Complications

Tube Feedings: Complications

Complications
Causes
Management
Gas, bloating, cramping Air in the tube, plus same causes as diarrhea Keep the tube clamped between intermittent feedings. Eliminate all air from the delivery system before attaching to feeding tube.
Nausea, vomiting Approximately 20% of patients experience N/V Increases the risk of aspiration Same causes as diarrhea, plus GI obstruction Auscultate for bowel sounds. Measure abdominal girth. Check residuals. If patient has gastrostomy, the tube's migration can mimic obstruction.
Delayed gastric emptying (most common) Consider reducing narcotics; switching to a low-fat formula; administering feeding formula at room temperature; reducing rate of administration
Gastric distention Encourage the patient to walk.
Diarrhea Common side effect Hyperosmolar formula; Lactose intolerance Change formula and/or decrease rate Consider formula with fiber
Rapid feeding Reduce rate to tolerance. Increase rate slowly.
Bacterial contamination Use full-strength, ready-to-use formula; do not allow formula to hang more thatn 6-8 hours; use aseptic technique when preparing feeding; use sterile water if mixing formula with water
Cold formula Administer formula at room temperature
Tube migration Verify placement to determine if tube has migrated from the stomach to the jejunum (may produce diarrhea with bolus feedings)
Constipation Inadequate fluids, fiber, or exercise Increase fluid intake. Monitor intake and output. Use fiber-enriched formula and give bulk-producing agents. Encourage walking and physical activity.
Aspiration Here are a couple of x-rays showing aspiration pneumonia:
Case 1 
Case 2
Incorrect tube placement Verify tube placement prior to instilling anything down the tube. 
Here is an x-ray of an NG in the right mainstem bronchus
Flat in bed when receiving feeding Keep head of bed elevated 30-450
Delayed gastric emptying Check residuals; if greater than 100 ml (or twice the hourly rate), reinstill the residual and hold feeding for one hour, and then recheck residual. May need to reduce rate or concentration of the formula. Auscultate bowel sounds, measure abdominal girth to detect abdominal distension.
Metabolic
Hyperglycemia (signs: hunger, extreme thirst, lethargy, polyuria) High-calorie formula Change to a formula with a lower calorie content if possible
Rapid feeding Slow rate of administration. Use a pump if necessary to administer feedings at a constant rate.
Infection or impending sepsis Monitor for signs of infection.
Steroid therapyDiabetes mellitusGlucose intolerance associated with aging Monitor for signs of hyperglycemia. If present or if potential causes present, check blood glucose level. Administer oral hypoglycemic agents or insulin as prescribed. Report changes in serum glucose level to the home health nurse/physician.
Hypoglycemia (signs: weakness, diaphoresis, tachycardia, clammy skin, confusion) Unable to tolerate feedingsReceiving medication for hyperglycemia Monitor for signs of hypoglycemia. If present or if potential causes present, check blood glucose level. Administer oral hypoglycemia agents or insulin as prescribed. Report changes in serum glucose level to the home health nurse/physician.
Hyponatremia (signs: weakness, headache, edema, hyperpnea, cramps, confusion) Overhydration Monitor fluid intake and output. Check for weight gain. Restrict fluids. Use a calorie-dense formula. Monitor for signs of hyponatremia
  Excess urination or GI losses from diarrhea or vomiting Notify home health nurse/physician
Hypernatremia Inadequate fluid intake Increase free water
Hypokalemia Refeeding syndrome; diarrhea Replace potassium
Evaluate causes of diarrhea
Hyperkalemia Excess potassium intake; renal insufficiency Change formula
Other
Dry oral mucosaInability to taste Lack of food to stimulate salivary glands and taste buds Provide good mouth care. Encourage patient to breathe through his nose. Provide gum, hard candy if condition permits.
Altered body image Loss of normal eating patternPresence of "tube" Encourage patient to express feelings about having to "wear" the tube. Provide privacy. Include patient in decisions about scheduling of feedings.
Refeeding syndrome Adversely affects most organ systems: cardiac dysrhythmias, heart failure, acute respiratory failure, coma, paralysis, nephropathy, and liver dysfunction The major cause of the effects of refeeding syndrome is the shift from stored body fat to carbohydrate as the primary fuel source. Serum insulin levels rise, causing intracellular movement of electrolytes. Refeeding of severely malnourished patients causes acute decreases in serum potassium, magnesium, and phosphate levels. When initiating refeeding with severely malnourished patients: "start low and go slow" Recognize patients at risk:
  • Anorexia nervosa
  • Classic kwashiorkor or marasmus
  • Chronic malnutrition
  • Chronic alcoholism
  • Prolonged fasting
  • Prolonged IV hydration
  • Significant stress and depletion

Correct electrolyte abnormalities before starting enteral feedings Administer volume and calories slowly Monitor pulse, intake/output, electrolytes closely Provide appropriate vitamin supplements Avoid overfeeding