Digestive
Considerations:
- Be sure to take steps to ensure student privacy when performing the procedure.
- The most significant risk with tube feedings is aspiration of feeding into the lungs, be sure the student is positioned properly with the head elevated at least 30 degrees.
- Verify with health care provider if residuals are to be checked prior to feeding.
- If residual checks are ordered, verify with health care provider how residuals should be returned to the abdomen (i.e. via gravity, continuous infusion, or ENFit/enteral syringe).
- If residual checks are not ordered, discuss with the health care provider how tube placement should be verified prior to feeding.
- Encourage the student to assist in the procedure as much as they are able to help the student learn self-care skills.
- Make feeding like mealtime: allow the student to sit with other children during mealtime, if possible.
- If sitting with other children is not possible, brainstorm alternatives such as having the student bring a lunch buddy to the nurse office, or train a Unlicensed Assistive Personnel (UAP) to accompany students to the cafeteria to assist with feeding.
Supplies:
- G-tube replacement “kit”
- Replacement gastrostomy tube
- 6-mL luer slip syringe
- Medical tape
- Water-soluble lubricant
- 60ml ENFit/enteral syringe
- Extension set, if applicable
- Graduated measuring cup
- Prescribed diet at room temperature
- Warm tap water, if prescribed
- Towel or washcloth
- Non-sterile gloves
- Student’s Individualized Health Care Plan (IHCP) and health care provider’s order
- Parent/Guardian authorization form
Procedure:
1. Review health care provider’s order including:
- the type of formula
- amount
- infusion type and rate
- frequency and timing of administration
- residual volume checks
- amount of water used to flush the tube
2. Review student’s allergy status
3. Ensure proper documentation of parent/guardian authorization to administer the feeding
4. Explain the procedure to the student at their level of understanding
5. Wash hands
6. Assemble equipment and place on clean surface
7. Confirm you have the correct formula
8. Note the integrity of the formula container
9. Check expiration date of the formula
10.Position student either sitting or supine with head up at least 30 degrees
a. The most significant risk with tube feedings is aspiration of liquid nutrition into the lungs, be sure the student is positioned properly with the head elevated at least 30 degrees
11. Put a towel or washcloth under student’s gastrostomy tube
12. Put on gloves
a. Compare external tube length to tube length measurements obtained after initial placement of the tube, contact parents/guardian and health care provider if discrepancy in measurements
b. If student has abdominal distention do not administer feeding, instead contact parent/guardian and health care provider
13. If residual check is ordered:
a. Remove plug from gastrostomy tube
b. Attach 60-mL ENFit/enteral syringe with plunger to the end of the gastrostomy tube
c. Unclamp the tubing and gently draw back on the plunger to remove any liquid or medication that may be left in the stomach (residual)
d. Note the amount withdrawn from tube feeding
e. Return residual to stomach
f. Clamp tubing and remove the ENFit syringe
• the type of formula
• amount
• infusion type and rate
• frequency and timing of administration
• residual volume checks
• amount of water used to flush the tube
14. If residual check is not ordered, verify with health care provider how placement of g-tube should be verified before administering feeding
15. If feeding is in a can, clean the top of the feeding (formula) can with an alcohol wipe or soapy cloth
16. Attach 60-mL ENFit/enteral syringe, with plunger removed, onto the end of the enteral tube
17. Measure prescribed amount of enteral formula to be infused into clean graduated measuring cup or an ENFit syringe
- Observe the appearance of the formula for any abnormalities
- Prepare the enteral formula per health care provider’s order
18. Pour feeding into the ENFit syringe until about one-half full
19. Elevate the ENFit syringe above the level of the stomach
20. Open G-tube clamp
21. Allow feeding to go in slowly, over prescribed amount of time
- The higher the ENFit syringe is held, the faster the feeding will flow
- Lower the ENFit syringe if the feeding is going too fast
22. Refill the ENFit syringe before it empties to prevent air from entering stomach
23. Monitor student during feeding for any signs of intolerance or complications
24. Stop feeding immediately for gagging, vomiting, coughing, abdominal distension, change in skin color, or difficulty breathing, etc.
25. Flush the gastrostomy tube with warm water when feeding is complete, amount determined by health care provider’s order
26. After flushing, lower the ENFit syringe below the stomach level to facilitate burping
27. Vent until gassiness is relieved and allow any gastric contents to instill via gravity
28. Remove the extension tubing, if used, and the ENFit syringe and insert the plug the gastrostomy device
29. Keep the student in a feeding (upright) position for at least 30 minutes after completing feeding
30. Wash the ENFit syringe with soap and warm water and put in home container
a. The ENFit syringe can be used repeated times for up to 24 hours
31. Remove gloves
32. Wash hands
33. Document assessment, interventions and outcomes in student’s health record
34. Follow up with parents/guardian and health care provider, as needed
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References:
Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., McGinnis, C., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii-Wolfe, C., Sullivan, J., Wood, A., Malone, A., Guenter, P., & ASPEN Safe Practices for Enteral Nutrition Therapy Task Force, American Society for Parenteral and Enteral Nutrition. (2017). ASPEN safe practices for enteral nutrition therapy [Formula: see text]. JPEN. Journal of parenteral and enteral nutrition, 41(1), 15–103. https://doi.org/10.1177/0148607116673053
Children’s Hospital St. Louis. (2015, May). Gastrostomy tubes home care manual (corpak, foley catheter, genie, malecot, mic-G). Retrieved June 22, from https://www.stlouischildrens.org/sites/legacy/files/Gastrostomy%20Tubes%20Home%20Care%20Manual.pdf
Cleveland Clinic. (2019, November 1). Home tube feeding – Checking residuals. Retrieved August 22, 2023, from https://www.youtube.com/watch?v=59tusCo2wAI
Lynn, P. (2019). Administering a tube feeding. In Skill checklists for Taylor’s clinical nursing skills. A nursing process approach. (5th ed.). (pp. 253-255).
Pediatric Home Services. (2017). Bolus feeding by syringe- Gravity method (Alimentación en bolo por jeringa—Método de gravedad). . Retrieved June 21, 2023, from https://www.pediatrichomeservice.com/tips-how-tos/bolus-feeding-syringe-gravity-method/?play=1
Perry, A. G., Potter, P.A., Ostendorf, W., & Laplante, N. (2021). Skill 32.4 administering enteral nutrition: Nasogastric, nasointestinal, gastrostomy, or jejunostomy tube. In Clinical nursing skills and techniques. (10th ed.). (pp. 965-972). St. Louis, MO: Elsevier.
Potter, P. A., Griffin Perry, A. G., Stockert, P. A., & Hall, A. (2023). Chapter 45 Nutrition. Skill 45.3 Administering enteral feedings via nasoenteric, gastrostomy, or jejunostomy tubes. In Fundamentals of Nursing. (11th ed.). (pp.1214-1219). St. Louis, MO: Elsevier.
Porter, S. M., Page, D., Engholm. H., & Somppi, C. (2019). Students supported by medical technology. In J. Selekman, Shannon, R.A., Yonkaitis, C.F. (Eds.). School nursing, a comprehensive text (3rd ed., pp. 721-740). Philadelphia PA.: F. A. Davis Co.
Spratling, R., Chambers, R., Lawrence, P., & Faulkner, M.S. (2021). Best practices with use of feeding tubes for children at home. Pediatric Nursing, 47(1), 7-10.
Toothaker, R., & Cook, P. (2018). A Review of Four Health Procedures That School Nurses May Encounter. NASN school nurse (Print), 33(1), 19–22. https://doi.org/10.1177/1942602X17725885
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Acknowledgment of Reviewers:
Angie Bulmahn, MSN, RN, NCSN
School Nurse Specialist
Missouri Department of Health and Senior Services
Marjorie Cole, MSN, RN, FASHA
State School Nurse Consultant
Missouri Department of Health and Senior Services
Renee Falkner, BSN, RN
School Nurse Supervision Specialist | Therapylog
Katherine Park, DNP, RN, NCSN
Nationally Certified School Nurse, Pierremont Elementary
Adjunct Professor, Maryville University School of Nursing
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Page last updated: February 18, 2024
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The information and materials presented in this Website are intended for informational purposes only and are not designed to diagnose or treat a health problem or disease, or assist in diagnosis or treatment of the same. The information is not intended to substitute for, supplement or replace clinical judgment. If there are any concerns or questions about or relating to a nursing or medical procedure, contact the individual’s healthcare provider. The information provided on this Website is not intended to be a substitute for medical orders and persons without the proper education, training, supervision and/or licensure should not perform the procedures.
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