By Deanna L. Reising, PhD, APRN,BC, and Ronald Scott Neal, BSN, RN

Transcription

1 HOURS CE3 Continuing Education What you think are the best practices may not be. By Deanna L. Reising, PhD, APRN,BC, and Ronald Scott Neal, BSN, RN Flushing an enteral tube (in other words, keeping it free of buildup) is essential because unclogging one wastes time, effort, and resources. And tubes that can t be unclogged have to be replaced, taking up even more nursing time, not to mention those resources the new tube, the X-ray to confirm tube placement that can cause the patient discomfort or injury and, of course, interrupt the delivery of crucial nutrition. Water is generally considered to be the best liquid for flushing, but there is little agreement on how much fluid to use, how often tubes should be flushed, or how to flush when administering medication. In order to shed some light on the best methods of flushing enteral tubes, we reviewed the available literature and current practices. DATA COLLECTION We took several approaches to examining the evidence. We contacted nursing education departments at 19 hospitals in Indiana to determine what, if any, practices were mandated at these institutions. We also conducted a search of nursing research and other review articles published between 1982 and 2002; for this we used the Cumulative Index to Nursing and Allied Health Literature. Using Medline, we searched medical and allied health research and nonresearch articles published in the same period; ultimately, we reviewed 21 articles. Finally, we searched for recommended practices in textbooks by major publishers that were Deanna L. Reising is an assistant professor at the Indiana University School of Nursing, Bloomington, and Ronald Scott Neal is a staff nurse on the critical care unit, Columbus Regional Hospital, Columbus, IN. The project the authors describe was funded by a grant from the Indiana University Undergraduate Research and Creative Activity Partnership. Contact author: Deanna L. Reising, dreising@indiana.edu. The authors of this article have no ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity. 58 AJN March 2005 Vol. 105, No. 3

2 used in nursing courses medical surgical nursing, fundamentals, nursing pharmacology, and nursing nutrition. Nineteen textbooks were reviewed. We focused on routine and special flushing procedures, including those used to relieve occlusions, for patients receiving nutrition or medication through enteral tubes. WHAT ARE NURSES DOING? As enteral tube flushing is under the clear purview of nursing, it s important to understand how it is generally accomplished. The results of our review reflect the variety of techniques nurses use in their practice. Nursing practices. In 1996 Mateo published the results of a study investigating nurse management of enteral tubes. 1 This research identified the main practices that nurses use when caring for patients with enteral tubes. Of the 180 nurses who responded to the 43-item questionnaire, 94% reported regularly flushing enteral feeding tubes; 29% of these flushed before feedings; 43% of them flushed after feedings; and 59% of them flushed every four hours. Nurses also flushed when administering medication: 47% of respondents reported flushing before giving medications, 95% flushed after giving medications, and 38% did so between medications. Respondents reported using tap water, sterile water, and sterile normal saline as fluids for routine flushing. Fluids used to unclog enteral tubes included carbonated beverages (81%), sterile water (49%), papain solution (46%; papain is a papaya extract used in meat tenderizers that acts as a pancreatic enzyme, breaking down proteins), and tap water (42%). Although experts routinely emphasize the importance of flushing before and after medication administration, a study reported that only 69% of nurses flushed before medication administration through enteral tubes; 98% of nurses flushed the enteral tube after administering medication. 2 This variance in practice may or may not contribute to clogged enteral tubes there is no research in this area. Institutional practices. When we contacted the 19 Indiana hospitals to ascertain their policies and procedures concerning enteral tube flushing, we found that institutions address this subject in a variety of ways. Of the hospitals surveyed, 10 had no formal policy on flushing enteral tubes. three followed flushing procedures outlined in the textbook Nursing Procedures (published by Springhouse). two required a clinician s orders for fluids and volumes. one required the use of sterile water but had no volume standard. one had no written standard, but the educator recommended 60 ml of tap water for flushes. Two important studies established water as the accepted flushing fluid and deemed cranberry juice ineffective. one required 150 ml of water to be administered before and after feedings or medications being passed through the tubes. one specified 30 to 50 ml of water to be given every four hours. A REVIEW OF THE LITERATURE How do these reported practices reflect what s in the literature? Flushing during enteral tube feedings. Two important studies established water as the accepted flushing fluid and deemed cranberry juice ineffective. 3, 4 Water was also the flushing fluid most often suggested in textbooks; only two didn t recommend a specific fluid. 5, 6 Recommendations on the amount of fluid used and the frequency and timing of flushing vary. In patients receiving continuous feedings, the amount of fluid recommended for flushing ranged from 20 to 100 ml, and the suggested frequency of flushing ranged from every four hours to every eight hours. In patients receiving intermittent or bolus feedings, the amount of fluid recommended ranged from 15 to 100 ml, and sources recommended flushing both before and after feeding. While a determination of the amount of fluid used, also called the flush volume, must take into account the patient s needs and restrictions, nurse expert Norma Metheny pointed out in a personal communication that the larger the ajn@lww.com AJN March 2005 Vol. 105, No. 3 59

3 Gastrostomy tube Abdominal wall Gastrostomy button X Entry Site Duodenum Stomach Gastrojejunostomy (through-the-stomach jejunostomy) tube Jejunum flush volume, the more likely the tube is to remain patent. Finally, many sources specified that the fluid used to flush should be warm or tepid. 6-9 Flushing between enteral medication administrations. Research and review articles have linked enteral tube clogging to the administration of med- ication. 10, 11 Scanlan and Frisch found that the number of enteral tube occlusions was greatly reduced by flushing with water before and after medication administration. 10 While all the literature examined recommended flushing with water between enteral medication administrations, there are differences of 60 AJN March 2005 Vol. 105, No. 3

4 Enteral Tubes The three most commonly placed tubes. Enteral tube feeding may be indicated when a patient cannot receive adequate nutrition orally. This inability can result from trauma, congenital dysphagia, impaired swallowing caused by neurologic conditions, or obstruction or tissue destruction caused by neoplasms. Metabolic disorders or absorption problems may necessitate enteral feeding, as well. Short-term feeding (of less than four weeks duration) can be managed with a nasogastric tube. The most commonly used tubes for long-term feeding are pictured at left: the gastrostomy tube, the gastrostomy button, and the gastrojejunostomy tube. A number of factors dictate the choice of tube, including the expected duration of feeding, the condition necessitating the feeding, concomitant conditions, and clinician preference. Percutaneous endoscopic gastrostomy (PEG) is the most common method of tube insertion because of its safety and effectiveness; it s associated with low rates of morbidity and mortality and decreased costs because surgery and general anesthesia aren t necessary for tube insertion. The tube is placed under direct endoscopic visualization through an abdominal incision and anchored in place with an outer flange and an inner bumper or balloon. The gastrostomy tube feeds directly into the stomach and poses fewer risks of serious adverse effects than the gastrojejunostomy tube. The gastrojejunostomy tube, the through-thestomach jejunostomy tube, delivers its contents into the jejunum and is indicated in patients with recurrent aspiration, upper gastrointestinal obstruction or fistula, gastroparesis, and gastroesophageal reflux. It cannot be used in patients with small-bowel disease because it can cause enterocutaneous fistulae. And because these are smaller-bore tubes they tend to clog more often than gastrostomy tubes, requiring more frequent tube flushing or replacement. The gastrostomy button came along in 1984 in an effort to prevent some of the chronic complications of gastrostomy tubes clogging, leakage, and skin irritation. The button is skin level and out of site when the patient is dressed. It usually replaces a gastrostomy tube four weeks after initial PEG (this period ensures a mature tract). Recent advances have allowed for primary button insertion if gastropexy (attachment of the stomach to the abdominal wall) is also performed at the time of insertion; long-term results of this procedure aren t known. Patients with any type of tube placement must be assessed for leakage (high abdominal pressure, as occurs with sneezing or coughing, often causes some normal leakage), skin irritation, infection, and formation of granulation tissue. Nutrition and hydration status, and signs or symptoms of aspiration, pneumonia, or gastrointestinal complications such as bleeding or peritonitis, must be assessed as well. Time spent with the patient while flushing and assessing tubes is an excellent opportunity for educating patients and caregivers on care of the gastrostomy tube. It s also important to offer support as patients adjust to changes in body image and the loss of the pleasures of eating. Karen Roush, MSN, NP, clinical editor opinion as to the amount of water to use and when the flushing should be done. Special considerations for small-bore enteral tubes. Most resources we consulted didn t distinguish between large- and small-bore tubes. But Perry and Potter specified that a small-bore tube required 30 ml of normal saline or tap water for flushing, while largebore tubes required 5 to 15 ml more than that. 12, 13 Kohn-Keeth emphasized that small-bore tubes should be flushed with water every four hours. 14 We found no research conducted on this topic. Checking feeding residual has been shown to increase the incidence of tube clogging. 15 When some enteral formulas, such as protein formulas, mix with low-ph gastric juices, sediment may form and collect in tubes, possibly leading to occlusions; as a result, the practice of flushing after checking for feeding residuals is gaining wider acceptance. 7, 9, 12, 14, It should be emphasized that nurses should not stop checking for residuals frequent flushing with water has been shown to prevent tube occlusion after this important procedure. Flushing fluids were compared in two now-classic studies published in the 1980s. Both sought to determine which fluids were the most effective in preventing occlusion. Metheny and colleagues compared water, Coca-Cola, and cranberry juice. 3 They found that water and Coca-Cola were superior to cranberry juice. Wilson and Haynes-Johnson compared the efficacy of water and cranberry juice, ultimately concluding that water was a more effective irrigant. 4 In that study, 73% of the tubes flushed with cranberry juice became occluded, while none of the tubes flushed with water did. The influence of these two studies has been enormous: their recommendations are reflected in almost all of the resources surajn@lww.com AJN March 2005 Vol. 105, No. 3 61

5 In Conclusion The following are some conclusions we have drawn from our review. Do flush at least every four hours: before, between, and after medication administration; before and after bolus feedings; and before and after checking for gastric residuals. use a syringe that holds at least 30 ml of fluid. flush with at least 30 ml of warm water. administer liquid forms of medications whenever possible. try pancreatic enzymes to unclog an occluded tube. develop a standard operating procedure on tube flushing for nurses in your institution. Don t force or apply excessive pressure when flushing the tube. use a syringe that holds less than 30 ml. flush with cranberry juice. crush sustained-release or enteric-coated medications. fail to activate pancreatic enzymes before instillation into the tube. assume that all nurses are flushing tubes correctly or consistently. veyed in this review, with the exception of one. While McKenry and Salerno suggest cranberry juice as a flushing fluid, 20 it s important to note that this recommendation isn t supported by research and does, in fact, contradict other research findings. Unclogging occluded enteral tubes is covered in various studies and textbooks. The findings of three studies support the use of certain pancreatic enzymes to remove obstructions if water or a carbonated beverage has failed. One study also 17, 21, 22 demonstrated the effectiveness of administering pancreatic enzymes in preventing tube obstruction. 23 Of the textbooks that specify how to treat a clogged enteral tube, two suggest water alone as the 6, 24 remedy, and two recommend water alone or water in combination with a carbonated beverage. 5, 25 Ignatavicius and Workman state that cranberry juice should not be used. 25 Craven and Hirnle recommend intervention as soon as there is difficulty flushing an enteral tube. 8 The intervention recommended is flushing with water and, if water is ineffective, using 30 to 50 ml of a carbonated beverage. Finally, it s important to note that pancreatic enzymes must be activated before use. Typically, a tablet of the pancreatic enzyme and a 324-mg tablet of sodium bicarbonate are dissolved in 5 ml of warm water just before instillation into the occluded tube. 26 Syringe size for flushing. Both Guenter and Lord, two experts in the field who associate tube rupture with syringe size, say a syringe of 30 ml or greater is needed to prevent rupture; other experts come to the same conclusion. 7, 9, 16 Two textbooks also support this premise. 19, 25 Although Lilly and Aucker recommend a 10- to 20-mL syringe for flushing small-bore tubes, 27 these smaller syringe sizes are believed to cause tube rupture because they generate considerable pressure. We found no research on appropriate syringe size for flushing; the only recommendations we found were from sources that weren t researched based. DISCUSSION While there is some overlap in many of the recommendations in the literature, there is also significant variance possibly caused by conflicting evidence in the nursing literature. According to a personal communication from Norma Metheny, the great variability in the information presented in textbooks demonstrates that practical experience is problematic. Standards should be written by experts. In fact, more research is needed to determine the best practices for routine enteral tube flushing. Studies to determine the preferred tube (large or small bore) must also be performed. Essential to this research will be determining the minimum amount of fluid necessary to maintain tube patency. Complete the CE test for this article by using the mail-in form available in this issue or visit NursingCenter.com s CE Connection to take the test and find other CE activities and My CE Planner. REFERENCES 1. Mateo MA. Nursing management of enteral tube feedings. Heart Lung 1996;25(4): Seifert CF, et al. A nursing survey to determine the characteristics of medication administration through enteral feeding catheters. Clin Nurs Res 1995;4(3): Metheny N, et al. Effect of feeding tube properties and three irrigants on clogging rates. Nurs Res 1988;37(3): Wilson M, Haynes-Johnson V. Cranberry juice or water? A comparison of feeding-tube irrigants. Nutr Support Serv 1987;7(7): Kee JL, Hayes ER. Pharmacology: a nursing process approach. 4th ed. Philadelphia: Saunders; AJN March 2005 Vol. 105, No. 3

6 6. Springhouse Corporation. Nursing procedures. 3rd ed. Springhouse, PA: Springhouse Corp.; Lord LM. Enteral access devices. Nurs Clin North Am 1997;32(4): Craven RF, Hirnle CJ. Fundamentals of nursing: human health and function. 4th ed. Philadelphia: Lippincott Williams and Wilkins; Bowers S. All about tubes: your guide to enteral feeding devices. Nursing 2000;30(12):41-7; quiz Scanlan M, Frisch S. Nasoduodenal feeding tubes: prevention of occlusion. J Neurosci Nurs 1992;24(5): Petrosino BM, et al. Implications of selected problems with nasoenteral tube feedings. Crit Care Nurs Q 1989;12(3): Perry AG, Potter PA. Clinical nursing skills and techniques. 5th ed. St. Louis: Mosby; Potter PA, Perry AG. Fundamentals of nursing. 5th ed. St. Louis: Mosby; Kohn-Keeth C. How to keep feeding tubes flowing freely. Nursing 2000;30(3): Powell KS, et al. Aspirating gastric residuals causes occlusion of small-bore feeding tubes. JPEN J Parenter Enteral Nutr 1993;17(3): Guenter P. Mechanical complications in long-term feeding tubes. Nurs Spectr (Wash D C) 1999;9(12): Marcuard SP, Perkins AM. Clogging of feeding tubes. JPEN J Parenter Enteral Nutr 1988;12(4): Peckenpaugh NJ, Poleman CM. Nutrition essentials and diet therapy. 8th ed. Philadelphia: W. B. Saunders; Smeltzer S, Bare B. Brunner and Suddarth s textbook of medical surgical nursing. 9th ed. Philadelphia: Lippincott Williams and Wilkins; McKenry LM, Salerno E. Mosby s pharmacology in nursing. 21st ed. St. Louis: Mosby; Marcuard SP, et al. Clearing obstructed feeding tubes. JPEN J Parenter Enteral Nutr 1989;13(1): Nicholson LJ. Declogging small-bore feeding tubes. JPEN J Parenter Enteral Nutr 1987;11(6): Sriram K, et al. Prophylactic locking of enteral feeding tubes with pancreatic enzymes. JPEN J Parenter Enteral Nutr 1997;21(6): Grodner M, et al. Foundations and clinical applications of nutrition: a nursing approach. 2nd ed. St. Louis: Mosby; Ignatavicius DD, Workman ML. Medical surgical nursing: critical thinking for collaborative care. 4th ed. Philadelphia: W. B. Saunders; Marcuard SP, Stegall KS. Unclogging feeding tubes with pancreatic enzyme. JPEN J Parenter Enteral Nutr 1990;14(2): Lilley LL, Aucker RS. Pharmacology and the nursing process. 2nd ed. St. Louis: Mosby; HOURS CE3 Continuing Education GENERAL PURPOSE: To examine current practice and the recommended methods for keeping enteral feeding tubes free of buildup and functioning optimally. LEARNING OBJECTIVES: After reading this article and taking the test on the next page, you will be able to discuss previous research about enteral tube flushing techniques. list appropriate evidence-based recommendations for routine flushing of enteral feeding tubes. outline evidence-based recommendations for declogging enteral feeding tubes. To earn continuing education (CE) credit, follow these instructions: 1. After reading this article, darken the appropriate boxes (numbers 1 15) on the answer card between pages 48 and 49 (or a photocopy). Each question has only one correct answer. 2. Complete the registration information (Box A) and help us evaluate this offering (Box C).* 3. Send the card with your registration fee to: Continuing Education Department, Lippincott Williams & Wilkins, 333 Seventh Avenue, 19th Floor, New York, NY Your registration fee for this offering is $ If you take two or more tests in any nursing journal published by Lippincott Williams & Wilkins and send in your answers to all tests together, you may deduct $0.75 from the price of each test. Within six weeks after Lippincott Williams & Wilkins receives your answer card, you ll be notified of your test results. A passing score for this test is 11 correct answers (73%). If you pass, Lippincott Williams & Wilkins will send you a CE certificate indicating the number of contact hours you ve earned. If you fail, Lippincott Williams & Wilkins gives you the option of taking the test again at no additional cost. All answer cards for this test on Enteral Tube Flushing must be received by March 31, This continuing education activity for 3 contact hours is provided by Lippincott Williams & Wilkins, which is accredited as a provider of continuing nursing education (CNE) by the American Nurses Credentialing Center s Commission on Accreditation and by the American Association of Critical-Care Nurses (AACN , category A). This activity is also provider approved by the California Board of Registered Nursing, provider number CEP11749 for 3 contact hours. Lippincott Williams & Wilkins is also an approved provider of CNE in Alabama, Florida, and Iowa, and holds the following provider numbers: AL #ABNP0114, FL #FBN2454, IA #75. All of its home study activities are classified for Texas nursing continuing education requirements as Type 1. *In accordance with Iowa Board of Nursing administrative rules governing grievances, a copy of your evaluation of this CNE offering may be submitted to the Iowa Board of Nursing. ajn@lww.com AJN March 2005 Vol. 105, No. 3 63