/ Policy Title: Insertion of Feeding Tube by
Nursing Personnel
Category:
Number
Date Originated:
August 2013 / Effective Date:
Last Review Date:

PURPOSE:

Establishment of a procedure for trained Critical Care nursing personnel to place weighted nasoduodenal feeding tubes (FT).

POLICY:

Post pyloric feeding tubes are inserted by a radiologist using fluoroscopy or by a physician via endoscopy or by trained Critical Care Nurses using non-radiological bedside technique.

NOTES:

  • For the insertion of the weighted feeding tube utilizing the Cortrak device, please refer to Mosby Nursing Skill for Cortrak: Small-bore feeding tube insertion.
  • Goal for first attempt by nursing staff to place weighted feeding tube at bedside placement is two hours within receipt of physician order.

EXCLUSION CRITERIA:

Nursing staff should not attempt to place feeding tube if patient has history of:

  • Previous or current esophageal or gastric disease, injury or surgery (i.e. varices, trauma, esophageal repair, Bilroth I or II or gastric bypass)
  • Recent suspected or confirmed facial trauma

PROCEDURE:

  1. Explain the procedure to the patient.
  2. Wash hands and put exam gloves on.
  3. Determine which nostril is preferable (i.e. patient preference, history of nasal fracture and/or septal deviation).
  4. If present, nasogastric tube may be removed per RN discretion. If left in place, empty stomach contents and then clamp NG tube prior to insertion of FT.
  5. Prepare FT for insertion according to the package directions. Ensure stylet is firmly inserted into FT.
  6. Measure distance from tip of the nose to the earlobe and from there to the xyphoid process. Add 10 cm. to this measurement.
  7. Place patient on right side with head of bed elevated, unless contraindicated.
  8. If patient is not allergic, 2% Lidocaine jelly may be used in nares prior to insertion of tube, for patient comfort.
  1. Pass feeding tube through the nares to a length of 30 cm, then rule out tracheal placement by capnography using the Easy Cap II CO2 Detector: take a 7.5 mm endotracheal tube (ETT) adapter and insert the tapered end into a 3 mL syringe, insert the other end of the syringe into the feeding tube port. Attach the CO2 detector to the ETT and wait 1 minute. No color change should be observed if feeding tube tip lies in esophagus. If color change is noted, withdraw tube and reattempt placement.
  2. When capnography is confirmed to be negative for CO2, continue with feeding tube placement to the fundus of the stomach as previously measured.
  1. Confirm gastric placement by one of the following methods:

a.Acidic pH (less than 5) of aspirate

  1. Aspiration of bilous material
  2. Auscultation of injected air over the epigatrium
  3. Abdominal x-ray (KUB). KUB is necessary only if gastric placement is questionable after capnography and a, b or c above.
  1. After gastric placement confirmed, proceed with post-pyloric placement by one of the following two methods (Air Insufflation or Zaloga):

a.Air Insufflation Method of Insertion:

i.Attach a 60 mL syringe to the end of the FT and insert 250 mL of air into the stomach.

ii.With the 60 mL syringe attached, slowly advance the FT 10 cm (distance estimated to be at pylorus).

iii.Bolus with an additional 250 mL air PRN (to total max of 500 mL).

iv.Slowly advance FT to the 95-105 cm mark (distance estimated to be small bowel placement).

v.Confirm small bowel FT placement by:

  • Absence of recoil or spring back action
  • Difficulty aspirating 10 mL bolus of air and/or 10 mL bolus of water.

vi.Proceed to step #13 below.

b.Zaloga Method of Insertion:

i.Remove stylet and then create a 30-degree bend in the stylet approximately 3 cm from the distal tip and reinsert stylet unless resistance felt.

ii.Attach a 60 mL syringe to the proximal end of the feeding tube.

iii.Slowly advance the feeding tube while rotating the syringe counter-clockwise in attempt to “hook” the pyloric outlet.

A sudden loss of resistance indicates that the feeding tube has looped back on itself in the stomach. If this occurs, retract the feeding tube and repeat step iii above. It may be necessary to repeat this process several times. If unable to advance through the pylorus, radiological placement is indicated.

iv.Continuous low-grade resistance accompanies advancement through the pylorus.

v.Advancement into the duodenum is initially confirmed by:

  • Difficulty aspirating 10 mL bolus of air and/or 10 mL bolus of water.
  • Recheck by reinserting the wire that there is not a kink in the tube allowing flush to go in but not come out. If resistance is felt, do not advance further and suspect gastric coiling of FT.

13.Order a KUB for absolute confirmation of tube placement.

  1. Contrast is not required for initial KUB. Radiology may request follow-up KUB with contrast in instances of poor feeding tube tip visualization.
  2. Wait for radiologist confirmation of proper tube placement before using tube. (For feeding tubes placed using non-fluoroscopic (blind) bedside technique, post pyloric placement is acceptable for feeding.)
  3. If FT is not in position after two bedside attempts or 12 hours after physician order for insertion, order FT placement in radiology.

14.Stylet must be removed before crushed medication or nutrition is given via FT.

15.Document procedure in Nurse’s Notes noting placement method used and radiologic verification of placement.

16.Mark tube at exit from nares with indelible marker.

MAINTENANCE

A. Administer tube feeding as ordered.

B. Do not use an infusion pump that can deliver pressures greater than 40 psi, since

excessive pressure can cause the feeding tube to rupture.

C. Do not use a syringe smaller than 50cc to irrigate or aspirate with, since it is possible to

exceed pressure limits with smaller syringes. Use only a 50cc syringe that has a regular

tip,not an irrigating or luer lock.

D.To maintain patency, irrigate feeding tube with 20-25cc of sterile water at least every 3-4

hours when patient is receiving intermittent feedings. Irrigate every 6 hours for continuous

feedings.

E. To maintain patency it is recommended that medications not be administered through the

feeding tube. Crushed medications do not flow through the tube adequately and even liquid

medications tend to adhere to the inside lumen of the feeding tube. Both of these

outcomes make it difficult to accurately determine the amount of medication actually

delivered to the patient.

F. Irrigate with every bag change, at least q 24 hours or as ordered.

G. Keep stylet in patient’s room in case it is needed for tube reinsertion.

H.Maintain patient in a semi-Fowler’s position to reduce risk of aspiration.

REVISION HISTORY
Date of Revision / Revision Explanation / Author

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