Digestive
Considerations:
- Be sure to take steps to ensure student privacy when performing procedure.
- 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.
- Verify with the 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 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 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:
- Gastrostomy tube replacement “kit”:
- Replacement gastrostomy tube
- 6-mL luer slip syringe
- Medical tape
- Water-based lubricant
- ENFit adaptor with tubing and clamp
- Feeding solution in can or container, at room temperature
- Feeding bag
- 60-mL ENFit/enteral syringe
- Warm tap water, if prescribed
- Pole to hold feeding container
- Student’s Individualized Health Care Plan (IHCP) and health care provider’s orders
- Parent/Guardian authorization form
Procedure:
- Review health care provider’s order including:
- the type of formula
- amount
- infusion type and rate
- frequency of administration
- residual volume checks
- amount of water used to flush the tube
- Review student’s allergy status
- Ensure proper documentation of parent/guardian authorization to administer the feeding
- Explain the procedure to student at their level of understanding
- Wash hands
- Assemble equipment and place on a clean surface
- Confirm you have the correct formula
- Check expiration date on formula
- Note the integrity of the formula container
- Position student either sitting or supine with head up at least 30 degrees
- 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
- Put a towel or washcloth under student’s G-tube
- Put on gloves
- Observe abdomen for signs of malposition or obstruction of gastrostomy tube such as difference in external tube length compared to baseline measurements or abdominal distention
- 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
- If student has abdominal distention do not administer feeding, instead contact parent/guardian and health care provider
- If residual check is ordered
- Remove cap or plug from G-tube
- Attach 60-mL ENFit/enteral syringe with plunger to the end of the g-tube
- Unclamp the tubing and gently draw back on the plunger to remove any liquid or medication that may be left in the stomach (residual)
- Note the amount withdrawn from tube feeding
- Return residual to stomach
- Clamp the tubing and disconnect the ENFit syringe
- If residual check is not ordered, verify with health care provider how placement of g-tube should be verified before administering feeding
- Shake the feeding container/can
- If feeding is in a can, clean the top of the feeding (formula) can with an alcohol wipe or soapy cloth
- 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
- Pour feeding/fluids into feeding bag
- Run feeding through tubing to the tip and clamp tubing
- Hang container on pole at height required to deliver prescribed flow
- Open safety plug on G-tube and insert tubing into the G-tube
- Open clamp on tubing and adjust flow to prescribed rate
- Check rate and flow periodically and adjust if needed
- You will need to adjust the flow rate if the student’s position changes or the position of the feeding bag changes
- Monitor student during feeding for any signs of intolerance or complications
- Stop feeding immediately for gagging, vomiting, coughing, abdominal distension, change in skin color, or difficulty breathing, etc.
- Make feeding like mealtime: allow student to sit with other students during mealtime
- When single feeding is completed (bag empty), clamp feeding bag tubing and remove
- Sometimes a larger volume water flush may be prescribed and will be administered using feeding container and will flush the remainder of the formula through the tubing
- Attach 60-mL ENFit/enteral syringe, with plunger removed, and flush tubing with 5ml or prescribed water volume
- After flushing, lower the ENFit syringe below stomach level to facilitate burping
- Vent until gassiness is relieved and allow any gastric contents to instill via gravity
- Disconnect the ENFit syringe
- Plug to G-tube
- Keep the student in a feeding (upright) position for at least 30 minutes after completing feeding
- Wash the ENFit syringe and tubing with soap and warm water and place in home container
- The ENFit syringe and feeding extension tubing can be used repeated times for up to 24 hours
- Remove gloves
- Wash hands
- Document assessment, interventions, and outcomes in student’s health care record
- 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 Mercy Kansas City. (2022, December 2). Gastronomy tube (g-tubes): Training for school nurses.. Retrieved June 21, 2023, from https://www.youtube.com/watch?v=_Gif-699CmM
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). Using a gravity feeding bag. . Retrieved June 20, 2023, from https://www.pediatrichomeservice.com/tips-how-tos/using-gravity-feeding-bag/?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.
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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.