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Introduction   

Enteral feeding is a fundamental nursing concept that many nurses are familiar with, though recent research is available that can improve nursing practices and provide better outcomes for patients. Indications for enteral feedings, administration tube types, and feeding methods can vary. Nurses must know the different types of products used in order to provide competent care and accurate patient and family education.  Nurses must understand the elements of enteral feeding, including assessment, care techniques, patient education, and safety considerations. Nurses also need to know how to troubleshoot problems that may occur. By providing competent enteral feeding care, nurses can improve the quality of the care they provide. 

Definition 

Enteral feeding occurs when a tube is used to administer nutrition, medications, and fluids to a patient who cannot consume enough calories, fluids, or necessary medications their body needs for essential functioning. The tube can be inserted through the mouth, nose, or directly through the skin into the stomach or intestine. There are various types of enteral feeding methods [1].  

History 

Enteral feeding is not a novel concept. In fact, there is evidence that shows enteral feeding was used about 3,500 years ago by ancient Greeks and Egyptians to treat various bowel disorders, like malnutrition, inflammation, and diarrhea, by infusing nutrient-containing fluids into the rectum. As early as the 12th century, there is evidence that the upper gastrointestinal (GI) tract was used for enteral feeding. In 1598, Capivacceus described using a hollow tube with a connected bladder that contained a feeding solution inserted into the esophagus.  

In the 17th century, Von Helmont developed a feeding tube made of leather, which Boerhave proposed could be used for a nasogastric feeding method. This was further developed in the 18th century when John Hunter used a syringe to infuse blended food through a hollow catheter into a patient’s stomach. Hunter continued to expand his methods, including using an orogastric tube made of whalebone encased in eel skin to deliver his custom nutrition formula. Thankfully, we no longer rely on whalebone and eel skin to provide enteral feedings.  

Research has continued through the centuries, establishing safer and more effective methods to provide nutrition to individuals who cannot chew or swallow. The first half of the 20th century saw much progress in the formulation of feeding solutions, leading to increased research in the second half of the 20th century on ways enteral feeding could benefit different conditions. Research and progress continue, with variations of standard formulas to provide targeted nutrition, improved technology, such as tubes that can be used for multiple purposes, development of feeding pumps, safety mechanisms like specialized connectors, and other new techniques to help provide enteral feedings in an increasingly safe manner [2].  

Indications of Use 

Who Needs Enteral Feeding? 

Enteral feeding is used when a patient is experiencing dysphagia and cannot safely chew or swallow. It may be used when part of the GI tract cannot tolerate the food. Enteral feeding may also be necessary for severe nutrition imbalances. Many conditions may require the use of enteral feeding. Patients with severe eating disorders may be psychologically unable to consume enough calories to support the essential functions of their body. Providing enteral feedings to address nutrition deficits may be necessary while the patient undergoes psychological treatment.  

Head and neck cancers, as well as injury or recent surgery to those areas, can impede chewing and swallowing. Some anatomical GI issues, such as narrowed esophagus or dysmotility, can cause challenges in consuming foods and fluids. Conditions like Crohn’s Disease and celiac disease can interfere with the body’s ability to absorb nutrients from foods. Neurological disorders, including stroke or paralysis, can make chewing and swallowing difficult to coordinate, which may be unsafe.  

Premature infants may not be strong enough to suck or neurologically developed enough to coordinate breathing, sucking, and swallowing. Patients in a coma cannot consume fluids and nutrition by mouth but still rely on them for basic body functioning. Patients in hospice care may also receive enteral feedings [1].  

What Methods of Enteral Feeding are Available? 

Several methods of enteral feeding are used, depending on the patient’s needs and the physician’s preference. Some feeding tubes are inserted through the mouth or nose and pass through the esophagus. Others are surgically placed through the abdomen and go directly into the stomach or intestine [1].  

Orogastric/Oroenteric Tubes 

An orogastric (OG) tube is inserted into the mouth, down the esophagus, and into the stomach. It is used in pre-term neonates as a feeding method due to a lack of neuromuscular coordination to effectively suck, swallow, and breathe safely and effectively. Orogastric feeding is recommended for newborns weighing less than 2kg (4.4 lbs) and those with anatomical issues, like cleft palate, to reduce respiratory complications. Research shows that OG and nasogastric (NG) tubes have similar risks, benefits, and outcomes, but the NG tube is more often used because it is less likely to become displaced [3].  

For adults, the OG route may be used in trauma situations if there is a present or suspected skull fracture or when there is surgical interference at the nasal airway. In some cases, the physician may prefer an OG tube for adults who are being mechanically ventilated. Oroenteric tubes are similar to OG tubes, though they are passed through the stomach and into the intestines. OG tubes are less comfortable for patients, are more challenging to place, and are more likely to become dislodged, so they are less commonly used than NG tubes. The placement and care of OG tubes are very similar to those of NG tubes [4].  

Nasogastric Tubes 

Nasogastric tubes (NG) are inserted in either nostril and extend into the stomach to allow for bolus or continuous feeding. They are commonly used to vent the stomach during surgery or when a patient is intubated to reduce the risk of aspiration. They are also an effective temporary method to provide enteral feeding. NG tubes are an appropriate option when the patient is unable to safely ingest food or fluids due to an issue with chewing or swallowing but whose GI system is functional [4]. It is imperative that the distal tip of the tube be placed in the stomach. If the length is too short, it may be in the esophagus, increasing the risk of aspiration. If the length is too long, the tube may curl up into the esophagus or extend into the duodenum, causing dumping syndrome [4].  

NG tubes are usually placed at the bedside. For many decades, the accepted method to estimate the length of tube to insert into the nostril was the distance from the nostril to the to the earlobe to the xiphoid process (NEX method). A meta-analysis completed in 2022 reviewed over 70 years’ worth of studies and found that this method only resulted in accurate NG tube placement in about 72.4% of cases. Despite this, it remains the most commonly used method of measurement. A recent study had substantial evidence to suggest that a corrected nose-earlobe-xiphoid (CoNEX) method using a combination of the NEX method and a mathematical formula was successful in placement in all cases studied [5].  

There are different techniques to confirm placement for NG tubes. These can also be applied to OG tube placement confirmation. Many seasoned nurses know the “whoosh” method, where air is injected into the tube, and the nurse auscultates to hear the sound in the stomach. It continues to be used in many settings despite being unreliable and without supporting clinical evidence to confirm correct tube placement. The gold standard for placement is x-ray confirmation by a radiologist to confirm placement.  

Another technique is testing the pH of fluid aspirated from the tube after placement, though there are many opinions on what the acidic threshold should be to confirm placement. Ultrasound visualization is another recommended method for verifying tube placement. In recent years, electromagnetic sensing has been utilized to aid in placement and confirmation, though it can be cost-prohibitive [5]. 

Nasoduodenal/Nasojejunal Tubes 

Nasoduodenal (ND) tubes are placed through the nostril and guided, typically via fluoroscopy, into the duodenum. Nasojejunal (NJ) tubes are placed similarly, but the distal tip lies in the jejunum. NJ tubes are used when the duodenum cannot facilitate feedings due to dysfunction or obstruction. 

ND/NJ placement is indicated for patients with severe gastric reflux, frequent vomiting, recent gastric surgery, gastroparesis, or other gastric dysfunction [6]. Bolus feedings cannot be administered via the nasojejunal route due to the risk of dumping syndrome. Instead, continuous feedings using a feeding pump are administered. Some medications are not absorbed effectively when the stomach is bypassed for administration [1]. 

Gastrostomy Tubes 

Gastrostomy tubes, commonly called G-tubes or PEG tubes, are placed percutaneously through the skin directly into the stomach and held with a balloon, much like a Foley catheter or a specialized tip that prevents dislodgement. The placement procedure may occur through endoscopy or laparoscopic surgery. Percutaneously placed feeding tubes are generally used when the patient will require ongoing enteral feeding, typically more than six weeks. They are considered semi-permanent, as the stoma will remain patent as long as a tube is in place. However, once the tube is removed, it usually closes quickly within a few days without surgical intervention [1]. Some g-tubes can be changed at home by a trained caregiver, while others must be changed by the physician.  

Jejunostomy tube (J-tube) 

J-tubes are indicated for the same conditions as ND/NJ tubes. Like g-tubes, they are a more permanent intervention and are placed through the abdomen directly into the jejunum. The provider must change J-tubes under fluoroscopy [6].  

Gastrostomy-Jejunostomy Tube 

Gastrostomy-Jejunostomy tubes (GJ tubes) are less commonly seen in clinical practice but are a valuable intervention for patients requiring enteral feeding and continuous gastric venting. Some medications may be administered via the gastrostomy port of the tube, and continuous feedings are typically administered through the jejunostomy port of the tube. It is important to note where the distal end of each port leads, as complications can occur if the incorrect port is used [1].   

Nursing Care 

Assessment 

Regardless of the type of enteral feeding tube used, the nurse must assess for tolerance of feedings. Vomiting, abdominal pain, diarrhea, abdominal distention, and insertion site problems are all indicators that the patient is not tolerating the enteral feedings. The tube site must be observed with each assessment to monitor skin integrity. Adhesive tapes and tube malfunctions can both cause skin breakdown.  

Once an NG, NJ, or OG tube is placed, the tube’s remaining visible length should be measured. The tube can migrate due to coughing, vomiting, or repositioning, so the placement should be verified before each use by confirming the tube length visible is consistent with the measurement observed when the x-ray confirmation was completed [7]. The tube itself should be assessed for signs of loss of integrity, like bumps on the tube, leaking, or pits/indentations on the tube [8].  

Fluid and Calorie Needs 

The amount of fluid and nutrition provided through the enteral feeding tube depends on several factors. The patient’s ability to tolerate more significant volumes, caloric needs, diagnosis, and fluid requirements must all be considered. A registered dietician typically determines the volume and type of formula the patient needs [1]. Those who are critically ill may initially require a lower caloric amount than usual to prevent hypoglycemia [9], while burn victims and infants with congenital heart defects may need a higher caloric concentration to accommodate the high energy consumption they experience due to their diagnoses.  

Site Care 

The tube insertion site must be cared for to prevent skin breakdown and infection. Employer policies regarding cleaning percutaneous insertion sites should be followed. Cleansing the insertion site with gauze dipped in warm water or saline is typically used [7]. The site should be allowed to air dry before securing the fixation plate or gauze dressing, if ordered. A barrier cream may be prescribed if there are issues with leaking around the tube site [7]. Any crust buildup on the NG or NJ tube at the nostril insertion site should be cleaned to prevent infection [1].  

Tube Care 

Feeding tubes must be replaced regularly according to the institution’s policy and the manufacturer’s recommendation. With most types of feeding tubes, this can be done at home by a trained caregiver or at the bedside [1]. Some types of tubes, like NJ and GJ tubes, must be replaced under fluoroscopy to ensure proper tip placement [9]. The tube should be flushed before and after feedings, medication administration, and at least once a day if not being utilized to preserve patency [1].  

Feeding Administration 

Enteral feedings are administered according to the physician’s order. There are several methods used to administer enteral feedings. Bolus intermittent feedings are administered over 5-10 minutes and typically include a water flush before and after the feeding. The risk of aspiration is higher with this method, so not every patient will be a candidate for this type of feeding. The head of the bed should be elevated to reduce the risk of aspiration. Bolus feedings can only occur when the distal tip of the feeding tube is placed in the stomach. Intermittent drip feeding occurs over an extended period, typically overnight, and often delivers a large volume.  

Continuous infusion feeding occurs when the feeding is administered via a feeding pump over 24 hours. This may be used for patients with incredibly low feeding tolerance or with tube placement in the duodenum or jejunum [9]. Feeding pumps can vary on how they function and how often the set used for administration must be changed. Some enteral feedings may be kept at room temperature longer than others. Refer to manufacturer instructions and facility policies for guidance.  

Trouble Shooting  

Any feeding tube can sometimes have problems. Below are some common issues and troubleshooting ideas.  

• Difficulty placing the tube: Try having the patient tuck their chin to their chest while slowly sipping water during tube placement. This may only be used for patients who can swallow and follow directions. At times, the tube may need to be placed with ultrasound guidance [1]. 

• Unable to flush the tube: First, ensure there are no kinks in the tubing and that the clamp on the tubing is not still closed (don’t feel bad—every seasoned nurse has experienced this!). Then, try using warm water to flush the tube. If that doesn’t work, infuse water into the tube via a syringe, using a back-and-forth plunging motion to dislodge any clogs. If the obstruction continues, follow the organizational policy for using enzymatic or mechanical declogging products [7]. 

• Feeding intolerance: If the patient complains of cramping during the feeding administration, try administering the formula at room temperature. Increasing feeding rate or volume can cause sudden feeding intolerance. Communication with the physician is essential to manage symptoms of intolerance [7].  

Safety Considerations 

Contraindications 

In some circumstances, enteral feeding is not preferred; in other instances, it is contraindicated. Enteral feeding is discouraged for patients experiencing moderate to severe malabsorption, diverticular disease, fistula in the small intestines, or early-stage short bowel disease. Enteral feeding is absolutely contraindicated for patients with poor end-organ perfusion, bowel ischemia, active GI bleeding, bowel obstruction, paralytic ileus, or peritonitis [9].  

Risks of Enteral Feeding 

There are risks to enteral feeding. Tube dislodgement can occur, requiring the tube to be replaced. Depending on the necessary method to replace the tube, the patient could miss feedings, fluid administration, or medication administration. Skin breakdown or sores can occur at the insertion site, which could be the nose, mouth, or abdomen [1]. Formula contamination due to manufacturing issues or poor storage techniques can cause infections [10]. The tube can become clogged or leak around the insertion site, which can also cause skin issues and loss of fluids.  

Bleeding can occur, though it is relatively rare. Aspiration can lead to pneumonia due to improper placement, backflow, or lower esophageal sphincter impairment. Gastroenteritis or peritonitis can occur.  Intolerance symptoms are a risk with enteral feeding, the most common being diarrhea. Refeeding syndrome can occur in patients who have experienced long-term malnutrition [9]. There are psychological side effects of receiving enteral feeding. Eating and gathering for meals is a vital part of many families and cultures, and the patient may miss the social aspects of sharing a meal [11]. 

Nursing Interventions for Safe Feeding 

There are techniques available that nurses can use to decrease the likelihood of complications related to enteral feeding. To reduce the risk of aspiration, the head of the bed should be elevated 30-45 degrees during and after feedings. Best practice guidelines recommend verifying the tube placement by tube measurement every four hours, observing for a change in length of the portion of the tube located outside of the body. A gastrointestinal assessment should also occur every four hours to monitor for intolerance [7].  

Communication with the multidisciplinary team can reduce the risk of complications and increase patient satisfaction [6]. Standard precautions should be observed when placing and using enteral feeding tubes to prevent infections. Proper storage techniques should be utilized. Many formulas are shelf-stable at room temperature but should be refrigerated after opening. Refer to the manufacturer’s instructions and employer policy to determine the length of time it is appropriate for the formula to remain in a continuous feeding set. Many healthcare facilities are transitioning to specific enteral feeding connector sets to avoid sentinel events associated with connecting the enteral feeding tubing to IV or surgical tubing.  

Nurses should also be aware of medications that should not be crushed for administration via an enteral feeding tube or that may interact with the feeding. Medications taken on an empty stomach must be scheduled with enteral feeding times considered [10]. 

Patient and Family Education  

Patients may be discharged with an enteral feeding plan for themselves or their family member. NG tubes are not typically used in home care due to the risk of aspiration but are seen at times. Most patients who receive an enteral feeding tube for home care will receive a percutaneous feeding tube. Depending on the patient, physician, and discharging facility, the caregivers may be taught to replace an NG or g-tube in the case of dislodgement. Other tubes will need to be replaced in the clinic or hospital.  

Caregivers should also be instructed on the schedule for changing the feeding tube. Caregivers must understand the feeding regimen, flush instructions, and site care requirements. Before discharge, they must demonstrate any skills needed, such as utilizing the feeding pump or administering medications via a g-tube. Nurses must educate the caregivers regarding who to call if there is a problem with the enteral feeding at home. Nurses can teach caregivers to unclog tubes with warm water but also educate them to bring the patient to the clinic or emergency department if they are unable to unclog the tube. Caregivers should never attempt to unclog the tube by inserting any wire into it [1].  Verbalizing understanding and return demonstrations are essential to enteral tube feeding patient education.  

Conclusion

While enteral feeding is not a preferred method of ingesting food, it is a vital and often life-saving intervention. Nurses must be aware of the equipment that may be used and evidence-based techniques to ensure optimal patient outcomes. Risks and complications are inherent with enteral feeding, but appropriate knowledge and best–practice nursing interventions can reduce the risk of adverse outcomes. Nurses are essential in ensuring interventions are completed skillfully, that patients receive relevant education, and reassuring patients and caregivers that receiving balanced nutrition through enteral feeding can improve their health outcomes.  

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