CHAPTER 28

ENTERAL NUTRITION AND INTRAVENOUS THERAPY

 ENTERAL NUTRITION
People who cannot chew or swallow often require enteral nutrition a nutritional
formula delivered into the gastrointestinal tract through a feeding tube. Gavage
is another term for tube feeding.
Feeding tubes are used when food cannot pass normally from the mouth into the
esophagus and then into the stomach.
This can arise from cancers of the head, neck, dysphagia caused by paralysis and
coma. People with dementia who no longer know how to eat may require tube
feedings. There are various feeding tubes.
 FEEDING TUBES
1. Nasogastric tube: is inserted through the nose into the stomach.
2. Nasointestinal tube: is inserted into the nose into the small intestine
3. Gastrostomy tube: is inserted into the the stomach, a surgically created
opening in the stomach is needed for this procedure
4. Gastrojejunostomy tube: is a combination device that includes access to both
the stomach and the jejunum. It is also known as a GJ-tube. Typically tubes
are placed into a G-tube stoma, with a narrower long tube continuing
through the stomach and small intestine. The Gj-tube is used if the client has
a high risk of aspiration or when a tube cannot be placed into the client’s
stomach. It must be inserted by a physician in a hospital setting.
 FEEDING TUBES
1. Jejunostomy tube: is inserted into the intestines. A surgically created
opening in the middle part of the small intestine is needed for this
procedure. It is also known as a J-tube.
2. Percutaneous endoscopic gastrostomy tube: is a G-tube that is inserted with
the use of an endoscope, which is a lighted instrument that allows the
physician to see inside a body cavity or organ, such as the stomach. The
physician inserts the endoscope through the person’s mouth and esophagus
and into the stomach. A stab or puncture wound is made through the skin
and into the stomach. A tube is inserted into the stomach through the
puncture wound.
 FEEDING TUBES
Gastronomy, J-tube, and PEG tubes are used for long term enteral nutrition.

An ostomy is a surgically created opening that is used to drain wastes or to feed

the client. The ostomy may be temporary or permanent. The nurse is normally
responsible for running the formula through the enteral site. The physician or
dietician orders the type of formula and the amount to be given to the client.

Most formulas contain protein, carbohydrates, fat, vitamins, and minerals.

 SCHEDULED AND CONTINUOUS FEEDINGS
Scheduled feedings usually are given four times a day using a syringe, a rigid plastic container,
or a feeding bag. Usually about 400 mL is given over 20 mins during a scheduled feeding. The
amount and rate are the same as those for regular meals. The physician will also specify how
much water is to be given to the client each day, with the usual recommended amount being
2000 mL/day.
Continuous feedings require electronic feeding pumps. Nasointestinal and jejunostomy tube
feedings are always continuous. Sometimes continuous feedings are kept cold with ice chips
around the container to prevent the growth of microbes. The formula warms to room
temperature as it drips from the bag and passes through the connecting tubing to the feeding
tube. Formula is given at room temperature, as cold fluids can cause stomach cramping. When
the feeding is continuous, the nurse adds formula as needed. When assisting with or providing
care to clients receiving enteral feedings, it is important to follow your facility policies and the
client’s care plan at all times.
 F0CUS ON HOMECARE
As a support worker you may provide home care to clients who are being fed via
tubes, or in a facility you may assist the nurse with a tube feeding.
You should take care never to:
1. Insert feeding tubes
2. Test the position of the tube
3. Give the first dose of a tube feeding
Some homecare agencies permit support workers to start feeding pumps and
tubes but only if the tube has been established. These tasks are always delegated
by a nurse. A home care nurse will teach you the task, either individually or in a
course given by your employer.
 PREVENTING PROBLEMS RELATED TO TUBE FEEDINGS
Nasogastric and nasointestinal tubes pass through the esophagus and then into the stomach or
small intestine. During insertion, the tube could accidentally slip into the respiratory tract,
causing aspiration, which can cause pneumonia and even death. An x-ray is therefore usually
taken after insertion to determine correct tube placement.

Coughing, sneezing, vomiting, suctioning, and poor positioning can move the tube out of place.
A confused client can also move the feeding tube by pulling on it. The tube can move from the
stomach or intestines into the esophagus and then into the airway. A nurse will check tube
placement before every scheduled feeding. In the case of continuous tube feedings, the nurse
checks tube placement every 4-8 hours, depending on the employer’s policy. To do so a nurse
attaches a syringe to the tube and aspirates gastrointestinal secretions. Then the nurse
measures the pH of the secretions. The pH readings will indicate if the tube has moved, since
the pH readings for stomach contents and intestinal contents differ.
 PREVENTING PROBLEMS RELATED TO TUBE FEEDINGS
With nasogastric, gastrostomy, and PEG tubes aspiration can also occur from
regurgitation, which is the backward flow of food from the stomach into the
mouth. Delayed stomach emptying and overfeeding are common causes of
regurgitation. To prevent regurgitation, the client should be in the sitting or
semi-Fowler’s position for the feeding and should remain in this position for 1-2
hours after the feeding to promote movement of the formula through the
gastrointestinal system and prevent aspiration. The left side lying position has to
be avoided, as it prevents emptying of the stomach,
The risk for regurgitation is less with nasointestinal and jejunostomy tubes.
Formula is given at a slow rate and passes directly into the small intestine.
 SIGNS OF ASPIRATION
Aspiration is the inhalation of fluid or an object into the lungs. It is a very serious
condition because it can cause breathing problems and infection. It is a major
complication of nasogastric and nasointestinal tube feedings. The following are
signs of aspiration in a client that should be immediatelyseen to:
1. Coughing or choking during the feeding
2. Change in breathing from normal to difficult, noisy, or rapid and shallow
3. Wet, gurgly voice
4. Pale or bluish lips
If you think that aspiration has occurred, stop the feeding immediately, make
sure the client is sitting up and the airway is clear, and call for medical help.
 OTHER POTENTIAL PROBLEMS RELATED TO TUBE FEEDINGS
Besides aspiration, which is the major risk, diarrhea, constipation, and delayed stomach emptying can
also occur with tube feeding. Report the following immediately:

1. Nausea
2. Discomfort during the tube feeding
3. Vomiting
4. Diarrhea
5. Distended (enlarged and swollen) abdomen
6. Coughing
7. Complaints of indigestion or heartburn
8. Redness, swelling, drainage, odour, or pain at the ostomy site
9. Elevated temperature
10. Signs and symptoms of respiratory distress
11. Increased pulse rate
12. Complaints of flatulence
 COMFORT MEASURES FOR THE CLIENT WITH A TUBE FEEDING
The client with a feeding tube is usually NPO. When dry mouth, dry lips, and sore throat
cause discomfort, clients can suck on hard candy or chew gum, if allowed. Since one
nostril is obstructed by the feeding tube, the client may breathe through the mouth, so
frequent oral hygiene, lubricant for the lips, and mouth rinses are necessary.
Sometimes an ice bag applied externally to the throat can give relief for a sore throat.

Nasogastric and nasointestinal tubes can irritate and cause pressure on the nose. The
nose and nostrils also are cleaned every 4-8 hours, depending on the policy of your
workplace. To ensure that the tube does not exert pressure against the nostril,
reposition the tube slightly away from the nostril. Sometimes, tubes alter the shape of
the nostrils or cause pressure sores. Securing the tube helps to prevent these problems.
 INTRAVENOUES THERAPY
Intravenous therapy also referred to as IV or IV infusion involves giving fluids through an
injection port, needle, or a cannula, or catheter into a vein. A cannula (sometimes called a
catheter) is plastic tubing threaded over a needle. Once the cannula or catheter is inserted into
the vein, the needle is withdrawn. Physicians order IV therapy for the following purposes:
1. To provide needed fluids when a client cannot take fluids by mouth
2. To reverse dehydration in the body
3. To replace minerals and vitamins lost because of illness or injury
4. To provide sugar for energy
5. To administer medications such as antibiotics
6. To administer blood and blood products
7. To provide hyperalimentation: which is the giving of a solution that is highly concentrated
in nutrients
IV therapy is given in the hospital, outpatient care, subacute care, LTC, and home care settings.
Nurses are responsible for IV therapy, they start and maintain the infusion, according to MD
orders and also give IV medications and administer blood.
 COMMON INTRAVENOUS SOLUTIONS
IV solutions vary in volume and contents, and are ordered by the physician or an NP.
They may be ordered to run intermittently, such as only when a medication needs to be
infused, or continuously, such as to rehydrate a person. Some may have electrolytes
such as potassium added to replenish what the client’s body has lost.
Specific types of IV solutions are ordered to meet the specific health needs of each
client. If the client is to have a blood transfusion, they may require a 0.09% NaCl
solution IV as this is isotonic and therefore compatible with bodily fluids such as blood.
Examples of common IV solutions include 5% dextrose solution, 0.09% NaCl solution, or
5% dextrose mixed with a 0.45% NaCl solution. Whatever the IV solution that is ordered,
it must be sterile, and sterile technique must be maintained to avoid introducing
potentially life threatening bacteria into the body.
 INTRAVENOUS THERAPY
Clients receiving IV therapy in their homes often have central venous catheters.
The nurse teaches the client and family about administering IV medications and
managing the catheter. Because these catheters or cannulas are inserted directly
into a vein, you must be very careful when providing care.
Ensure that you do not do anything around the insertion point that could
dislodge the catheter. Report immediately any redness around the site. If a
catheter falls out, apply pressure with sterile gauze until bleeding stops, and
immediately inform your nurse. If you are giving a tub bath to the client, ensure
that the IV tubing is kept dry if your client has a pump, it must be unplugged
before the client enters the water. If your client is having a shower, keep the IV
site dry by covering it with plastic wrap. Your nurse will give directions for care.
 ASSISTING WITH INTRAVENOUS THERAPY
As a support worker, you help meet the hygiene and activity needs of clients who
are receiving IV therapy but you are never responsible for starting or maintaining
IV therapy.

A client who has an IV will also need the support worker’s assistance to dress and
either the support worker or nurse should teach the client how to ambulate safely
with an IV line.

Complications can occur from IV therapy. Report at once if you see any signs and
symptoms.
 SIGNS AND SYMPTOMS OF INTRAVENOUS THERAPY
COMPLICATIONS
As a support worker, you must report any of these signs or symptoms to your
nurse immediately:

1. Bleeding
2. Puffiness or swelling
3. Pale or reddened skin
4. Complaints of pain at or above the IV site
5. Hot or cold skin near the site
6. Leaking or fluid from the site
 SIGNS AND SYMPTOMS OF INTRAVENOUS THERAPY
COMPLICATIONS
Systemic: involving the whole body:
1. Fever
2. Itching
3. Drop in blood pressure
4. Tachycardia (pulse rate more than 100 beats per minute)
5. Irregular pulse
6. Cyanosis
7. Changes in mental function
8. Loss of consciousness
9. Difficulty breathing
10. Shortness of breath
11. Decreasing or no urine output
12. Chest pain
13. Nausea
14. Confusion
 SAFETY MEASURES FOR INTRAVENOUS THERAPY
1. The position of the IV needle or catheter must be maintained. Do not move the
needle, cannula, or catheter. If the needle or cannula is moved, it may come out of
the vein; fluid will flow into the tissues, or the flow will stop. If the needle or
catheter becomes dislodged, the site will bleed, apply pressure with sterile gauze
according to standard practices and contact the nurse immediately.
2. Sometimes, the nurse may apply splints or restraints to prevent movement of the
extremity and thus, the movement of the needle or cannula.
3. Protect the IV bag, tubing and needle or cannula when ambulating the client.
Portable IV stands are rolled along next to the client. When assisting the client to
change gowns, care must be taken to prevent dislodging the needle or cannula.
4. Assist the client with turning and repositioning. Move the bag to the side of the bed
where the client is lying. Always allow enough slack in the tubing to ensure the
needle or cannula does not dislodge due to pressure on the tube.
 SUBCUTANEOUS INFUSION THERAPY
Many clients who receive palliative care or suffer from persistent pain may
require frequent injections of pain medications to help reduce their pain. In
many instances, the client may still be in pain despite having a topical pain patch.
Numerous injections may cause discomfort and possible infections or skin
problems around the injection sites. To eliminate the need for frequent
injections subcutaneous infusion therapy is ordered.

The injection is given through a port in which a needle is inserted into the fatty
area. IV tubing is then connected, pain medication as well as fluids can be given.