Equipment
|
Assessment
- Wash and dry hands
- Introduce self to patient and check ID band
- Check patient records for food allergies
- Check length of exposed tube for proper placement and ensure length correlates to post x-ray placement. If there is a significant length difference tube must be re-checked by radiology
- Assess fluid status by checking lung sounds, skin turgor, mucous membranes, I&O, and edema
- Obtain baseline weight and labs
- Monitor vitals before and after feedings
- Auscultate for bowel sounds before each feeding or every 4 to 8 hr for continuous feeding
- Check for distension, nausea, vomiting, and diarrhea
Key Points
- Check MAR for prescription for formula type, rate, route and frequency of feeding
- Check formula for expiration date and color/consistency
- Confirm tube placement at bedside by:
- Measuring pH of aspirate
- Changes in residual volume
- Observing length of exposed tube
- Injecting air into the tube and auscultating for the "Whoosh"
- Asking patient to speak
- Elevate HOB at least 30 to 45 degrees while administering feedings and for one hour after administration
- Check residual before intermittent feedings
- For continuous feeding: check gastric residual volume at least once every shift. If the residual is 10% greater than the formula flow rate for one hour or > 150 mL hold the feeding for one hour and recheck. Notify provider if residual is not within normal limits
- Flush tubing with 30 - 50 mL before and after each feeding, and every 4 hours for continuous feeding, and for every medication administration
- Label and hang the bag, prime the tubing and thread it through the pump, regulate the drip rate, or elevate the syringe to feed with an open-system syringe
- REMEMBER TO UNCLAMP THE TUBING!!!!
- Change tube feeding administration set and other supplies every 24 hours
- Continuous feedings should be infused by pump
Post-Procedure Assessment
- Assess tolerance to feeding
- Assess bowel sounds and vital signs every 4 hours
- Check gastric residual volume every 4 hours
- Monitor I&O every 8 hours
- Weigh patient at least 3 times per week
- Monitor the site for skin breakdown
- Assess frequency of bowel movements
- Check lab values to evaluate nutritional status
Documentation
- Chart the type of tube feeding, rate and volume of infusion, amount of gastric residual volume, and tolerance of procedure
- Document feeding amount on the I&O flowsheet
- Record all flushes as intake: subtract any liquids that were aspirated and do not reinstill