Which action is used to check the placement of a feeding tube before administering feeding?
The practice of administering drugs via enteral feeding tubes has become complex. Show
AbstractVOL: 99, ISSUE: 46, PAGE NO: 46 Kate Pickering, BA, RGN, DipN, is nutrition nurse specialist, Leicester General Hospital, University Hospitals of Leicester NHS Trust. She is also vice chair of the National Nurses Nutrition Group
The range of enteral feeding tubes and medicines has increased dramatically in recent years and this has led to a gap between clinical practice and best practice (Naysmith and Nicholson, 1998; Seifert et al, 1995). Facts about enteral feeding tubesEnteral feeding tubes are designed to provide access to the lumen of the stomach or jejunum. They are designed to bypass dysfunction and obstruction, reduce discomfort or remove the need for patients to actively eat. The lumen of a narrow enteral tube has the potential to occlude and once occluded can be difficult to unblock. If enteral tubes not designed for long-term feeding are used for this purpose, they can develop problems associated with the integrity of the materials used to manufacture the tube, or the tube design. It is therefore important when caring for a patient with an enteral feeding tube to know the type of material the tube is made of. Administration of medicines via an enteral feeding tubeThe type of tube and the abbreviation used should be standardised for the hospital or unit, for example ‘nasogastric tube’ (NG). It is important to know where the tip of the enteral feeding tube lies and therefore the site for drug administration. The position of the tip may affect the type of feed that can be used and the absorption of some drugs. Know your drugThe route stated on the patient’s prescription chart should match the type of enteral tube and the placement of the tip of the enteral tube in the gastrointestinal tract, for example, nasogastric (NG), percutaneous endoscopic gastrostomy (PEG) or nasojejunal (NJ). Never assume that a drug can be given via a feeding tube - always ask a pharmacist for advice. In order for the drug to have bioavailability (be able to be absorbed and used), it must be delivered to the correct part of the gastrointestinal tract. If a drug designed for absorption in the stomach is placed directly into the jejunum, this may compromise its overall effect. For example, digoxin is primarily absorbed in the stomach, therefore administering digoxin via a jejunal tube may significantly reduce the rate of absorption. Drug doses may alter if the formulation of a drug is changed. For example, if a prescription of a drug is changed from a slow-release formulation to a liquid, the drug dose and the frequency may need to be recalculated. Not all liquid drug preparations are suitable for enteral tube administration. The osmolality of some drugs may be high (causing fluid to be drawn into the gastrointestinal tract) and some preparations contain sorbitol. Both of these may cause diarrhoea and hence failure of drug absorption. If the drugs do not appear to be working or the patient experiences diarrhoea, the pharmacist and dietitian should review the patient’s medicines and feeding regime. Enteral feeds may bind with some drugs and stop their absorption. For example, it is important to stop the enteral feed for two hours before phenytoin is administered via an enteral feeding tube and for two hours afterwards. Before and after administration the tube should be flushed with water to prevent the drug binding to the feed and dramatically reducing serum levels. Adding drugs directly to a feed container can lead to contamination. It can also destabilise the feed or the drug and lead to chemical interactions. Procedure for drug administration via an enteral feeding tubeBefore administering a drug via an enteral feeding tube, it is important to:
Administering the drug
ConclusionVariations in practice do exist and the British Association for Parenteral and Enteral Nutrition (BAPEN) guidelines attempt to provide a safe method of drug prescription and delivery that will maximise effectiveness of the drug therapy. Altering drugs - for example by crushing - for administration in enteral feeding tubes may not be covered by the drug manufacturer’s licence. It is important to remember that the person administering the drug takes responsibility for complications that arise from his or her actions. FURTHER INFORMATION A large wall poster, Administering Drugs Via Enteral Feeding Tubes: A Practical Guide, provides clear, easily accessible information for use in areas such as hospital drug preparation rooms, nursing homes and GP surgeries. This is complemented by the leaflet Tube Feeding and Your Medicines - A guide for Patients and Carers. This records tube details, hospital contact points and medication information with an advice column for soluble tablets and dilution. This record will be completed by the multidisciplinary team in acute hospitals as part of the patients’ discharge back into the community. The leaflet Drug Administration Via Enteral feeding Tubes - A Guide for General Practitioners and Community Pharmacists explains the need for guidance, preferred formulations, legal implications, drug interactions, tube blockage, and other information. For copies of leaflets and posters from the British Association for Parenteral and Enteral Nutrition, contact the BAPEN office on tel: 01527 457850 or visit: www.bapen.org.uk When should the placement of a feeding tube be verified?After feedings are started, tube location should be checked at four-hour intervals.
What do you assess for when a patient is receiving tube 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 verification is done when feeding tubes are first positioned?Ultrasound. The use of ultrasound at the neck can confirm NGT position in the esophagus and its use at the epigastrium can confirm a stomach placement.
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