A review of the nursing care of enteral feeding tubes in critically ill adults: part II

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  • Intensive and Critical Care Nursing (2005) 21, 515

    ORIGINAL ARTICLE

    A review of the nursing care oftubes in critically ill adults: par

    Teresa A. Williamsa,, Gavin D. Leslieb,1

    a ICU, Royal Perth Hospital, P.O. Box X2b Critical Care Nursing, Centre for NursHospital, P.O. Box X2213, Perth, Wester

    Accepted 9 August 2004

    KEYWORDSEnteral tube;Feeding;Intensive care

    Summaryand gastrof patienritual andclassicatNursing anmanagemSeveral

    idence todominal Xvolumes aFrequencyconsideraof feeds is problematic. Other recommendations include continuous rather than

    * Corresfax: +61 08

    E-mail(T.A. Willia1 Tel.: 61

    0964-3397/doi:10.1016intermittent feeding, semi-recumbent positioning to reduce the risk of airway aspi-ration and diligent articial airway cuff management. Contamination of feeds canbe minimised by minimal, meticulous handling and the use of closed rather thanopen systems. Generally, there was little high quality evidence to support prac-tice recommendations leaving signicant scope for further research by nurses in themanagement of patients with enteral tubes. 2004 Elsevier Ltd. All rights reserved.

    ponding author. Tel.: +61 08 9224 2601;9224 3196.addresses: teresa.williams@health.wa.gov.aums), gavin.leslie@health.wa.gov.au (G.D. Leslie).08 9224 8081; fax: 61 08 9224 1958.

    Introduction

    Critically ill patients commonly have enteral tubesin situ for gastric decompression, delivery of med-ications and food substitutes. It is essential thatcritical care nurses use best practice that includescurrent evidence-based knowledge and skills to

    $ see front matter 2004 Elsevier Ltd. All rights reserved./j.iccn.2004.08.003213, Perth, Western Australia 6847, Australiaing Evidence Based Practice, Education and Research, Royal Perthn Australia 6847, Australia

    Enteral tubes are frequently used in critically ill patients for feedingic decompression. Many of the nursing guidelines to facilitate the carets with enteral tubes have not been based on current research, but onopinion. Using a computerised literature search and an evidence-basedion system as described by the Joanna Briggs Institute for Evidence Basedd Midwifery (JBI), a comprehensive review was undertaken of enteral tubeent.nursing practices related to enteral tube management are described. Ev-support alternate methods of tube placement assessment other than ab--ray was inconclusive. Enteral feeding should continue if gastric residualre not considered excessive, as feeding is often withheld unnecessarily.of checking gastric residual volumes is largely opinion based and varies

    bly, but prokinetics that aid gastric emptying should be used if absorptionenteral feedingt II

  • 6 T.A. Williams, G.D. Leslie

    care for these patients. To facilitate the benetsand minimise the harm associated with any therapy,nursing practice should be based on the highestlevels ofapproachndings ithe develand recomcare for ehigh levelcriticallyof this panursing cafeeding tuvent aspirenteral tfor impletube and

    Data sou

    Several mticles forsearch ofEMBASE (the CochrSearchesadults anviewed aerence liadditionaevidencewas adapJoanna Brand Midw(Table 1).

    Nursingtubes us

    Nursing ctubes usepromotetions. Safetion and eof aspirat

    Verifying

    A numberverify tubsition of t

    Table 1 Levels of evidence.

    Level Description

    EoEptEcEsprEwrEadc

    duceNurs

    sertbergndaeviass

    nd bon,l tudent oppprof enteral tubes are radiography and bedsidement (Fellows et al., 2000).

    graphygraphy is a widely accepted, reliable methodnrm enteral tube placement (Arrowsmith,Bowers, 1996; Davis et al., 1995; Metheny, 1998a,b) and is considered the most ac-form of assessment (Dorsey and Cogordan,

    Goodwin, 1996; Roubenoff and Ravich, 1989;ll et al., 1991) although no RCTs have beento support this. It is recommended prior toing tube feeding and whenever the tube po-is in doubt. Intubation or the presence of aostomy tube does not prevent placement ofteral tube into the respiratory tract (Breachaldanha, 1988; Fater, 1995) and should notde the need for radiological conrmation ofosition. Accidental pulling, violent vomiting,ing or movement may dislodge the tube af-diological conrmation of placement (Fater,evidence. The systematic and rigorousto the analysis and grading of researchn terms of level of evidence facilitatesopment of specic guidelines, standardsmendations to provide the best possiblevery patient. There is, however, limitedevidence supporting nursing practice ofill patients with enteral tubes. In part 1per, the current research ndings for there of critically ill patients with enteralbes was reviewed. Nursing care to pre-ation was discussed. This paper describesube management and recommendationsmenting evidence-based protocols forfeeding management.

    rces and levels of evidence

    ethods were used to identify relevant ar-this review. A computerised literatureonline databases MEDLINE (19662003),19662003), CINAHL (19821996), andane Library (19922003) was conducted.were restricted to the English language,d humans. Relevant abstracts were re-nd identied articles assessed. The ref-sts of all articles were examined forl papers not previously identied. Thebase applied in classifying literatureted from the recommendations of Theiggs Institute for Evidence Based Nursingifery (The Joanna Briggs Institute, 2002)

    care of patients with enteraled for feeding

    are of critically ill patients with enterald for feeding should facilitate feeding,patient comfort and minimise complica-ty issues include verication of tube posi-nsuring tube patency to minimise the riskion (The Joanna Briggs Institute, 2002).

    tube position

    of different methods have been used toe position (Fater, 1995). Checking the po-he enteral tube is recommended after ini-

    I

    II

    III.1

    III.2

    III.3

    IV

    ReproBased

    tial in(Eisenommeenticate totion aadditienteraan eviexperTwo ation oassess

    RadioRadioto co1993;et al.curate1985;Wendedoneinitiatsitiontrachean enand Spreclutube pcoughter ravidence obtained from a systematic reviewf all relevant randomised controlled trials.vidence obtained from at least oneroperly designed randomised controlledrial.vidence obtained from well-designedontrolled trials, not randomized.vidence obtained from comparative studiesuch as cohort studies, case control studiesreferably from more than one centre oresearch group.vidence obtained from multiple time seriesith or without the intervention. Dramaticesults in uncontrolled experiments.vidence from opinion of respecteduthorities, based on clinical experience,escriptive studies, or reports of expertommittees.

    d from: The Joanna Briggs Institute for Evidenceing and Midwifery (2002).

    ion and once per shift in continuous feeds, 1994; Metheny, 1993). Both these rec-tions are based on opinion rather than sci-dence. However, it would seem appropri-ess the position of the tube after inser-efore the commencement of feeding. Inregular re-assessment to check that thebe has not been dislodged, whilst lackingce base, appears to be well supported byinion (Eisenberg, 1994; Metheny, 1993).aches for determining the correct posi-

  • A review of the nursing care of enteral feeding tubes in critically ill adults: part II 7

    1995) and indicate the need for re-assessment ofenteral tube position.

    Bedside aBedside asumentatiotered photesting of1995; EiseMetheny,et al., 199of limitinify enterahas been c1993; Reito mark tthe nosein its intetally relialength dohas beenduodenumoropharyntors for svomiting a

    Regulargested froradiologictube posit1993; Theuid pH hintestinalMedicatiotritis in ICassociatedet al., 19to be moare subjeif gastricper (Themal readinbe instilleincludingfor 60minshould thesufationprocess is(Metheny

    Auscultto verify2030mlteral tubewhilst auspositive reof gastroiten makin

    to differentiate tube position (Arrowsmith, 1993;Metheny et al., 1990). The auscultation method hasbeen found to be ineffective in determining correct

    al tuno

    ne eny,er minclurautionO2)onlynitog annd Sevaof Cenctentet ameta coen

    . Thvaluusehonatiegh i-bolly iestual ig ifftenstri. Useeteyan,behavf plreass anetthanws es airouldr (Arana, 19entot yenyssessmentsessment includes measurement and doc-n of limiting marks, air auscultation, al-nation, visualisation of aspirate and pHaspirate (Arrowsmith, 1993; Davis et al.,nberg, 1994; Kearns and Donna, 2001;1993; Metheny et al., 1990; Metheny8a,b). Measurement and documentationg marks has been recommended to ver-l tube position once the initial positiononrmed by other methods (Arrowsmith,lly, 1998). Indelible ink has been usedhe point of a feeding tubes exit fromto determine if the tube has remainednded position, but this method is not to-ble (Metheny, 1993). Measurement of tubees not preclude internal migration whichreported to occur downward in to theor jejunum as well as upward into the

    x or lungs (Rakel et al., 1994). Risk fac-pontaneous dislocation include retching,nd violent coughing (Fater, 1995).bedside pH testing has been sug-

    m clinical studies to be a reliable non-al assessment tool for verifying enteralioning (Eisenberg, 1994; Metheny et al.,Joanna Briggs Institute, 2002). Gastric

    as been shown to range from 1 to 4, andpH from 6 to 7 (Metheny et al., 1993).ns prescribed to prevent the risk of gas-U patients, aging and gender differenceswith aging may alter gastric pH (Metheny

    93). Meter readings have been observedre accurate than paper pH tests, whichctively based, and difcult to interpretor intestinal aspirate discolour the pa-Joanna Briggs Institute, 2002). For opti-gs, before testing for pH, nothing shouldd through the tube that alters the pH,enteral feeds which should be withheld. Immediately prior to testing, the tuben be cleared