OSCE: Enteral Feeding Flashcards
Outline the steps for the assessment prior to administering enteral feeds? (8)
1) Perform hand hygiene before patient contact.
2) Introduce yourself to the patient.
3) Verify the correct patient using two identifiers.
4) Assess the patient’s need for enteral tube feedings and consult with the nutrition support team or practitioner. These conditions and circumstances
may require tube feedings:
- Decreased level of consciousness
- Head or neck surgery
- Facial trauma
- Impaired swallowing
- Prolonged nothing-by-mouth (NPO) status
- Inability to ingest required nutrients orally
- Failure to meet nutritional needs from oral feedings
- Another nutritional deficit
5) Assess the patient for food sensitivities and allergies (e.g., lactose intolerance, celiac disease, soy allergy).
6) Perform an abdominal assessment that includes bowel sounds, distention,
discomfort, and signs of feeding intolerance.
- Absent bowel sounds are not a contraindication to feeding, but report this finding and other changes from baseline
assessment findings to the practitioner to determine if feeding
can proceed safely.
7) Verify the patient’s actual admission weight in kilograms. Reweigh the patient if appropriate.
8) Assess the patient for signs and symptoms of fluid, electrolyte, and
metabolic abnormalities. Check for laboratory values that indicate these
conditions.
Outline the steps for the preparation for administering enteral feeds? (3)
1) Verify the practitioner’s order for the formula, rate, route, and frequency.
2) Use enteral devices (tubes, syringes, administration and extension sets)
with enteral connectors that comply with ISO standard 80369-3 (ENFit).
3) Use aseptic technique when handling enteral formula, administration sets, and feeding tubes.
Outline the steps for the procedure for administering enteral feeds? (14)
1) Perform hand hygiene and don gloves.
2) Verify the correct patient using two identifiers.
3) Explain the procedure to the patient and ensure that he or she agrees to
treatment.
4) Prepare the feeding container and tubing or prepare the feeding pump set or gravity bag with tubing as ordered.
a. Check the formula expiration date and the integrity of the container.
b. Identify and confirm the EN label.
c. Ensure that the formula is at room temperature.
d. Connect the tubing of the administration set to the prefilled container or prepare the feeding pump set or gravity bag with tubing.
i. When connecting and hanging the feeding system (including
the bag, connections, and tubing), use aseptic technique to
avoid contaminating it.
ii. Ensure that the correct tubing is used. Do not use IV tubing or IV pumps for enteral
feedings.
e. Shake the formula container well.
f. If administering canned formula, wipe the top with an alcohol swab
and let it dry before opening and pouring the formula into the administration bag. When filling a feeding container bag with formula, pour only the amount needed for 4 to 8 hours of
feeding.
- In an open system, a maximum hang time of 4
hours for reconstituted powder formula and 8 hours for canned
premixed formula reduces the risk of bacterial colonization.
g. Label the bag with patient information, enteral access type, and the tube feeding formula type, strength, and amount. Include the date
and time and initial it.
h. Label commercial enteral containers “Not for IV Use” to decrease
the risk of an enteral misconnection.
i. Open the roller clamp on the tubing or use the priming function on
the tube feeding pump to fill the tubing with formula. Close the roller
clamp and cap the end of the tubing.
j. Label the administration set “Tube Feeding Only” or use the label provided by the manufacturer.
k. Hang the bag on the feeding pole.
5) Place the patient in the high-Fowler position or elevate the head of the bed (HOB) 30 to 45 degrees. Place a patient who must remain supine in reverse Trendelenburg position.
6) Verify the placement of the enteral feeding tube every 4 hours, using
observation of tube length, observation of gastric aspirate, pH testing of gastric aspirate, or capnography per the organization’s practice.
- Obtain radiographic confirmation before the first use for feeding or when the tube’s location is in doubt.
a. If the patient has a nasoenteric tube and is receiving gastric or
small bowel feedings and tube displacement is suspected, check the patient’s gastric residual volume (GRV).
i. Draw 30 ml of air into a 60-ml enteral syringe, attach the syringe to the proximal end of the enteral feeding tube, and
inject the air into the tube.
ii. Draw back on the syringe slowly and aspirate the total
amount of gastric contents. If necessary,
reposition the patient to facilitate the withdrawal of fluid from the tube.
iii. Note the amount of gastric aspirate. Observe the volume of aspirate for changes. A large increase in gastric volume may indicate the
displacement of a small bowel feeding tube upward into the stomach.
b. Return aspirated gastric contents to the stomach unless the volume exceeds 500 ml or an amount determined by the organization’s
practice or practitioner’s order.
c. Flush the tube with 30 ml of water.
7) Initiate the feeding at the ordered volume, frequency, and rate on the pump or with the roller clamp.
a. Perform these steps for intermittent enteral feeding administration
i. Pinch the proximal end of the feeding tube and remove the cap.
ii. Trace tubing or catheter from the patient to point of origin (1)
before connecting or reconnecting any device or infusion, (2) at any transition (e.g., new setting), and (3) as part of the hand-off process.
iii. Attach the distal end of the primed administration set tubing to the proximal end of the feeding tube.
iv. Do not force connections and avoid workarounds.
v. Check vital signs immediately after making any connection
per the organization’s practice.
vi. Set the rate using a tube feeding pump or by adjusting the administration set roller clamp and allowing the bag to empty gradually over 30 to 60 minutes or as ordered.
b. Perform these steps for continuous enteral feeding administration:
i. Trace tubing or catheter from the patient to point of origin (1) before connecting or reconnecting any device or infusion, (2) at any transition (e.g., new setting), and (3) as part of the hand-off process.
ii. Connect the distal end of the primed administration set
tubing to the proximal end of the feeding tube.
iii. Do not force connections and avoid workarounds.
iv. Check vital signs immediately after making any connection per the organization’s practice.
v. Connect the tubing through the tube feeding pump (if not already in place), open the roller clamp on the tubing, set the rate on the pump, turn on the pump, and check the alarm
function.
8) Gradually advance the rate of the feeding.
9) Keep the HOB elevated at 30 to 45 degrees during intermittent and
continuous enteral feeding administration, after a bolus or intermittent feeding, and after a continuous feeding is stopped for any reason.
- When the patient cannot tolerate a backrest elevated position, use reverse Trendelenburg position to elevate the HOB, unless contraindicated.
10) Use purified or sterile water for flushing and medication preparation. Use sterile water for reconstituting powdered formula and for all procedures that involve immunocompromised patients.
11)Flush the feeding tube.3
a. After the administration of medications or formula, clear the tube by
flushing with a minimum of 15 ml of purified or sterile water.
b. Flush with 30 ml of water after GRV measurements.
c. Flush with a minimum of 30 ml of water before and after feedings and every 4 hours during continuous feedings.
12) Clamp and cap the proximal end of the feeding tube if the patient is receiving intermittent tube feedings.
13 ) Discard supplies, remove gloves, and perform hand hygiene.
14) Document the procedure in the patient’s record.
Outline the steps for the monitoring and care of enteral feeds? (12)
1) Monitor the patient’s laboratory values, including blood glucose levels, especially for patients at risk of glycemic shifts (e.g., those with diabetes,
renal failure).
2) Monitor intake and output.
3) Consult the practitioner for orders regarding supplemental electrolyte-free
water.
4) Weigh the patient daily until caloric intake goals are met and tolerance is established. Then weigh him or her less frequently per the organization’s practice.
- If necessary, take steps to unclog the enteral feeding tube.
a. Instill warm water into the EAD using a 30- or 60-ml syringe and
apply a gentle back-and-forth motion with the plunger of the
syringe. For children, use a smaller syringe as appropriate.
b. If water flush does not resolve the clog, use an uncoated pancreatic enzyme solution.
i. Crush one uncoated pancreatic enzyme tablet and one 325-
mg sodium bicarbonate tablet, then mix the crushed tablets
into 5 ml of water.
ii. Add the solution to the clog and clamp the feeding tube for at
least 30 minutes.
iii. If the clog is not cleared in 30 minutes, remove the solution
from the tube and replace it with a fresh mixture.
c. If water flush or pancreatic enzyme solution does not resolve the clog, use an enzyme-containing declogging kit or mechanical declogging device.
- Notify the practitioner if the obstruction is not relieved.
6) Monitor the patient’s respiratory status.
- Notify the practitioner of a change in respiratory status.
7) Monitor the patient’s level of comfort.
8) Assess, treat, and reassess pain.
9) Auscultate bowel sounds and monitor them for trends and changes.
10) Change the formula in an open enteral feeding system every 4 to 8 hours. Change the formula in a closed enteral feeding system per the manufacturer’s instructions.
11) Change the enteral feeding container and tubing for an open enteral feeding system according to the manufacturer’s instructions. Change the
tubing for a closed enteral feeding system according to the manufacturer’s
instructions.
- Do not reuse the enteral delivery devices for open or closed
feeding systems.
12) Assess the patient every 24 hours for signs of feeding tolerance (e.g., presence of flatus and stool, absence of abdominal distention or pain).
a. Check the GVR if the patient’s condition changes and feeding
intolerance is suspected.
i. Draw 30 ml of air into a 60-ml enteral syringe, attach the syringe to the proximal end of the enteral feeding tube, and inject the air into the tube.
ii. Draw back on the syringe slowly and aspirate the total
amount of gastric contents. If necessary,
reposition the patient to facilitate the withdrawal of fluid from the tube.
iii. Note the amount of gastric aspirate. Observe the volume of
aspirate for changes.
b. Return aspirated gastric contents to the stomach unless the volume exceeds 500 ml or an amount determined by the organization’s
practice or practitioner’s order.
c. Implement measures to reduce the risk of aspiration, but do not
hold the feeding for a GRV less than 500 ml in the absence of other
signs of intolerance (e.g., patient report of abdominal discomfort,
bloating, gas, vomiting).
- Notify the practitioner if the GRV is greater than 500 ml because other measures, such as repositioning the tube
to a more distal postpyloric location or administering a
prokinetic agent, may be indicated.
d. Flush the tube with 30 ml of water.
