ORIGINAL ARTICLE
A review of the nursing care of enteral feeding tubes in critically ill adults: part II

https://doi.org/10.1016/j.iccn.2004.08.003Get rights and content

Summary

Enteral tubes are frequently used in critically ill patients for feeding and gastric decompression. Many of the nursing guidelines to facilitate the care of patients with enteral tubes have not been based on current research, but on ritual and opinion. Using a computerised literature search and an evidence-based classification system as described by the Joanna Briggs Institute for Evidence Based Nursing and Midwifery (JBI), a comprehensive review was undertaken of enteral tube management.

Several nursing practices related to enteral tube management are described. Evidence to support alternate methods of tube placement assessment other than abdominal X-ray was inconclusive. Enteral feeding should continue if gastric residual volumes are not considered excessive, as feeding is often withheld unnecessarily. Frequency of checking gastric residual volumes is largely opinion based and varies considerably, but prokinetics that aid gastric emptying should be used if absorption of feeds is problematic. Other recommendations include continuous rather than intermittent feeding, semi-recumbent positioning to reduce the risk of airway aspiration and diligent artificial airway cuff management. Contamination of feeds can be minimised by minimal, meticulous handling and the use of closed rather than open systems. Generally, there was little high quality evidence to support practice recommendations leaving significant scope for further research by nurses in the management of patients with enteral tubes.

Introduction

Critically ill patients commonly have enteral tubes in situ for gastric decompression, delivery of medications and food substitutes. It is essential that critical care nurses use best practice that includes current evidence-based knowledge and skills to care for these patients. To facilitate the benefits and minimise the harm associated with any therapy, nursing practice should be based on the highest levels of evidence. The systematic and rigorous approach to the analysis and grading of research findings in terms of level of evidence facilitates the development of specific guidelines, standards and recommendations to provide the best possible care for every patient. There is, however, limited high level evidence supporting nursing practice of critically ill patients with enteral tubes. In part 1 of this paper, the current research findings for the nursing care of critically ill patients with enteral feeding tubes was reviewed. Nursing care to prevent aspiration was discussed. This paper describes enteral tube management and recommendations for implementing evidence-based protocols for tube and feeding management.

Section snippets

Data sources and levels of evidence

Several methods were used to identify relevant articles for this review. A computerised literature search of online databases MEDLINE (1966–2003), EMBASE (1966–2003), CINAHL (1982–1996), and the Cochrane Library (1992–2003) was conducted. Searches were restricted to the English language, adults and humans. Relevant abstracts were reviewed and identified articles assessed. The reference lists of all articles were examined for additional papers not previously identified. The evidence base applied

Nursing care of patients with enteral tubes used for feeding

Nursing care of critically ill patients with enteral tubes used for feeding should facilitate feeding, promote patient comfort and minimise complications. Safety issues include verification of tube position and ensuring tube patency to minimise the risk of aspiration (The Joanna Briggs Institute, 2002).

Recommendations for nursing practice

Nursing care of critically ill patients should be based on the best available current evidence. It is widely acknowledged when making therapy decisions the hierarchy of evidence, which recognises the pre-eminence of the systematic review and RCT is clearly appropriate (The Joanna Briggs Institute, 2002). However, other qualitative study methodologies can be more helpful in assessing patient feelings and behaviours in relation to therapeutic decisions. It is important nurses are cognisant of

Conclusion

Nursing care should focus on maximising benefits and minimising the risks of enteral tubes and nutrition. When caring for critically ill patients with enteral tubes used for feeding minimising the use of medications that impair gastric emptying such as sedation, minimising interruption of feeding and accepting higher gastric residual volumes, elevating the head of the bed and administering prokinetics are effective nursing strategies supported by a high level of evidence. Regular checking of

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