancer, diabetes, methicillin-resistant staphylococcus aureus, or malnutrition. [1]

Dietary Considerations 

Formula should be selected based on individual needs and prepared per the package instructions. Whole foods can be liquified and administered through the tube if desired. [1] Oral feeding can also be considered for pleasure or to maintain/ develop oral skills (especially true for newborns). [18,19]

Documentation 

It is important to keep track of several variables when administering enteral feedings. These include:

• Feeding times (if on an intermittent schedule)
• Amount of feed administered
• Any complications noted
• Tube position
• Positioning (if different than the usual)
• A time formula was added to the system
• Tube feeding residuals and ph
• Any potential concerns at the insertion site

Bowel movements should also be monitored. [20]

Regular Tube Changes 

The feeding tube should be changed regularly. According to The Cleveland Clinic, tubes with a hard end (no balloon) typically need to be changed every year. Tubes with a balloon end must be changed every three to six months. The type of tube and healthcare provider will determine the frequency and intensity of the replacement procedure. [3]

Conclusion

Enteral feedings are a key medical intervention for various diagnoses to optimize nutrition in and out of the hospital. However, the patient typically needs the assistance of a caregiver, and it is the nurse’s responsibility to ensure that the caregiver is ready to take on the responsibility at home.

This course has reviewed indications for enteral feeds, preparation, post-feeding care, potential complications (including instructions for emergency care), troubleshooting, routine care, and additional supportive resources. Initially, caregivers may be hesitant to take on this huge task of keeping their loved one adequately nourished, but with the right training, they can be instructed on how to care for their loved one safely at home.