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

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<ul><li><p>Intensive and Critical Care Nursing (2005) 21, 515</p><p>ORIGINAL ARTICLE</p><p>A review of the nursing care oftubes in critically ill adults: par</p><p>Teresa A. Williamsa,, Gavin D. Leslieb,1</p><p>a ICU, Royal Perth Hospital, P.O. Box X2b Critical Care Nursing, Centre for NursHospital, P.O. Box X2213, Perth, Wester</p><p>Accepted 9 August 2004</p><p>KEYWORDSEnteral tube;Feeding;Intensive care</p><p>Summaryand gastrof patienritual andclassicatNursing anmanagemSeveral</p><p>idence todominal Xvolumes aFrequencyconsideraof feeds is problematic. Other recommendations include continuous rather than</p><p>* Corresfax: +61 08</p><p>E-mail(T.A. Willia1 Tel.: 61</p><p>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.</p><p>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.</p><p>Introduction</p><p>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</p><p>$ 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</p><p>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</p><p>bly, but prokinetics that aid gastric emptying should be used if absorptionenteral feedingt II</p></li><li><p>6 T.A. Williams, G.D. Leslie</p><p>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</p><p>Data sou</p><p>Several mticles forsearch ofEMBASE (the CochrSearchesadults anviewed aerence liadditionaevidencewas adapJoanna Brand Midw(Table 1).</p><p>Nursingtubes us</p><p>Nursing ctubes usepromotetions. Safetion and eof aspirat</p><p>Verifying</p><p>A numberverify tubsition of t</p><p>Table 1 Levels of evidence.</p><p>Level Description</p><p>EoEptEcEsprEwrEadc</p><p>duceNurs</p><p>sertbergndaeviass</p><p>nd bon,l tudent oppprof enteral tubes are radiography and bedsidement (Fellows et al., 2000).</p><p>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,</p><p>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.</p><p>rces and levels of evidence</p><p>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)</p><p>care of patients with enteraled for feeding</p><p>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).</p><p>tube position</p><p>of different methods have been used toe position (Fater, 1995). Checking the po-he enteral tube is recommended after ini-</p><p>I</p><p>II</p><p>III.1</p><p>III.2</p><p>III.3</p><p>IV</p><p>ReproBased</p><p>tial in(Eisenommeenticate totion aadditienteraan eviexperTwo ation oassess</p><p>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.</p><p>d from: The Joanna Briggs Institute for Evidenceing and Midwifery (2002).</p><p>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-</p></li><li><p>A review of the nursing care of enteral feeding tubes in critically ill adults: part II 7</p><p>1995) and indicate the need for re-assessment ofenteral tube position.</p><p>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</p><p>Regulargested froradiologictube posit1993; Theuid pH hintestinalMedicatiotritis in ICassociatedet al., 19to be moare subjeif gastricper (Themal readinbe instilleincludingfor 60minshould thesufationprocess is(Metheny</p><p>Auscultto verify2030mlteral tubewhilst auspositive reof gastroiten makin</p><p>to differentiate tube position (Arrowsmith, 1993;Metheny et al., 1990). The auscultation method hasbeen found to be ineffective in determining correct</p><p>al tuno</p><p>ne eny,er minclurautionO2)onlynitog annd Sevaof Cenctentet ameta coen</p><p>. 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</p><p>x or lungs (Rakel et al., 1994). Risk fac-pontaneous dislocation include retching,nd violent coughing (Fater, 1995).bedside pH testing has been sug-</p><p>m clinical studies to be a reliable non-al assessment tool for verifying enteralioning (Eisenberg, 1994; Metheny et al.,Joanna Briggs Institute, 2002). Gastric</p><p>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</p><p>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 of residual feed by the in-of 20ml of air (Metheny et al., 1993). Thisdisruptive of continuous feeding regimensand Titler, 2001).ation is a popular method used by nursesenteral tube position. Approximatelyof air is rapidly injected though the en-to produce the sound of air gurgling</p><p>cultating over the upper abdomen. Falsesults have been experienced, regardlessntestinal or respiratory placement, of-g it difcult for even skilled clinicians</p><p>entershouldtermiMethe</p><p>Othmenting) (Ainspectect Ccommto motioninAsai araphylevelsor absadver(Burnscoloritectsplacem2002)fully efor its</p><p>If ptive palthounarrowcriticaable t</p><p>Visleadinuid ofor ga1990)cose dand R</p><p>Thesitiontors oan incKearnRakelmore(Fellowell aray shauthomendet al.sessmhave n(Methbe position (Metheny et al., 1990) andt be relied on as the sole method to de-nteral tube location (Arrowsmith, 1993;1993).ethods used to verify enteral tube place-de capnometry (carbon dioxide monitor-jo-Preza et al., 2002) phonation and visual. Capnometry and capnography (both de-are noninvasive monitoring techniquesused in critical care and anaesthesia</p><p>r and evaluate respiratory system func-d ventilation (Araujo-Preza et al., 2002;tacey, 1994; Burns et al., 2001). Capnog-luates breathing patterns and differentO2 graphically. Recognising the presencee of a waveform is used to determine in-respiratory placement of enteral tubesl., 2001). A simpler method is to attach aric end-tidal CO2 detector. This device de-lour when exposed to CO2, implying mis-t of the feeding tube (Araujo-Preza et al.,is promising new technology is yet to beated for clinical use and may be limitedoutside the ICU.ation becomes impaired in a communica-nt then tracheal entry may have occurredmpairment of phonation is not likely withre tubes (Arrowsmith, 1993). As manyll patients are intubated, this is not a suit-for ICU.nspection of gastric contents may be mis-the aspirate is straw coloured. Pleuralis yellowish colour and may be mistaken</p><p>c uid (Metheny, 1993; Metheny et al.,of coloured dyes in enteral feeds and glu-</p><p>ction methods are not supported (Maloney2002).dside methods to verify enteral tube po-e all been reported as unreliable indica-acement and have been associated withed risk of aspiration (Arrowsmith, 1993;d Donna, 2001; Metheny et al., 1990;al., 1994). In the absence of an X-ray,one bedside method should be employedt al., 2000). pH testing of the aspirate asauscultation (if there is any doubt, an X-be performed) is recommended by onerowsmith, 1993), whereas others recom-lysing aspirate colour and pH (Metheny98a,b). Reliable versions for bedside as-using enzyme tests and bilirubin analysiset been developed for clinical applicationand Titler, 2001).</p></li><li><p>8 T.A. Williams, G.D. Leslie</p><p>Feeding regimens</p><p>The optimum commencing volume of feed or howquickly target nutrition goals should be obtainedhas not been established by research. Regimes usedare derived from expert opinion preventing recom-mendations for best practice to be made. A vari-ety of feeds are available and should be tailored tomeet each patients individual needs. Studies inves-tigating enteral immunonutrition have found somebenets including decreased infections, ventilatordays and hospital length of stay but no change inmortality rates (Atkinson et al., 1998; Beale et al.,1999). Further research of different feeding regi-mens and types of feed are needed to determinebest practice.</p><p>Tube patency</p><p>Tube patency is important for maintaining nutri-tional and uid balance requirements (Table 2). En-teral tubes are easily blocked if feeding is stoppedor interrupted for gastric aspiration or medica-tion administration. Narrow-bore tubes may col-lapse when aspirated, maybe inaccurate and aremore likewith the p(Marcuard2002; Srirteral tubedo not ha(Powell etnal tubes</p><p>for gastric residual volumes whilst the intestinaltube is used for feeding (Davies et al., 2002). Tech-nical limitations inuence the amount of residualvolume aspirated from narrow-bore tubes includ-ing the use of small syringes, collapsible siliconetubes and fewer orices on the tip of the enteraltube (McClave and Snider, 2002). Regular ushingof the intestinal tube has been reported to be ef-fective in minimising blockage (Arrowsmith, 1993).However, narrow-bore enteral tubes may ruptureif ushed (The Joanna Briggs Institute, 2002). Tounblock tubes, a large syringe (50ml) is recom-mended with 2030ml water (Arrowsmith, 1993).Pancreatic enzymes have proved successful in un-blocking enteral tubes (Marcuard and Perkins, 1988;Marcuard and Stegall, 1990; Metheny et al., 1997;Sriram et al., 1997). It is particularly importantto minimise the risk of blockage of narrow-boretubes, as they are more difcult to place than gas-tric tubes, often requiring image intensication toaid with correct positioning.</p><p>Contamination of feeds and equipment</p><p>Contamination in enteral feeds is inuenced by thef fehe eand, 20ioned iionoms</p><p>Table 2</p><p>Study</p><p>Marcuardevaluatocclusioefcacypancreaclear o</p><p>0</p><p>Powell etwhetheoccludethey wegastricgastricchecke</p><p>Sriram etthe propancreapatencyly to block when the gastric acid mixesrotein of enteral feed congealing the feedand Perkins, 1988; McClave and Snider,</p><p>am et al., 1997). A lower incidence of en-occlusion may be experienced if patientsve their gastric residual volumes checkedal., 1993). Rather than aspirating intesti-, a gastric tube may be used to check</p><p>type oand tparedet al.infectand fenutritsympt</p><p>St...</p></li></ul>

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