Editing Nursing Skills and Procedures (section)

== Enteral Nutrition and Tube Feeding ==

=== Tube types ===
Nasogastric and orogastric tubes are short-term, generally under four to six weeks. Gastrostomy and jejunostomy tubes are surgically or endoscopically placed for long-term feeding. Small-bore feeding tubes are more comfortable but collapse with aspiration and clog easily. Large-bore sump tubes such as the Salem sump are used for decompression, and the blue air vent, the pigtail, is kept above the level of the stomach and is never clamped or used for irrigation.

=== Verifying placement ===
Radiographic confirmation is the gold standard after initial blind insertion and before the first use of a small-bore tube. Before each feeding or medication administration thereafter, the nurse aspirates gastric contents and checks pH. A pH of about 5.5 or lower supports gastric placement, although acid-suppressing medications raise gastric pH and reduce the reliability of this test. The nurse also measures the external tube length and compares it with the documented insertion mark. Auscultation of an air bolus over the epigastrium, the "whoosh" test, is not reliable and is not acceptable practice. Any new coughing, choking, voice change, or falling oxygen saturation demands that feeding stop and placement be reverified.

=== Administration ===
* Head of bed elevated 30 to 45 degrees during feeding and for at least 30 to 60 minutes afterward, unless contraindicated. This is the single most important aspiration precaution.
* Check gastric residual volume per policy. Traditional thresholds hold feeding for a residual above 500 mL and prompt closer assessment between about 200 and 500 mL. Current critical care guidance discourages routine residual checks as the sole marker of tolerance; assess for distension, nausea, vomiting, and bowel sounds as well. Return aspirated contents per facility policy to avoid electrolyte and acid loss.
* Flush with about 30 mL of water before and after feeding and medications and every four to six hours during continuous feeding, and use warm water, not cola or juice, to relieve or prevent clogging.
* Formula hangs no longer than the manufacturer's stated time, commonly four to eight hours for open systems, and the container and tubing are changed per policy.
* Give medications one at a time in liquid form when available, flushing between each. Do not crush enteric-coated, sustained-release, or extended-release forms, and do not add medications directly to the formula bag.
* Hold enteral feeding for one to two hours before and after phenytoin, because the formula markedly reduces its absorption.

=== Complications ===
Diarrhea is the most common complication and prompts evaluation of formula osmolarity, rate, sorbitol-containing medications, and infection rather than immediate discontinuation. Dumping syndrome, seen especially with jejunal feeding and hyperosmolar formula, produces cramping, diaphoresis, tachycardia, and diarrhea shortly after feeding. Refeeding syndrome occurs when nutrition is restarted in a severely malnourished patient and produces a dangerous drop in phosphate, magnesium, and potassium with cardiac and respiratory failure; start slowly and monitor electrolytes. Aspiration is the most dangerous complication: stop the feeding immediately, turn the patient to the side, suction, provide oxygen, assess breath sounds and saturation, and notify the provider.