The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [278]
If a number of different medications are required always administer separately. Do not mix medications unless advised to do so by a pharmacist.
Procedure guideline 8.13 Enteral feeding tubes: administration of medication
Essential equipment Optional equipment
50 mL enteral syringe
Mortar and pestle or tablet crusher if tablets are being administered (BAPEN 2003a)
Tap water or sterile water (for jejunostomy tubes or for patients who are immunosuppressed) (NICE 2003). Water should be fresh and kept covered
Preprocedure
Action Rationale
1 Check whether patient can take medication orally, whether medication is necessary or if it can be temporarily suspended.
If patient can take medication orally this reduces the risk of tube blockage (BAPEN 2003b, C).
2 Consider whether an alternative route can be used, for example buccal, transdermal, topical, rectal or subcutaneous.
If patient can take medication via an alternative route this reduces the risk of tube blockage (BAPEN 2003b, C).
3 Check drug is absorbed from the site of delivery.
Some drugs may not be absorbed directly from the jejunum (BAPEN 2003b, C).
4 Clean hands with bactericidal soap and water or alcoholic handgel. Put on non-sterile gloves.
To minimize cross-infection and protect the practitioner from gastric/intestinal contents (Fraise and Bradley 2009, E).
Procedure
5 Stop the enteral feed and flush the tube with at least 30 mL of water (sterile water for jejunostomy administration), using an enteral syringe.
To clear the tube of enteral feed as this may cause a blockage or interact with medications. Sterile water should be used for jejunostomy tubes as the water is bypassing the protective acidic environment of the stomach. E
Where there is an absolute contraindication for medicine to be taken with feed:
6 Stop the feed 1–2 hours before and 2 hours after administration (this will depend on the drug), for example for phenytoin administration, stop feed 2 hours before and 2 hours after.
To avoid interaction with enteral feed. E
7 Consult with the dietitian to prescribe a suitable feeding regimen.
To ensure that the patient’s nutritional requirements are met in the time available around medicine administration (BAPEN 2003b, C).
8 Prior to preparation, check with the pharmacist which medicines should never be crushed.
Some medications are not designed to be crushed.
These include:
(a) modified-release tablets: absorption will be altered by crushing, possibly causing toxic side-effects
(b) enteric-coated tablets: the coating is designed to protect the drug against gastric acid
(c) cytotoxic medicines: this will risk exposing the practitioner to the drug (BNF 2011, C).
9 Prepare each medication to be given separately. Volumes greater than 10 mL may be drawn up in a 50 mL syringe and administered via the tube. For small volumes (less than 10 mL) follow step 12.
To avoid interaction between different medications and to ensure solubility (BAPEN 2003b, C).
Either
Soluble tablets: dissolve in 10–15 mL water.
Or
Liquids: shake well. For thick liquids mix with an equal volume of water.
Or
Tablets: crush using a mortar and pestle or tablet crusher and mix with 10–15 mL water.
10 Never add medication directly to the enteral feed.
To avoid interaction between medicines and feed (BAPEN 2003b, C).
11 Administer the medication through the tube via a 50 mL syringe. Rinse the tablet crusher or mortar with 10 mL water, draw up in a 50 mL syringe, and flush this through the tube.
To ensure the whole dose is administered (BAPEN 2003b, C).
12 If volumes of less than 10 mL are required, the dose should be measured in a 10 mL oral syringe. The plunger of a 50 mL syringe should be removed and the 50 mLsyringe connected with the enteral tube. The dose should then be administered into the barrel of the 50 mL syringe and the 10 mL syringe rinsed with water, which should also be administered via the barrel of the 50 mL syringe.
To ensure the whole dose is administered (BAPEN 2003b, C).
13 If more than one