Enteral Tubes

3
CE
HOURS
Continuing Education
What you think are the best practices may not be.
By Deanna L. Reising, PhD, APRN,BC,
and Ronald Scott Neal, BSN, RN
lushing an enteral tube (in other words, keeping it free of buildup) is essential because unclogging one wastes time, effort, and resources. And tubes
that can’t be unclogged have to be replaced, taking up even more nursing
time, not to mention those resources—the new tube, the X-ray to confirm
tube placement—that can cause the patient discomfort or injury and, of
course, interrupt the delivery of crucial nutrition.
Water is generally considered to be the best liquid for flushing, but there is little
agreement on how much fluid to use, how often tubes should be flushed, or how
to flush when administering medication. In order to shed some light on the best
methods of flushing enteral tubes, we reviewed the available literature and current
practices.
F
DATA COLLECTION
We took several approaches to examining the evidence. We contacted nursing education departments at 19 hospitals in Indiana to determine what, if any, practices
were mandated at these institutions. We also conducted a search of nursing
research and other review articles published between 1982 and 2002; for this we
used the Cumulative Index to Nursing and Allied Health Literature. Using
Medline, we searched medical and allied health research and nonresearch articles
published in the same period; ultimately, we reviewed 21 articles. Finally, we
searched for recommended practices in textbooks by major publishers that were
Deanna L. Reising is an assistant professor at the Indiana University School of Nursing, Bloomington, and
Ronald Scott Neal is a staff nurse on the critical care unit, Columbus Regional Hospital, Columbus, IN. The
project the authors describe was funded by a grant from the Indiana University Undergraduate Research and
Creative Activity Partnership. Contact author: Deanna L. Reising, [email protected]. The authors of this article have no ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity.
58
AJN ▼ March 2005
▼
Vol. 105, No. 3
http://www.nursingcenter.com
used in nursing courses—medical–surgical nursing,
fundamentals, nursing pharmacology, and nursing
nutrition. Nineteen textbooks were reviewed. We
focused on routine and special flushing procedures,
including those used to relieve occlusions, for
patients receiving nutrition or medication through
enteral tubes.
WHAT ARE NURSES DOING?
As enteral tube flushing is under the clear purview of
nursing, it’s important to understand how it is generally accomplished. The results of our review reflect
the variety of techniques nurses use in their practice.
Nursing practices. In 1996 Mateo published the
results of a study investigating nurse management
of enteral tubes.1 This research identified the main
practices that nurses use when caring for patients
with enteral tubes. Of the 180 nurses who
responded to the 43-item questionnaire, 94%
reported regularly flushing enteral feeding tubes;
29% of these flushed before feedings; 43% of them
flushed after feedings; and 59% of them flushed
every four hours. Nurses also flushed when administering medication: 47% of respondents reported
flushing before giving medications, 95% flushed
after giving medications, and 38% did so between
medications. Respondents reported using tap water,
sterile water, and sterile normal saline as fluids for
routine flushing. Fluids used to unclog enteral tubes
included carbonated beverages (81%), sterile water
(49%), papain solution (46%; papain is a papaya
extract used in meat tenderizers that acts as a pancreatic enzyme, breaking down proteins), and tap
water (42%).
Although experts routinely emphasize the importance of flushing before and after medication administration, a study reported that only 69% of nurses
flushed before medication administration through
enteral tubes; 98% of nurses flushed the enteral
tube after administering medication.2 This variance
in practice may or may not contribute to clogged
enteral tubes—there is no research in this area.
Institutional practices. When we contacted the 19
Indiana hospitals to ascertain their policies and procedures concerning enteral tube flushing, we found
that institutions address this subject in a variety of
ways. Of the hospitals surveyed,
• 10 had no formal policy on flushing enteral
tubes.
• three followed flushing procedures outlined in
the textbook Nursing Procedures (published by
Springhouse).
• two required a clinician’s orders for fluids and
volumes.
• one required the use of sterile water but had no
volume standard.
• one had no written standard, but the educator
recommended 60 mL of tap water for flushes.
[email protected]
Two important studies
established water as the
accepted flushing fluid
and deemed cranberry
juice ineffective.
• one required 150 mL of water to be administered
before and after feedings or medications being
passed through the tubes.
• one specified 30 to 50 mL of water to be given
every four hours.
A REVIEW OF THE LITERATURE
How do these reported practices reflect what’s in
the literature?
Flushing during enteral tube feedings. Two
important studies established water as the accepted
flushing fluid and deemed cranberry juice ineffective.3, 4 Water was also the flushing fluid most often
suggested in textbooks; only two didn’t recommend
a specific fluid.5, 6
Recommendations on the amount of fluid used
and the frequency and timing of flushing vary. In
patients receiving continuous feedings, the amount
of fluid recommended for flushing ranged from 20
to 100 mL, and the suggested frequency of flushing
ranged from every four hours to every eight hours.
In patients receiving intermittent or bolus feedings,
the amount of fluid recommended ranged from 15
to 100 mL, and sources recommended flushing both
before and after feeding. While a determination of
the amount of fluid used, also called the “flush volume,” must take into account the patient’s needs and
restrictions, nurse expert Norma Metheny pointed
out in a personal communication that “the larger the
AJN ▼ March 2005
▼
Vol. 105, No. 3
59
Gastrostomy tube
Abdominal
wall
Gastrostomy
button
X
Entry Site
Stomach
Duodenum
Gastrojejunostomy
(through-the-stomach
jejunostomy) tube
Jejunum
flush volume, the more likely the tube is to remain
patent.” Finally, many sources specified that the fluid
used to flush should be warm or tepid.6-9
Flushing between enteral medication administrations. Research and review articles have linked
enteral tube clogging to the administration of med60
AJN ▼ March 2005
▼
Vol. 105, No. 3
ication.10, 11 Scanlan and Frisch found that the number of enteral tube occlusions was greatly reduced
by flushing with water before and after medication
administration.10 While all the literature examined
recommended flushing with water between enteral
medication administrations, there are differences of
http://www.nursingcenter.com
Enteral Tubes
nteral tube feeding may be indicated when a
patient cannot receive adequate nutrition orally.
This inability can result from trauma, congenital
dysphagia, impaired swallowing caused by neurologic conditions, or obstruction or tissue destruction
caused by neoplasms. Metabolic disorders or
absorption problems may necessitate enteral feeding, as well.
Short-term feeding (of less than four weeks’ duration)
can be managed with a nasogastric tube. The most
commonly used tubes for long-term feeding are pictured
at left: the gastrostomy tube, the gastrostomy button,
and the gastrojejunostomy tube. A number of factors
dictate the choice of tube, including the expected duration of feeding, the condition necessitating the feeding,
concomitant conditions, and clinician preference.
Percutaneous endoscopic gastrostomy (PEG) is
the most common method of tube insertion because
of its safety and effectiveness; it’s associated with low
rates of morbidity and mortality and decreased costs
because surgery and general anesthesia aren’t necessary for tube insertion. The tube is placed under
direct endoscopic visualization through an abdominal incision and anchored in place with an outer
flange and an inner bumper or balloon.
The gastrostomy tube feeds directly into the stomach and poses fewer risks of serious adverse effects
than the gastrojejunostomy tube.
The gastrojejunostomy tube, the through-thestomach jejunostomy tube, delivers its contents into the
jejunum and is indicated in patients with recurrent
aspiration, upper gastrointestinal obstruction or fistula,
gastroparesis, and gastroesophageal reflux. It cannot
be used in patients with small-bowel disease because
it can cause enterocutaneous fistulae. And because
these are smaller-bore tubes they tend to clog more
often than gastrostomy tubes, requiring more frequent
tube flushing or replacement.
The gastrostomy button came along in 1984 in an
effort to prevent some of the chronic complications of
gastrostomy tubes—clogging, leakage, and skin irritation. The button is skin level and out of site when
the patient is dressed. It usually replaces a gastrostomy tube four weeks after initial PEG (this period
ensures a mature tract). Recent advances have
allowed for primary button insertion if gastropexy
(attachment of the stomach to the abdominal wall) is
also performed at the time of insertion; long-term
results of this procedure aren’t known.
Patients with any type of tube placement must be
assessed for leakage (high abdominal pressure, as
occurs with sneezing or coughing, often causes some
normal leakage), skin irritation, infection, and formation of granulation tissue. Nutrition and hydration status, and signs or symptoms of aspiration, pneumonia,
or gastrointestinal complications such as bleeding or
peritonitis, must be assessed as well. Time spent with
the patient while flushing and assessing tubes is an
excellent opportunity for educating patients and caregivers on care of the gastrostomy tube. It’s also
important to offer support as patients adjust to
changes in body image and the loss of the pleasures
of eating.—Karen Roush, MSN, NP, clinical editor
opinion as to the amount of water to use and when
the flushing should be done.
Special considerations for small-bore enteral
tubes. Most resources we consulted didn’t distinguish
between large- and small-bore tubes. But Perry and
Potter specified that a small-bore tube required 30 mL
of normal saline or tap water for flushing, while largebore tubes required 5 to 15 mL more than that.12, 13
Kohn-Keeth emphasized that small-bore tubes should
be flushed with water every four hours.14 We found no
research conducted on this topic.
Checking feeding residual has been shown to
increase the incidence of tube clogging.15 When some
enteral formulas, such as protein formulas, mix with
low-pH gastric juices, sediment may form and collect
in tubes, possibly leading to occlusions; as a result,
the practice of flushing after checking for feeding
residuals is gaining wider acceptance.7, 9, 12, 14, 16-19 It
should be emphasized that nurses should not stop
checking for residuals—frequent flushing with
water has been shown to prevent tube occlusion
after this important procedure.
Flushing fluids were compared in two now-classic
studies published in the 1980s. Both sought to determine which fluids were the most effective in preventing occlusion. Metheny and colleagues compared
water, Coca-Cola, and cranberry juice.3 They found
that water and Coca-Cola were superior to cranberry juice. Wilson and Haynes-Johnson compared
the efficacy of water and cranberry juice, ultimately
concluding that water was “a more effective irrigant.”4 In that study, 73% of the tubes flushed with
cranberry juice became occluded, while none of the
tubes flushed with water did. The influence of these
two studies has been enormous: their recommendations are reflected in almost all of the resources sur-
The three most commonly placed tubes.
E
[email protected]
AJN ▼ March 2005
▼
Vol. 105, No. 3
61
In Conclusion
following are some conclusions we have
from our review.
T hedrawn
Do
• flush at least every four hours: before,
between, and after medication administration;
before and after bolus feedings; and before
and after checking for gastric residuals.
• use a syringe that holds at least 30 mL of
fluid.
• flush with at least 30 mL of warm water.
• administer liquid forms of medications whenever possible.
• try pancreatic enzymes to unclog an occluded tube.
• develop a standard operating procedure on
tube flushing for nurses in your institution.
juice should not be used.25 Craven and Hirnle recommend intervention as soon as there is “difficulty”
flushing an enteral tube.8 The intervention recommended is flushing with water and, if water is ineffective, using 30 to 50 mL of a carbonated beverage.
Finally, it’s important to note that pancreatic
enzymes must be activated before use. Typically, a
tablet of the pancreatic enzyme and a 324-mg tablet
of sodium bicarbonate are dissolved in 5 mL of
warm water just before instillation into the
occluded tube.26
Syringe size for flushing. Both Guenter and Lord,
two experts in the field who associate tube rupture
with syringe size, say a syringe of 30 mL or greater is
needed to prevent rupture; other experts come to the
same conclusion.7, 9, 16 Two textbooks also support this
premise.19, 25 Although Lilly and Aucker recommend a
10- to 20-mL syringe for flushing small-bore tubes,27
these smaller syringe sizes are believed to cause tube
rupture because they generate considerable pressure.
We found no research on appropriate syringe size for
flushing; the only recommendations we found were
from sources that weren’t researched based.
Don’t
• force or apply excessive pressure when
flushing the tube.
• use a syringe that holds less than 30 mL.
• flush with cranberry juice.
• crush sustained-release or enteric-coated
medications.
• fail to activate pancreatic enzymes before
instillation into the tube.
• assume that all nurses are flushing tubes
correctly or consistently.
veyed in this review, with the exception of one.
While McKenry and Salerno suggest cranberry juice
as a flushing fluid,20 it’s important to note that this
recommendation isn’t supported by research and
does, in fact, contradict other research findings.
Unclogging occluded enteral tubes is covered in
various studies and textbooks. The findings of three
studies support the use of certain pancreatic enzymes to remove obstructions if water or a carbonated beverage has failed.17, 21, 22 One study also
demonstrated the effectiveness of administering
pancreatic enzymes in preventing tube obstruction.23
Of the textbooks that specify how to treat a
clogged enteral tube, two suggest water alone as the
remedy,6, 24 and two recommend water alone or
water in combination with a carbonated beverage.5,
25
Ignatavicius and Workman state that cranberry
62
AJN ▼ March 2005
▼
Vol. 105, No. 3
DISCUSSION
While there is some overlap in many of the recommendations in the literature, there is also significant
variance—possibly caused by conflicting evidence
in the nursing literature. According to a personal
communication from Norma Metheny, “the great
variability in the information presented in textbooks demonstrates that practical experience is
problematic. Standards should be written by
experts.”
In fact, more research is needed to determine the
best practices for routine enteral tube flushing. Studies to determine the preferred tube (large or small
bore) must also be performed. Essential to this
research will be determining the minimum amount of
fluid necessary to maintain tube patency. ▼
Complete the CE test for this article by
using the mail-in form available in this
issue or visit NursingCenter.com’s
“CE Connection” to take the test and find
other CE activities and “My CE Planner.”
REFERENCES
1. Mateo MA. Nursing management of enteral tube feedings.
Heart Lung 1996;25(4):318-23.
2. Seifert CF, et al. A nursing survey to determine the characteristics of medication administration through enteral feeding catheters. Clin Nurs Res 1995;4(3):290-305.
3. Metheny N, et al. Effect of feeding tube properties and three
irrigants on clogging rates. Nurs Res 1988;37(3):165-9.
4. Wilson M, Haynes-Johnson V. Cranberry juice or water?
A comparison of feeding-tube irrigants. Nutr Support Serv
1987;7(7):23-4.
5. Kee JL, Hayes ER. Pharmacology: a nursing process
approach. 4th ed. Philadelphia: Saunders; 2003.
http://www.nursingcenter.com
6. Springhouse Corporation. Nursing procedures. 3rd ed.
Springhouse, PA: Springhouse Corp.; 2000.
7. Lord LM. Enteral access devices. Nurs Clin North Am
1997;32(4):685-704.
8. Craven RF, Hirnle CJ. Fundamentals of nursing: human
health and function. 4th ed. Philadelphia: Lippincott
Williams and Wilkins; 2003.
9. Bowers S. All about tubes: your guide to enteral feeding
devices. Nursing 2000;30(12):41-7; quiz 48.
10. Scanlan M, Frisch S. Nasoduodenal feeding tubes: prevention of occlusion. J Neurosci Nurs 1992;24(5):256-9.
11. Petrosino BM, et al. Implications of selected problems with
nasoenteral tube feedings. Crit Care Nurs Q 1989;12(3):1-18.
12. Perry AG, Potter PA. Clinical nursing skills and techniques.
5th ed. St. Louis: Mosby; 2001.
13. Potter PA, Perry AG. Fundamentals of nursing. 5th ed.
St. Louis: Mosby; 2001.
14. Kohn-Keeth C. How to keep feeding tubes flowing freely.
Nursing 2000;30(3):58-9.
15. Powell KS, et al. Aspirating gastric residuals causes occlusion
of small-bore feeding tubes. JPEN J Parenter Enteral Nutr
1993;17(3):243-6.
16. Guenter P. Mechanical complications in long-term feeding
tubes. Nurs Spectr (Wash D C) 1999;9(12):12-4.
17. Marcuard SP, Perkins AM. Clogging of feeding tubes. JPEN
J Parenter Enteral Nutr 1988;12(4):403-5.
18. Peckenpaugh NJ, Poleman CM. Nutrition essentials and diet
therapy. 8th ed. Philadelphia: W. B. Saunders; 1999.
19. Smeltzer S, Bare B. Brunner and Suddarth’s textbook of
medical–surgical nursing. 9th ed. Philadelphia: Lippincott
Williams and Wilkins; 2000.
20. McKenry LM, Salerno E. Mosby’s pharmacology in nursing.
21st ed. St. Louis: Mosby; 2001.
21. Marcuard SP, et al. Clearing obstructed feeding tubes. JPEN
J Parenter Enteral Nutr 1989;13(1):81-3.
22. Nicholson LJ. Declogging small-bore feeding tubes. JPEN
J Parenter Enteral Nutr 1987;11(6):594-7.
23. Sriram K, et al. Prophylactic locking of enteral feeding tubes
with pancreatic enzymes. JPEN J Parenter Enteral Nutr
1997;21(6):353-6.
24. Grodner M, et al. Foundations and clinical applications of
nutrition: a nursing approach. 2nd ed. St. Louis: Mosby;
2000.
25. Ignatavicius DD, Workman ML. Medical–surgical nursing:
critical thinking for collaborative care. 4th ed. Philadelphia:
W. B. Saunders; 2002.
26. Marcuard SP, Stegall KS. Unclogging feeding tubes with pancreatic enzyme. JPEN J Parenter Enteral Nutr 1990;14(2):
198-200.
27. Lilley LL, Aucker RS. Pharmacology and the nursing
process. 2nd ed. St. Louis: Mosby; 1999.
3
CE
HOURS
Continuing Education
GENERAL PURPOSE: To examine current practice and
the recommended methods for keeping enteral feeding tubes free of buildup and functioning optimally.
LEARNING OBJECTIVES: After reading this article and
taking the test on the next page, you will be able to
• discuss previous research about enteral tube flush-
ing techniques.
• list appropriate evidence-based recommendations
for routine flushing of enteral feeding tubes.
• outline evidence-based recommendations for
declogging enteral feeding tubes.
To earn continuing education (CE) credit, follow these
instructions:
1. After reading this article, darken the appropriate boxes
(numbers 1–15) on the answer card between pages 48
and 49 (or a photocopy). Each question has only one
correct answer.
2. Complete the registration information (Box A) and help
us evaluate this offering (Box C).*
3. Send the card with your registration fee to: Continuing
Education Department, Lippincott Williams & Wilkins, 333
Seventh Avenue, 19th Floor, New York, NY 10001.
4. Your registration fee for this offering is $19.95. If you take
two or more tests in any nursing journal published by
Lippincott Williams & Wilkins and send in your answers to
all tests together, you may deduct $0.75 from the price of
each test.
Within six weeks after Lippincott Williams & Wilkins
receives your answer card, you’ll be notified of your test
results. A passing score for this test is 11 correct answers
(73%). If you pass, Lippincott Williams & Wilkins will
send you a CE certificate indicating the number of
contact hours you’ve earned. If you fail, Lippincott
Williams & Wilkins gives you the option of taking the
test again at no additional cost. All answer cards for this
test on “Enteral Tube Flushing” must be received by March
31, 2007.
This continuing education activity for 3 contact hours
is provided by Lippincott Williams & Wilkins, which is
accredited as a provider of continuing nursing education (CNE) by the American Nurses Credentialing
Center’s Commission on Accreditation and by the
American Association of Critical-Care Nurses (AACN
00012278, category A). This activity is also provider
approved by the California Board of Registered
Nursing, provider number CEP11749 for 3 contact
hours. Lippincott Williams & Wilkins is also an
approved provider of CNE in Alabama, Florida, and
Iowa, and holds the following provider numbers: AL
#ABNP0114, FL #FBN2454, IA #75. All of its home
study activities are classified for Texas nursing continuing education requirements as Type 1.
*In accordance with Iowa Board of Nursing administrative
rules governing grievances, a copy of your evaluation of this
CNE offering may be submitted to the Iowa Board of Nursing.
[email protected]
AJN ▼ March 2005
▼
Vol. 105, No. 3
63