Editing Nutrition (section)

== Enteral Nutrition ==

Enteral nutrition delivers formula directly into the gastrointestinal tract. The governing principle is: '''if the gut works, use it.''' Enteral feeding preserves gut mucosal integrity, reduces bacterial translocation, costs less, and carries lower infection risk than parenteral nutrition.

=== Access Routes ===

* '''Nasogastric and orogastric tubes:''' short-term, generally under 4 to 6 weeks.
* '''Nasoduodenal and nasojejunal tubes:''' post-pyloric placement for patients with gastroparesis, high aspiration risk, or pancreatitis.
* '''Gastrostomy (PEG) and jejunostomy (PEJ) tubes:''' long-term access placed surgically, endoscopically, or radiologically.

=== Delivery Methods ===

* '''Bolus:''' a set volume delivered over about 15 minutes by syringe several times daily. Most physiologic and allows mobility, but is least tolerated.
* '''Intermittent:''' a set volume over 30 to 60 minutes by gravity or pump.
* '''Continuous:''' pump-delivered over 12 to 24 hours. Best tolerated and required for post-pyloric feeding, because the small bowel has no reservoir capacity.
* '''Cyclic:''' continuous infusion over a compressed window, often overnight, to allow daytime freedom or to promote appetite.

=== Nursing Management of Tube Feeding ===

# '''Verify placement.''' Radiographic confirmation is the gold standard after initial insertion of a blindly placed tube and before the first use. Thereafter, check the exit-site marking on the tube, measure the external tube length, and assess gastric aspirate. Auscultating an air bolus over the epigastrium is '''not''' a reliable method and is no longer recommended. Gastric aspirate pH is typically 5.5 or lower, though acid-suppressing medications raise it.
# '''Elevate the head of the bed to 30 to 45 degrees''' during feeding and for at least 30 to 60 minutes afterward. This is the single most important aspiration precaution.
# '''Check gastric residual volume''' per institutional policy, typically every 4 to 6 hours during continuous feeding. Current guidance from professional societies is not to hold feeding for a residual under 500 mL in the absence of other signs of intolerance, but many facilities still use 250 to 500 mL thresholds. Return the aspirate unless policy directs otherwise, since discarding it discards electrolytes.
# '''Flush the tube''' with 30 mL of water before and after each feeding and each medication, every 4 hours during continuous feeding, and any time the feeding is interrupted. Water is the flush of choice. Cranberry juice and cola are not effective and can worsen clogging.
# '''Give medications separately.''' Crush immediate-release tablets finely and dissolve them, or use liquid forms. '''Never''' crush enteric-coated, sustained-release, or extended-release formulations. Flush between each medication.
# '''Hang time.''' Discard open ready-to-hang formula per policy, generally within 24 to 48 hours for closed systems and within 4 to 8 hours for decanted or reconstituted formula. Change the administration set every 24 hours.
# '''Formula temperature.''' Administer at room temperature. Cold formula causes cramping and diarrhea.
# '''Monitor''' daily weight, intake and output, glucose, electrolytes, bowel pattern, and abdominal distention.

=== Complications ===

{| class="wikitable"
! Complication !! Cause !! Nursing action
|-
| Aspiration pneumonia || Reflux of formula, flat positioning, impaired gag reflex || '''Stop the feeding immediately''', turn the patient to the side, suction, administer oxygen, assess breath sounds and oxygen saturation, and notify the provider. This is the priority complication.
|-
| Diarrhea || Rapid infusion rate, hyperosmolar formula, cold formula, sorbitol-containing or hyperosmolar medications, antibiotic-associated ''Clostridioides difficile'', low fiber || Slow the rate, check medications, obtain stool studies if infection is suspected, consider a fiber-containing formula
|-
| Constipation || Inadequate free water or fiber, immobility, opioids || Increase free water flushes, consider fiber formula, mobilize
|-
| Tube occlusion || Inadequate flushing, crushed medications, formula residue || Flush with warm water using a gentle push-pull technique with a large syringe. Never force with a small-barrel syringe, which generates high pressure and can rupture the tube.
|-
| Dehydration and hypernatremia || Insufficient free water; formula is not all water || Calculate and provide free water; monitor sodium and BUN
|-
| Hyperglycemia || High carbohydrate load, stress response, steroids || Monitor glucose, adjust formula or insulin
|-
| Nausea and high residuals || Delayed gastric emptying, rapid rate || Reduce rate, consider post-pyloric access or a prokinetic agent
|-
| Tube dislodgement || Traction, agitation || For a mature gastrostomy tract, cover and notify the provider promptly, since the stoma can begin to close within hours. Do not blindly reinsert unless trained and authorized.
|}