The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) estimated that 246,999 hospitalized patients received enteral nutrition, and 188,051 patients had a percutaneous endoscopic gastrostomy (PEG) tube inserted during hospital admission in 2007.1
Although the exact number of adults receiving tube feeding at home and in long-term care centers is unknown, researchers estimate there are approximately 73,000 home enteral nutrition patients,2
and 63,528 cognitively impaired long-term care patients on tube feedings in the United States.3 (Level B)
RNs know that vital enteral support can go awry if the mechanics of tube feedings aren’t properly managed. They also know that their expertise and vigilance in acute, home and long-term care settings are often patients’ best defense against the complications of tube feedings.
A.S.P.E.N. guidelines recommend enteral nutrition for patients when oral feedings aren’t an option, and when patients do not adequately meet nutritional needs.4 (Level C)
However, patients must have a functional gastrointestinal (GI) tract, and if they need tube feedings for longer than four weeks, a long-term feeding tube should be considered.4
Terms that describe long-term feeding tubes are often used interchangeably and sometimes incorrectly. For example, not every tube is a PEG tube. The most commonly used tubes are named after the positions of their feeding tips. For instance, those positioned in the stomach are gastrostomy tubes and those in the jejunum are jejunostomy tubes. Healthcare providers place these devices using endoscopic, open surgical, laparoscopic or radiological techniques. Beyond the tip location, nurses should know the size, material and brand of any tube that has been placed in their patients, as well as who inserted it. Most tubes are made of polyurethane or silicone.5
Red-rubber tubes and Foley-type catheters shouldn’t be used as feeding tubes due to rapid degradation of the tubes5 (Level C)
and lack of internal and external retention devices, which can cause tube migration and enteral misconnection.4 (Level C)
Gastrostomy tubes generally range in size from 12 to 28 French5
and have a balloon, mushroom tip or disc to secure them internally. The external portion has a disc or bumper at the skin level, an end adapter that links with the feeding-bag tubing and often a side port for medication administration. Jejunostomy tubes range in size from 8 to 14 French,5
and are inserted directly into the jejunum or through the stomach and passed through the pylorus into the small bowel. Jejunostomy tubes are used to bypass the stomach in patients with an upper GI obstruction, gastroparesis, increased risk of aspiration and pancreatitis.4
Go to www.nlm.nih.gov/medlineplus/ency/presentations/100125_1.htm
to view diagrams of gastrostomy tube placement.
Vigilant nursing care can prevent most common mechanical complications, which include tube displacement, exit site (or stoma) problems, tube injury, tube clogging and tubing misconnections. Tube displacement can occur when the tube slides in or is pulled out of the GI tract. If the tube slides into the GI tract, the internal end can block the gastric outlet, causing nausea and vomiting. A jejunal tube can also be sucked into the small bowel, causing obstruction. If the internal balloon deflates or if the external tube suture, bumper or disc is inadvertently removed, the tube may slide out, and the tract will quickly close. This loss of enteral access often precipitates a return to the operating, endoscopy or radiology suite for tube replacement.
Tube displacement: Tube displacement can be prevented through a combination of measures. A number of tube-anchoring devices are available on the market to help secure the tube. Using the external marks on the tube, note the length of the tube outside the body. If no marks are on the tube, measure from the level of the exit site to the external end and document this length in the nursing record. A nurse on each subsequent shift needs to verify the external length. The nurse should also check to ensure the disc, suture or attachment device holding the tube externally is secure, as well as ensure the patient or staff does not pull on the attached feeding-set tubing. Assess the residual tube fluid for presence of GI secretions (gastric juice or bile) to determine that the tube is within the GI tract.6 If the nurse is unable to pull any fluid from the tube and suspects that the tube has migrated, a confirmatory X-ray may be required before restarting feedings.
It takes up to four weeks for the tract to form.5 Tubes removed before the formation of a mature tract may need to be replaced surgically, radiologically or endoscopically.5
Replacement of jejunal tubes is a medical procedure.7 Feeding tubes that fall out must be replaced within a few hours. Depending on the practice area, practice act or privileges and the type of tube, a nurse may be able to replace the feeding tube. Otherwise, notify the physician immediately and make arrangements for replacement in radiology, endoscopy or at the bedside. Nurses should verify radiological confirmation of the reinserted feeding tube prior to restarting feedings.6
Exit site care: Procedures for tube exit site care may vary across institutions. For newly placed tubes (less than one week old), cleanse the area with sterile saline using aseptic technique.8-10 Hydrogen peroxide and Povidine iodine aren’t recommended to cleanse the exit site, as these agents are corrosive, leading to excessive drying and cracking, which may cause eventual tube leakage.11 Once the site is healed (usually in seven to 10 days), cleanse the skin with mild soap and warm water by wiping around the site in a circular fashion and moving outward.6 Soaps with fragrance and alcohol should be avoided, as this can lead to drying and cracking of the skin.11 Be sure to dry the exit site thoroughly to prevent soreness and excoriation.6 Use a dressing for only 24 to 48 hours after tube insertion or if a large amount of drainage persists.6 Once the site has healed, a dressing isn’t needed.7 If dressings continue to be used, they should be small and allow air to circulate so the area stays dry.7 Dressings and heavy tape may actually promote skin problems.
Use a cotton-tipped applicator to clean under the external disc, bumper or bolster. The bumper should be positioned just above the skin level, not taut against the surface where skin breakdown may occur. The bumper should be positioned to allow 1 cm of movement,11 or about a dime size above the skin.7 Gently rotate the gastrostomy tube 360 degrees by rolling the tube between the fingers to allow a small amount of space between the bumper and skin. Dry thoroughly and leave open to the air. If the surrounding skin appears mildly excoriated, a protective barrier may be applied. A wound care specialist or enterostomal therapist can often be of assistance. If the skin breakdown is severe, the patient may need systemic antibiotics, debridement or tube removal.
Stoma problems: Exit site (stoma) problems can further complicate the use of feeding tubes. An unsecured tube can pivot at the tube exit site and cause a build-up of granulation tissue and widening of the tract. Stabilizing the tube is essential in preventing these exit site problems. If the tract widens, enteral contents containing digestive enzymes and formula can then leak up through the tract, causing skin excoriation. The nurse should frequently inspect the skin surrounding the exit site for redness, tenderness, swelling, purulent drainage or enteral leakage. Tube leakage can cause severe excoriation around the tube due to the acidity of gastric content. The acidity of gastric content can be lowered with histamine blockers or proton pump inhibitors, thereby decreasing excoriation.11 If hypergranulation is noted, or if skin integrity around the stoma is altered, a wound care nurse should be consulted.
Buried bumper syndrome: Another mechanical problem most often associated with PEG tubes is the “buried bumper syndrome,” which ranges from ulceration of the tissue at the feeding tube exit site or beneath the bolster, to complete erosion or penetration of the tube through the abdominal wall.11 This syndrome can occur when the tube becomes fixed and cannot be moved in and out, necessitating replacement of the tube.11 Excessive tension between the bumpers promotes ulceration and migration of the tube into the muscular layer of the stomach.
Tension may be caused by excessive traction at the time of tube insertion, an overly tight skin disc, a failure to pull back the external bumper after weight gain or excessive dressings under the external bumper. Abdominal pain, tenderness, increased drainage, peristomal infection, inability to infuse liquid through the tube, stomal bleeding, enteral formula or GI fluid leakage or sudden intolerance to enteral nutrition can herald this complication.11 To minimize the risk of this problem, strict attention must be paid to the amount of tension between the external and internal bumpers so that a small amount of space between the bumper and skin level remains. Treatment of the problem ranges from removal of the external bumper and local skin care to an extensive procedure to remove and replace the tube.11 To prevent buried bumper syndrome associated with PEG tubes, the following procedure is recommended to advance and rotate a PEG tube:9
1. Release the fixation device.
2. Cleanse the PEG site and tube.
3. Gently push the PEG tube into the abdomen approximately 2 cm to 3 cm. There should be no resistance.
4. Only once the PEG tube has been advanced should it be rotated 360 degrees. Rotating the PEG tube without advancing it into the abdomen will not prevent buried bumper.
5. Once the tube has been advanced and rotated, gently pull the tube back out of the abdomen until resistance is felt.
6. Replace the fixation device.
Tube injury: Tube injury includes tube rupture, deterioration or balloon breakage. Generally, feeding tubes are not routinely replaced, and the life of tubes can be extended through preventive measures. Follow a regular flushing schedule with a syringe larger than 30 mL.6 Smaller syringes provide higher pressures that may cause tube rupture. Inspect the tube for cracking, wall aneurysm areas or deteriorating anchoring devices. If the feeding tube has an internal balloon, the integrity of the balloon must be assessed on a routine basis. Check the internal balloon for proper inflation every seven to 10 days (or according to the manufacturer’s guidelines) by withdrawing the balloon fluid, noting the volume and comparing it to the amount initially injected into the balloon.6 If the amount is significantly less, refill the balloon with the correct volume and check again in one hour. If the balloon has lost more fluid, leakage has occurred and the tube needs to be replaced. Document the date and time the balloon was checked and the amount of fluid instilled into the balloon. Air or normal saline shouldn’t be used to inflate the balloon,6 only sterile water. A volume loss of greater than 5 mL in seven to 10 days suggests balloon leakage.6 If a tube injury occurs at the connection to the feeding bag, it can sometimes be repaired with a tube adapter. Request the replacement of a damaged or worn tube as soon as possible.
Tube occlusion (or a clogged tube):
Tube occlusion or clogging is one of the most common mechanical complications of enteral nutrition. One study reported a tube-clogging rate of 12.5%.12 (Level B)
Occlusions can be caused by —4
- Inappropriate administration of medications
- Poor flushing techniques
- Thick formulas
- Slow administration rates
- Reflux of gastric or intestinal contents up into the tube, causing curdling of the formula, which in turn, clogs the tube
Many nurses use a variety of flush fluids to prevent clogging or restore patency for occluded tubes. Cranberry juice and carbonated cola beverages have been commonly used and noted in nursing literature. However, these beverages are acidic and may actually contribute to tube clogging from protein denaturation. Sterile water is the best flush solution, as tap water can cause infection if contaminants are present in the tap water.4 (Level C)
Sterile water is also recommended as a flush before and after medications in immunocompromised or critically ill patients when safety of tap water is not reasonably assessed.4
Flushing with 30 mL of water before and after checking for residuals, administering medications or intermittent feedings, every four to six hours, is ideal for preventing tube occlusion.4
Other preventive measures include the use of an administration pump when slow rates of enteral formula are required.4
Improper medication administration can also cause tube occlusion. A recent systematic review of nursing administration of medications via enteral tubes in adults clearly indicates the lack of high-quality research on important issues related to enteral medication administration.13 (Level B)
Furthermore, two surveys of nursing practice demonstrate that nurses’ knowledge regarding medication administration may not translate into proper practice. In one study, 223 RNs and LPNs who worked in a variety of healthcare settings reported that medications caused 50% of feeding tube obstructions. Even though 97% of the nurses perceived that medications given in a liquid form reduced clogging and 94% made an effort to seek liquid dose forms, they used liquids only about 55% of the time; the rest of the time, crushed tablets were used. Nurses who received pharmacy assistance reported significantly less feeding catheter obstruction due to medications. The survey also found that 78% of nurses crushed and administered an enteric-coated dosage form, and 50% administered a sustained-release dosage form. Also, only 69% of those surveyed flushed the feeding tube with water before medication administration, only 59% diluted liquid medications and 57% delivered several medications together.14 (Level B)
In a more general survey of nursing management of enteral tube feedings, a researcher found similar results — only 47% of the sample flushed before medication delivery and only 38% flushed between medications.15 (Level B)
These two surveys clearly identify areas where nurses need to incorporate pharmacological principles into enteric medication administration.
If an occlusion does occur, immediate attention to the clog is important. The first step is to check if the feeding tube is kinked. Place your flushing syringe into the tube end and gently pull back on the plunger to dislodge the clog. If the blockage remains, instill warm water into the tube. The tube can also be milked with the fingers from the insertion site out. Declogging can also be achieved with the instillation of a pancreatic enzyme and sodium bicarbonate solution.11 A few noteworthy commercial products to unclog tubes are now available. Several thin, plastic devices for clearing out a clog include the Intro-Reducer.6 Another product that combines a thin catheter and chemical declogging powder that is put into solution and instilled into the clog via the catheter is the Clog-Zapper.6 Nurses should check that their nursing practice act or clinical privileges allow for such procedures before using any of these devices or products.