17.3: Assessments Related to Enteral Tubes
When caring for patients with enteral tubes, it is important for the nurse to routinely assess and document the patient’s condition.
Subjective Assessment
When a patient is receiving enteral feeding, the nurse should assess the patient’s tolerance of tube feeding.
| Interview Questions | Follow-up |
|---|---|
| How long have you been receiving tube feeding? | Tell me more about why you are receiving tube feeding and how you feel about the tube feeding. (Patients may experience psychosocial reactions to receiving tube feeding that can be addressed with therapeutic communication.) |
| Are you experiencing symptoms of stomach cramping, nausea, vomiting, excess gas, diarrhea, or constipation? | Please describe. |
| Are you experiencing any discomfort where the tube is inserted? | Please describe. |
| Have you noticed any coughing or respiratory symptoms after receiving tube feeding? | Please describe. |
Objective Assessment
Objective assessments for patients with enteral tubes include assessing skin integrity, tube placement, gastrointestinal function, and for signs of complications:
- Assess the tube insertion site daily for signs of pressure injury and skin breakdown. Cleanse and protect the area as indicated.
- Assess tube placement every four hours and prior to administration of feedings or medications according agency policy. Verify the visible tube length and compare it to the length documented after X-ray verification.
- Trace the tubing from the insertion site to prevent tubing misconnections.
- Assess the abdomen. If tube suctioning is in place, the suction should be turned off prior to auscultation. Bowel sounds should be present in all four quadrants, and the abdomen should be soft and nondistended.
- Monitor the patient’s weight and overall nutritional status in collaboration with the multidisciplinary team.
- Monitor serum electrolytes and blood glucose as indicated.