Policystat hospital policy and procedure management system

Current Status: Active
PolicyStat ID: 399614
Last Approved Date:
Last Revised:
Policy Area:
Enteral Nutrition Support
To provide guidelines for the safe and effective use of enteral tube feedings for inpatients.
A. The following patients should be considered for enteral nutrition support: 1. Inpatients that have a functional gastrointestinal tract, but have clinical indications in which oral intake is impossible, inadequate or unsafe.
2. Inpatient who are malnourished and those who are at high risk for becoming malnourished through oral intake alone.
3. The critically ill patient who is unable to maintain volitional intake.
B. Inpatients shall not be without adequate nutrition support for greater than five consecutive days in adult patients and not more than three consecutive days in pediatricpatients or neonates, unless a reason (e.g., patient or family refuses) is documented inthe medical record.
1. It is the responsibility of the resident and attending physician to order appropriate 2. For critically ill patients, enteral feeding should be started early within the first 24-48 hours following admission if medically able. Neither the presence norabsence of bowel sounds nor evidence of passage of flatus and stool is requiredfor the inititation of enteral feeding.
3. If failure to comply with provision of adequate nutrition continues, a retrospective review may occur via an online Incident Report.
A. The physician or physician designee orders nasogastric or nasoduodenal feeding tubes 1. Small tubes, 8-12F are recommended. Infant feeding tubes (inserted with larger tube and gelatin capsule) and weighted tubes are available Retrieved 03/06/2013. Official copy at http://uci.policystat.com/policy/399614/. Copyright 2013 University of California Irvine 2. Large 18F tubes (e.g. Levin or Salem) are not in general recommended because of inpatient discomfort, tube-induced trauma, increased gastroesophageal reflux,and risk of aspiration B. Placement of feeding tubes in inpatients: 1. Nasogastric or nasoduodenal/nasojejunal tubes: physician or physician delegate or nursing places either styleted or non-styleted tubes. Physician or physiciandelegate confirms placement by radiologic technique for nasogastric feedingtubes for all adult and pediatric patients, except neonates in the NICU; confirmsplacement for nasoduodenal/nasojejunal feeding tubes for all patients.
2. Gastrostomy feeding tubes: placed by a credentialed surgeon in the appropriate patient care area. Gastroenterologist/Radiologist places gastrostomy inappropriate patient care area.
3. Jejunostomy feeding tubes: the credentialed surgeon places the jejunostomy tube in the operating room. The credentialed Radiologist places the jejunostomytube in the Radiology Intervention Suite.
C. The Hospital Enteral Nutrition Formulary is developed and maintained by the Clinical Nutrition Department and the Nutrition Support Committee.
1. The Clinical Nutrition Department presents significant changes to the Enteral Nutrition Formulary to the Nutrition Support Committee and then the Pharmacy &Therapeutics Committee for review and approval. Cost effectiveness will beevaluated.
2. Registered Dietitians make enteral feeding recommendations for individuals based on nutrition assessment, consideration of metabolic abnormalities,evaluation of gastrointestinal function, overall medical condition, and expectedoutcomes for each individual patient.
3. The physician or physician delegate orders enteral feeding products from the approved formulary that are clinically appropriate for patients D. The physician or physician delegate orders enteral tube feedings for inpatients 1. Patient identifiers, enteral formula name, specific delivery site/device with administration method and rate (bolus, gravity, or continuous method; volume orrate of administration, and timing of formula delivery within a specified period oftime, 24 hours or cyclic) should be clearly set forth in an enteral nutrition order. Inaddition, tube feeding advancement and transitional orders need to be specified.
2. Ancillary orders for care of the enterally fed patient, such as orders for flushing the enteral access device, head of bed elevation, monitoring residuals,observation for gastrointestinal tolerance and monitoring laboratory parametersshould also be clarified.
3. For adults: bolus and gravity-controlled feedings may be initiated with full- strength formula 3-8 times per day with increases of 60-120ml every 8-12 hours,or faster, as tolerated up to the goal volume. Pump-assisted feedings arefrequently initiated at full strength at 10-60ml/hour and advanced to the goal ratein increments of 10-20ml/hour every 4-6 hours as tolerated.
4. For children: bolus feedings and gravity-controlled feedings may be started with 25% of the goal volume divided into the desired number of daily feedings.
Retrieved 03/06/2013. Official copy at http://uci.policystat.com/policy/399614/. Copyright 2013 University of California Irvine Formula volume may be increased by 25% every 4-12 hours as tolerated. Pump-assisted feedings may be initiated at full strength at 1-10ml/hour and advancedto the goal rate in increments of 1-10ml/hour every 4-12 hours as tolerated.
5. Neonates: a specific Enteral Feeding Protocol is used for neonates in the NICU.
6. Aspiration precautions should be ordered with esophageal or gastric feedings a. Evaluate all enterally fed patients for risk of aspiration.
b. Check gastric residuals every 4 hours during the first 48 hours for all gastric or post pyloric fed patients and then after enteral feeding goal rateis achieved, gastric residual monitoring may be decreased to every 6-8hours in non-critically ill patients. In critically ill patients, gastric residualmonitoring should continue every 4 hours daily even though goal rate hasbeen attained.
c. If the GRV (gastric residual volume) is 200-500ml after a second gastric residual check, the patient may be at risk for aspiration. Considerimplementation of a promotility agent or post pyloric feeds d. A GRV >500ml should result in holding enteral feeding and reassessing patient tolerance by use of physical assessment, evaluation of glycemic control, minimization of sedation, and consideration of promotility agentuse, if not already prescribed.
E. Nursing administers tube feedings in inpatients.
1. Maintain patients in an upright to a minimum of 30 degrees and preferably to 45 degrees or reverse Trendelenburg position during the feedings and for 30minutes following intermittent feedings.
2. Verify tube placement every shift.
3. Aspirate gastric contents to determine residual. If the residual is greater than the MD ordered residual amount, discard the residual and hold the tube feeding for 2hours, then recheck.
4. Obtain enteral feeding formulas from the Nutrition Services Department. Mixed feedings (feedings that have been diluted or prepared from powder of those withadded modular components) are delivered to the nourishment center refrigeratoron each patient floor. Full strength canned feedings and closed feedings aredelivered to inpatients’ unit nourishment area. Standard infant formulas arestocked on the neonatal units.
5. Discard refrigerated mixed feedings or open cans after 24 hours.
a. For open system: place no more than a 4 hour volume of mixed feeding formula in the feeding bag. Sterile, decanted formula should have an 8hour hang time unless used for a neonate where hang time should belimited to 4 hours. Formula should be discarded from the bag after fourhours at room temperature. Administration sets and bags containing anyunused enteral formula should be discarded after this time.
b. For closed system: the closed tube feeding system may hang up for up to 24 hours; a longer hang time of 48 hours may be permitted ifrecommended by the manufacturer. Strict aseptic technique should be Retrieved 03/06/2013. Official copy at http://uci.policystat.com/policy/399614/. Copyright 2013 University of California Irvine used in the preparation and administration of enteral formulas. Use ofdisposable gloves is recommended in the administration of enteralformula.
6. Flush tube feeding bag and tube with water (e.g. 30ml) every 4 hours during continuous feeding or before and after intermittent feedings in and adult patientor per MD order.
7. Administration sets for open system enteral feedings should be changed at least every 24 hours. Label the bag with the date and time it was changed and initial.
9. Flush feeding tube with at least 30ml water every four hours if feeding is temporarily discontinued for adult patients.
F. Feeding tubes will be unclogged as follows (age 1 or greater): 1. The physician, physician delegate or nurse enters order for Creon capsule (amylase 30,000, lipase 6,000, protease 19,000) or similar pancreatic enzymeformulation.
2. Open and empty contents of capsule and finely crush the microsphere contents.
3. Crush one sodium bicarbonate 324mg tablet.
4. Mix Creon and sodium bicarbonate powder together with 5ml sterile water 5. Draw up solution into a Toomey syringe (or similar oral syringe) and instill into feeding tube. Clamp the tube below the Toomey syringe /tube connection to holdsolution within the tube.
6. Clamp for 30-60 minutes. Flush with warm water until clear.
7. Refrigerate remaining solution and use within 24 hours.
8. DO NOT attempt to unclog feeding tubes with soda or juice.
G. Inpatients will be monitored while receiving enteral tube feedings.
1. The physician or physician delegate monitors fluids and electrolytes and other metabolic parameters as needed based on the patient’s clinical situation. Checksmetabolic and nutrition parameters and corrects depleted levels prior to theinitiation of enteral feedings.
2. The physician or physician delegate orders appropriate labs and monitoring a. Patients may need special tests such as nitrogen balance, serum 3. Nursing measures and records intake and output every shift, including volume of 4. Nursing measures weights weekly or more frequently if ordered by the physician.
Weights are recorded on nursing flow sheets and in QUEST.
5. Hold tube feedings one hour prior to administration of liquid dilantin and one hour post administration unless otherwise specified.
H. Enteral tube feedings for inpatients will be documented in the medical record as follows: Retrieved 03/06/2013. Official copy at http://uci.policystat.com/policy/399614/. Copyright 2013 University of California Irvine 1. The Registered Dietitian assesses and documents the adequacy and appropriateness of the ordered tube feeding regimen and actual intake based onthe patient’s tolerance, medical condition and a reasonable estimate of needsper high risk protocol.
2. The physician or physician delegate acknowledges the Registered Dietitian’s IV. REFERENCES
1. ASPEN Enteral Nutrition Practice Recommendations. JPEN J Parenter Enteral Nutr 2. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society forParenteral and Enteral Nutrition (ASPEN). JPEN J Parenter Enteral Nutr 2009; 33:277-316 3. Parrish, Carol: Nutritional issues in Gastroenterology, series #9 Enteral Feeding:Dispelling Myths. Practical Gastroenterology. September 2003 4. McClave, Stephen A. et al: Poor Validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care med. 2005 vol. 33, No.2 5. Williams, A.T., Leslie, Gavin D.,: A Review of the Nursing care of enteral feeding tubes in critically ill adults: Part II. Intensive and Critical Care nursing (2005) 21, 5-15 6. Lippincott, William & Wilkins: 2006 Lippincott Manual of Nursing Practice, Eighth edition Author: Jennifer Fix, Nutrition Services
Nance Hove 03/2013Nance Hove 03/2013Nance Hove 03/2013 Retrieved 03/06/2013. Official copy at http://uci.policystat.com/policy/399614/. Copyright 2013 University of California Irvine

Source: http://www.healthaffairs.uci.edu/hr/uclc/elearning/linkeddocs/kangarooepump/nutritionenteralguidelines.pdf

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