The Selection and Care of Enteral Feeding Tubes

The Selection and Care 

of Enteral Feeding Tubes 

Objectives 

Identify disease states and conditions that may require 

enteral feeding 

Describe the types of tubes used for enteral feeding 

Explain complications associated with enteral 

feeding tubes 

Discuss nursing care required to avoid these complications 

Definitions 

Enteral feeding tubes are enteral access devices 

placed directly into the gastrointestinal (GI) tract for 

the delivery of nutrients and/or drugs 

Enteral feeding is: 

• The delivery of liquid nutrients via tube or mouth into the 

gastrointestinal tract 

• Preferred over intravenous parenteral feeding for those 

patients with normally functioning GI tracts 

Guenter, P, Silkroski, M. 2001. Tube Feeding: Practical Guidelines and Nursing Protocols. 

The Selection and Care of 

Enteral Feeding Tubes 

A continuing education activity sponsored by: 

Grant funds provided by: 

1 2 

3 

5 

Definitions 

Enteral refers to 

within the stomach 

or intestine 

Indications for 

Enteral Feeding 

liver 

gallbladder 

duodenum 

transverse colon 

tongue 

pharynx 

esophagus 

ascending colon 

cecum 

vermiform appendix 

rectum 

anus 

Guenter, P, Silkroski, M. 2001. Tube Feeding: Practical Guidelines and Nursing Protocols. 

oral cavity 

salivary glands 

stomach 

pancreas 

descending colon 

jejunum 

ileum 

sigmoid colon 

sphincter muscle of anus 

4 

6

Indications for Enteral Feeding 

Enteral feeding is indicated for patients who 

have a functional GI tract but they: 

• will not, should not, or cannot eat 

• are/will become malnourished 

• are unable to maintain optimal nutritional status via 

oral feedings 

Guenter, P. 2001. Chapter 2 Enteral Nutrition Basics, Tube Feeding: Practical Guidelines and Nursing Protocols 7 

Disease States/Conditions that May 

Require Enteral Feeding Include … 

Disease/Condition Examples 

Hypermetabolism major surgery, sepsis, trauma 

Neurological Disease stroke, multiple sclerosis, head injury 

CREST. April 2004. Guidelines for the Management of Enteral Tube Feeding in Adults. 






Gastrointestinal Disease 

esophageal obstruction, bowel disease, 

pancreatic insufficiency, gastroparesis 

Cancer chemo or radiotherapy, surgery 

Psychiatric Disease anorexia nervosa, severe depression 

Organ System Failure respiratory, renal, cardiac, hepatic 

Learning Disability cerebral palsy, Rett syndrome 

Failure to Thrive Cystic fibrosis, celiac disease, Crohn’s Disease 


9 

11 

Indications for Enteral Feeding 

If oral dietary intake remains 

compromised or 

is contraindicated for more 

than 5-7 days, enteral 

feeding may be necessary 







Gastrointestinal Disease 

esophageal obstruction, bowel disease, 

pancreatic insufficiency, gastroparesis 

Cancer chemo or radiotherapy, surgery 

Psychiatric Disease anorexia nervosa, severe depression 


Tube Types 


8 

10 

12

Evolution of Feeding Tubes 

Nasogastric tubes 

Modified drainage 

Levine tubes 

Foley catheters 

Current balloon retained 

Oroenteric Feeding Tubes 

Orogastric 

Oroduodenal 

Orojejunal 

May be placed via oral route 


Enterostomy Tubes 

Two categories: 

• Gastrostomy tubes 

• Jejunostomy tubes 

Method of placement: 

• Open surgical 

• Laparoscopic 

• Endoscopic 

• Radiologic 

Orogastric 

feeding tube 

Orojejunal 

feeding tube 

Guenter, P. 2001. Chapter 3. Enteral Feeding Access Devices, Tube Feeding: Practical Guidelines and Nursing Protocols; Bowers, S. Dec 2000. 

All About tubes, Nursing 30. 

13 

15 

17 

Nasoenteric Feeding Tubes 

Nasogastric 

Nasoduodenal 

Nasojejunal 


Nasoenteric Tubes 

Short-term (< 4 weeks) 

Most common 

Easiest to place 

Least expensive 

Placement 

Method 

Surgical 

Insertion 

Laparoscopic 

Endoscopic 

Guenter, P. 2001. Chapter 3 Enteral Feeding Access Devices, Tube Feeding: Practical Guidelines and Nursing Protocols 


Remarks 

• General anesthesia required; often as a secondary 

procedure during abdominal surgery for another condition 

• May have ileus 24 hours post-op; Gastric decompression 

usually ordered 

• Observe for post-surgical complications 

• Monitored conscious sedation; deep sedation or general 

anesthesia may be required for some patients 

• Less invasive than surgical 

• Local anesthesia and conscious sedation; requires 

monitoring 

• Popular placement method 


All About tubes, Nursing 30.; Duh, Q. et al. 1999 Laparoscopic Gastrostomy and Jejunostomy: Safety and cost with Local vs. General Anesthesia. 

ARCH SURG 134:151-6. 

14 

16 

18

Percutaneous Endoscopic 

Gastrostomy (PEG) 

Gastrostomy Tubes 

PEG Tube 

Examples of balloon and pigtail retained gastrostomy tubes 

Balloon Retention – recessed tip 

Jejunostomy Tubes 

Standard 

Pigtail Retention (modified drainage) 

Does not have an external retention mechanism 

Low profile 

19 

21 

23 

Placement 

Method 

Surgical 

Insertion 

Laparoscopic 

Endoscopic 

Radiologic 


Remarks 

• General anesthesia required; often as a secondary 

procedure during abdominal surgery for another condition 

• May have ileus 24 hours post-op; Gastric decompression usually 

ordered 

• Observe for post-surgical complications 

• Monitored conscious sedation; deep sedation or general 

anesthesia may be required for some patients 

• Less invasive than surgical 

• Local anesthesia and conscious sedation; requires monitoring 

• Popular placement method 

• Monitored conscious sedation; does not typically require general 

anesthesia 

• Least invasive; lower costs and risks than other methods 


All About tubes, Nursing 30.; Duh, Q. et al. 1999 Laparoscopic Gastrostomy and Jejunostomy: Safety and cost with Local vs. General Anesthesia. 

ARCH SURG 134:151-6. 

Low-Profile Gastrostomy Devices (LPGDs) 

Alternative to traditional gastrostomy or PEG tube 

Anchored in the stomach and protrudes just above skin 

More acceptable cosmetically; affords greater independence 

Difficult to dislodge; good choice for children/confused adults 

Non-balloon retained Balloon retained 

Gastro-Jejunal Tubes 

Standard 

Low profile 

20 

22 

24

Enteral Feeding Tube Decision Tree 

Factors to consider prior to selecting an access 

route and device for enteral feeding include: 

• The patient’s prognosis 

• The patient’s medical condition 

• Availability of local technical expertise 

• Potential complications of tube insertion 

• Length of time that the tube feeding will be needed 



Short Term 

Less than 3 to 4 weeks 

Nasoenteric Tube 

Enteral Nutrition Needed 

Long Term 

Greater than 3 to 4 weeks 

Guenter, P., Silkroski, M. 2001. Enteral Feeding Access Devices. Tube Feeding Practical Guidelines and Nursing Protocols. 


Short Term 


No Aspiration Risk or 

Gastric Problems 

Nasogastric Tube 



Aspiration Risk or 

Delayed Gastric 

Emptying 

Nasoduodenal or 

Nasojejunal Tube 

Long Term 



25 

27 

29 


Short Term 



Long Term 







Short Term 




Long Term 




Short Term 









Emptying 



Long Term 


No Aspiration Risk 

or Gastric Problems 

Gastrostomy Tube 

Enterostomy Tube 


26 

28 

30


Short Term 






Long Term 


Nasoenteric Tube Enterostomy Tube 



Emptying 



No Aspiration Risk 

or Gastric Problems 

Gastrostomy Tube 


Aspiration Risk or Delayed 

Gastric Emptying [patient 

condition dependent ] 

Jejunostomy or 

Combined 

Gastrostomy- 

Jejunostomy 

Nasoenteric Tube Complications 

Sinusitis 

Epistaxis 

Dysphasia 

Dislodgement 

Tube occlusion 

Pulmonary aspiration 

Nasopharyngeal discomfort 

Erosion of the nasal septum 

Migration and displacement 

Iyer, K.R., Crawley, T.C. Complications of Enteral Access. Gastrointestinal Endoscopy Clinics of North America, 17 (2007) 717-729. 

Enterostomy Tube Complications 

Infection 

Pressure necrosis/ulcers 

Skin irritation/breakdown 

Excessive granulation tissue 

Peritubular allergic reactions 

Tube deterioration 

Tube occlusion 

Tube displacement 

Guenter, P. tube Chap 7. 2001. tube Feeding: Practical Guidelines and Nursing Protocols. CREST. April 2004. Guidelines for the Management of Enteral Tube Feeding In Adults. 

31 

33 

35 

Complications 

Associated with 


Tubes 

Nasoenteric Tube Complications 

Nasoenteric feeding 

tubes should NOT be 

used for periods 

longer than 4 weeks. 

O’Keefe, S.J.D.Na.Rev.Gastroenterol.Hepatol,6,210 (2009) 

The Joint Commission 

Sentinel Event Alert: Issue 36 – April 3, 2006 

“Tubing misconnections – a persistent and potentially deadly occurrence” 

Reported cases to Joint Commission: 

eight deaths and one instance of permanent 

loss of function; 7 adults and 2 infants 

“tube feeding formula is accidentally connected to intravenous 

or other lines or catheters for which it was not intended” 

The Joint Commission Sentinel Event Alert, Issue 36, April 3, 2006. 

32 

34 

36

Caution! 

Avoid placement of Foley 

catheters or tubes not intended for 

use as enteral feeding devices 

Why? 

Tube migration, occlusion, skin 

irritation and allergies, excess 

tubing on outside of body, tube 

misconnections 

ASPEN. 2009 Jan 26. Enteral Nutrition Practice Recommendations. J Parenter Enteral Nutr OnlineFirst,doi:10.1177/0148607108330314. Accessed 3/24/2009. 37 

Care of Enteral Feeding Tubes 

Pulmonary Aspiration: 

Evaluate all enterally fed patients for risk of aspiration. 

Assure the feeding tube is in the proper position before 

initiating feedings. 

Keep head of bed elevated at 30 - 45 at all times during 

the administration of enteral feedings. 

ASPEN. 2009 Jan 26. Enteral Nutrition Practice Recommendations. J Parenter Enteral Nutr OnlineFirst, doi:10.1177/0148607108330314. Accessed 3/24/2009. 

Care of Nasoenteric Tubes 

Tube placement should be checked: 

• every 8 hours during continuous feedings 

• before each intermittent feeding 

Change fixator device or tape as 

needed and at least every 3 to 5 days 

Inspect the nares, mouth, and pharynx daily for skin 

irritation, ulceration, pressure necrosis and lesions 

Guenter, P. 2001. Chapter 4: Nursing Care of Patients with Enteral Feeding Devices. Tube Feeding Practical Guidelines and Nursing Protocols. ASPEN. 

39 

41 

Care of Enteral 

Feeding Tubes 

Standard policies and protocols 

should be developed and 

followed to enable staff to provide 

consistent, safe, quality care 


Regularly assess and monitor to: 

• Ensure correct placement 

• Protect mucosal surfaces 

• Avoid complications such as skin 

breakdown or infection, tube clogging 

If problems arise, early intervention 

is key to maintaining enteral access 

Enteral Nutrition: Procedures and Guidelines 


Maintain good oral hygiene 

• Follow facility policy for oral 

care and for flushing the tube 

Daily assessment 

Brush teeth (and tongue) 

Frequent rinsing 

Suction (if indicated) 

Guenter, P. 2001. Chapter 4: Nursing Care of Patients with Enteral Feeding Devices. Tube Feeding Practical Guidelines and Nursing Protocols. ASPEN. 

38 

40 

42

Care of Enterostomy Tubes 

Regularly assess and monitor to: 

• Ensure correct placement 

• Protect skin at the exit site 

• Maintain tube patency and integrity 

If problems arise, early intervention 

is key to maintaining enteral access 

Enteral Nutrition: Procedures and Guidelines 

Routine Stoma Site Care 

Strict adherence to infection control 

protocols 

Daily inspection for irritation or infection 

Cleanse skin per facility policy 

Inspect gastrostomy tube and rotate 

the bumper/bolster to ensure proper fit 

Do not rotate jejunal tubes 


Infection (i.e. bacterial, fungal): 

Practice appropriate hand hygiene 

Assess skin daily for signs of irritation or infection 

Document findings 

Keep dressing dry 

Protect skin from moisture 

Wound Ostomy and Continence Nurses Society, Management of Gastrostomy Tube Complications for Pediatric and Adult Patient. 

43 

45 

47 


Tube displacement/migration: 

Secure the device 

Check for placement, stabilization and fit daily and prn 

Balloon retention devices should have the internal 

balloon checked for proper inflation every 7 to 10 days 

Guenter, P. 2001. Chap 4. Tube Feeding: Practical guidelines and Nursing Protocols..; 


Skin Irritation/Allergy: 

Inspect skin around tube site daily for signs of skin 

breakdown, infection, tenderness or excoriation; if 

present, assess and address cause 

Cleanse skin with warm water and mild soap; avoid 

routine use of hydrogen peroxide 

Assess for tube migration and/or inappropriate inflation 

of balloon (if applicable) 

Bowers, S. All About Tubes: Your Guide to Enteral Feeding Devices. Nursing2000. 



Hypergranulation Tissue: 

Restrict the use of hydrogen peroxide 

Prevent: 

• excessive tube movement 

• excessive moisture 

• constant exposure to drainage 


44 

46 

48


Injury to the Patient (e.g. pressure ulcers, necrosis): 

Ensure internal bolster contains proper fill volume 

(for balloon-retained devices) 

Ensure external bolster/stabilizer rests comfortably 

against the skin without excess tension 

Rotate bumper daily 

Avoid bulky dressings under the external bumper 

Do not rotate jejunal tubes 

Wound Ostomy and Continence Nurses Society. Management of Gastrostomy Tube Complications for the Pediatric and Adult Patient. 


Tube Occlusion and Deterioration: 

Flush feeding tubes with 30 ml. of water: 

• every 4 hours during continuous feeding 

• before and after intermittent feedings in an adult patient 

Adhere to protocols that call for proper flushing of tubes 

before and after medication administration 

Establish and follow flushing protocol for neonatal and 

pediatric patients; fluid restricted patients 

Observe for tube for signs of deterioration 

ASPEN. 2009 Jan 26. Enteral Nutrition Practice Recommendations. J Parenter Enteral Nutr OnlineFirst, doi:10.1177/0148607108330314. Accessed 3/24/2009. 

Keep Informed of 

New Developments! 

“The field of interventional tube feeding is 

expanding rapidly, which has led to a profusion of 

enteral access techniques, specialized feeding 

tubes, and liquid formula diets being developed.” 

O’Keefe, S.J.D. Nat.Rev.Gastroenterol.Hepatol.6, 207-215 (2009) 

49 

51 

53 


Leakage around the Tube: 

Stabilize the tube 

Check for appropriate balloon inflation 

Note manufacturer’s mark on the tube to assess for 

migration 

Verify leakage has stopped 

If uncontrolled, considerations include replacement, 

barrier ointment, skin sealant, absorbent dressings 

Wound Ostomy and Continence Nurses Society. Management of Gastrostomy Tube Complications for the Pediatric and Adult Patient. 

50 

Summary 

The placement of enteral feeding tubes is required in 

certain patient conditions/disease states 

Different tube types are required depending on placement 

requirements 

Enteral feeding tubes are associated with complications 

Establish a protocol for care and consistently perform best 

practice when caring for patients with enteral feeding tubes 

The Selection and Care of Enteral Feeding Tubes 

• Conditions Requiring Enteral Feeding 

• Types of Feeding Tubes 

• Complications 

• Nursing Care 

Thank You! 

© 2009 Kimberly-Clark Worldwide, Inc. All rights reserved. The material in this presentation is proprietary 

to Kimberly-Clark and may not be reproduced or used without written permission. 

52 

54

The Selection and Care of Enteral Feeding Tubes

Create successful ePaper yourself

Delete template?

Save as template?