The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [270]
Paediatric feeds
These are designed for children 1–12 years old and/or 8–45 kg in weight. The protein, vitamin and mineral profile is suitable for children. Generally they are lower in osmolarity than adult feeds. The whole-protein/polymeric feeds are based on cow’s milk but are lactose free. Some of these feeds may contain dietary fibre. These feeds provide 1.0–1.5 kcal/mL for children who require additional energy and protein in a smaller volume. Protein hydrolysate feeds and elemental feeds are used in conditions such as food allergies or malabsorption. Some specialist centres use these feeds for enteral feeding during bone marrow transplants as children may have malabsorption caused by gut mucositis. The osmolarity of these feeds is higher than whole-protein feeds. They need to be introduced carefully (Thomas and Bishop 2007).
Immune-modulating feeds
There is evidence to show that the addition of glutamine, arginine or omega-3 fatty acids, if given preoperatively, may benefit postsurgical GI patients by reducing the risk of postoperative infections. These specialized liquids may be given pre- or postoperatively (Braga et al. 2002, Weimann et al. 2006).
Up-to-date information on the exact composition of dietary supplements and enteral feeds can be obtained from the manufacturers.
Enteral tube insertion
Evidence-based approaches
Rationale
It is essential that the position of the nasogastric tube is confirmed prior to feeding to ensure that it has been placed safely in the gastrointestinal tract and has not been inadvertently placed in the lungs. A wire introducer is provided with many of the fine-bore tubes to aid intubation.
Indications
Patients who require short-term enteral tube feeding (2–4 weeks) as a sole source of nutrition or for supplementary feeding.
Indications for insertion without using an introducer: it is recommended that a nasogastric tube designed for feeding purposes be used wherever possible, for example fine-bore feeding tube, rather than a Ryle’s tube, without an introducer, which is used for drainage of gastric contents.
Contraindications
Patients who require long-term enteral tube feeding in whom it may be more appropriate to use a gastrostomy tube.
Patients with coagulation disorders should have blood clotting checked by the medical team and appropriate blood products administered if required prior to insertion.
Anticipated patient outcomes
The patient has a nasogastric tube inserted comfortably and safely. The position is checked and it is confirmed that the tube is placed in the stomach.
Legal and professional issues
Those passing the nasogastric tube should have achieved competencies set by the local trust. The procedure should be compliant with the National Patient Safety Agency (NPSA) recommendations, that is, only using syringes that are compatible with enteral feeding tubes (NPSA 2007b).
Preprocedural considerations
Specific patient preparations
The planned procedure should be discussed with the patient so they are aware of the rationale for insertion of a nasogastric tube. Verbal consent for the procedure must be obtained from the patient.
Prior to performing this procedure, the patient’s medical and nursing notes should be consulted to check for potential complications. For example, anatomical alterations due to surgery, such as a flap repair, or the presence of a cancerous tumour can prevent a clear passage for the nasogastric tube, resulting in pain and discomfort for the patient and further complications. The assessment of the patient and consent obtained should be clearly documented.
Social and psychological impact
For some patients a nasogastric tube can be distressing. This is not only due to physical discomfort but also people’s perceptions of their body image, particularly as this type of feeding tube is highly visible. Some people find that they limit their social activity due