In the final part of our “Ftag of the Week” series for F693 Tube Feeding Management/ Restore Eating Skills, we will review the key nutritional aspects and concerns related to tube feeding. Mary Quinn, RN, MA will be lending some clinical insight for this post.
Physician’s Orders
Physician’s orders typically include a significant amount of information. Orders usually include the type of formula to administer (including caloric value), total volume and rate of administration/duration, mechanism of administration and the amount and frequency of water flushes. In last week’s post, we reviewed a Harm-level citation where issues with the orders resulted in a negative outcome for a resident receiving a tube-feeding, so your process related to orders needs to be sound – consistency with the components of your tube feeding orders is key.
A lot can go wrong if orders are not entered/ scheduled and documented clearly and correctly. Some things to think about:
- Total volume to be administered may require the use of a second bottle of formula, i.e. total ordered 1200ml bottles in use 1000ml. There have been instances of significant weight loss which, when investigated, demonstrated the resident was not receiving the total amount of formula ordered. Figure out how multiple nurses can let this occur over a period of time without identifying that the wrong amount was administered. Do the nurses know how to check (and do they) the amount of formula administered? Why didn’t they identify that 200mls a day were not being administered.
- Staff should be familiar/competent in the use of the specific tube feeding pump(s) in use in the facility. Ideally the pump should be reset each day to monitor the amount of formula infused.
- Policy should indicate the amount of water to be administered before/after and between medications.
- Additional water flushes are recommended to be individually signed for as administered on the MAR. Issues have been identified when multiple water flushes are contained in one order without clear scheduling/documentation of administration times.
Policies and Procedures
The Interpretive Guidance (IG) in Appendix PP of the State Operations Manual (SOM) states the physician and IDT need to identify the nutritional needs of a resident receiving nutrition via tube feeding and the procedures need to direct staff who are providing care and services to the resident.
Enteral Nutrition
The IG notes that procedures should include directions to staff regarding the nutritional product being used and ensure the resident’s nutritional needs are met. This includes addressing how to determine whether tube feedings are meeting the resident’s nutritional needs and when to adjust them accordingly and balancing nutritional support while ensuring potential tube feeding complications are minimized. Also included in the guidance are those potential gotchas, such as:
- Additional water is order for flushes as appropriate – and staff follow orders
- Enteral nutrition is administered in accordance with physician’s orders
- Products used have not expired
- Manufacturer’s recommendations are followed
Flow Feeding
The IG at F693 also discusses the need to ensure procedures include clear directions for staff regarding how to manage and monitor the rate of flow. It is important that staff know what frequency to evaluate the amount of feeding being administered to ensure it remains consistent with physician’s orders. Procedures should also include use of gravity flow or pump, calibration of devices and conducting periodic maintenance of the pump.
Management of Potential Complications
As we have discussed in the past two parts of this Ftag series, there are potential complications associated with use of a feeding tube and administration of Enteral Nutrition to be aware of. Per regulatory expectations, providers are expected to identify and address actual or potential complications related to tube feeding (or the actual tube) and notify and involve the physician in the evaluation and management of care to address risk factors and potential/actual complications. Here’s some things to think about:
- Aspiration – HOB should be elevated at all times when meds and or feedings are in progress as well as 30- 60 minutes after feeding is completed. When care is provided that requires the HOB to be lowered, the feeding should always be paused/stopped. Do your staff know who is allowed to shut off the pump and turn it back on?
- Mouth care – Care of the resident’s teeth, tongue and gums should be evident during observation. A resident with crusts on his/her lips or tongue or are noted with their lips “adhered” to their teeth due to the absence of mouth care do not present a picture of a well-cared for resident.
Of course, there’s Infection Control considerations to be aware of:
- Use of standard precautions – hand hygiene/glove use
- Site care – a dressing is not required
Handling and storage of equipment also creates potential infection control concerns, so here are some best practices/reminders:
- Storing of supplies kept in the room in an appropriate area- separation of clean/soiled
- Rinsing irrigation syringes after each use
- Labeling/dating – changing of equipment daily
- Label completion
- Covering/dating/refrigeration of opened formula per manufacturers recommendations/facility policy
As discussed above, there can be issues related to insufficient intake/absorption. There should be evidence of the following related to this type of concern:
- Monitoring of weights/labs
- Adjustment of medication times
- Monitoring of symptoms i.e. abdominal distention, vomiting, diarrhea – formula and/or rate adjustments may be necessary
- Reporting of refusals
- Preventative maintenance of pumps
Restoration of Normal Eating
If the resident’s goal is to resume oral intake, cognitive and function ability need to be assessed on an on-going basis. Don’t forget about the importance of:
- Restorative services – speech/OT
- Assistive devices
- Call bell placement
- Staff monitoring/supervision/assistance
- Providing pleasure feeds
Deciding to have nourishment provided via a tube feeding is always an individual decision and people make decisions to use this method for a number of reasons. Our responsibility is to ensure that this decision is respected and carried out adhering to clinical standards of practice. Remember a well-trained staff is your best asset, including those CNAs that don’t know how the tube came out during turning and positioning!