administering medications through an enteral feeding tube safely

Running head: ADMINISTERING MEDICATIONS THROUGH AN ENTERAL 1

Administering Medications Through an Enteral Feeding Tube Safely

Michael Welborn

Grand Canyon University

NRS 441V:Professional Capstone

Instructor: Ms. Nora Hamilton RN MSN

February 10, 2013

ADMINISTERING MEDICATIONS THROUGH AN ENTERAL 2

Abstract

Medication administration through an enteral feeding tube often requires the clinician to

alter medication form. Altering the medications form can either decrease or increase a

drug’s absorption, affect, interaction, availability, and has caused death. The safe

administration of medications via enteral feeding tubes has been highlighted as a cause

for concern and one that requires improvements in practice (National Patient Safety

Agency [NPSA], 2007). Previous research has shown that 80% of medications

administered through an enteral feeding involve a change of pharmaceutical form

(Cursano, et al., 2012). According to Phillips and Endacott, only 40.9% of respondents

stated that hospital procedures guided their administration of medication through an

enteral feeding tube, but that 80% relied primarily on their practice experience (Phillips

& Endacott, 2011, p. 2590). Development of new guidelines and procedures through a

multidisciplinary approach have proved beneficial in improving the risk to benefit ratio of

drug therapy administration through an enteral feeding tube (Cursano, et al., 2012).

Through the development of new procedure guidelines, training programs, and

evaluation rubrics facilities can increase safe administration practices among nurses

administering medication through an enteral feeding tube.


Administering Medications Through an Enteral Feeding Tube Safely

In patients with enteral feeding tubes a greater risk exist for the

development of medication reaction when administering an oral medication that

has been altered from tablet to solute. Medications taken orally can interact with

other medications taken concurrently. The risk of interaction is greater in

patients with an enteral feeding tube when a nurse is required to crush oral

medications and administer them through an enteral feeding tube. Nurses

require a greater understanding of each drugs properties, mechanism of action,

absorption rate, and general pharmacological principles to administer form

altered oral medications through the enteral feeding tube. The safe

administration of medications via enteral feeding tubes has been highlighted as a

cause for concern and one that requires improvements in practice (National

Patient Safety Agency [NPSA], 2007).

Medications when altered from their original form allow the immediate

absorption of the entire medications. This can be dangerous if the medication is

meant to be long acting or time released. Additional safety concerns exist when

altering medication forms because of proper medication absorption. Medications

are balanced for the area of the gastrointestinal tract in which the medication is

meant to be absorbed. Medications use binders and fillers that maintain the

medication pH levels to prevent the medication from being absorbed in the wrong

area of the gastrointestinal tract. These fillers often time include Sodium

Bicarbonate and Magnesium. Sodium Bicarbonate and Magnesium both


decrease the acid levels of the stomach, deceasing digestion, and the

subsequent absorption of medications (Boullata, 2009).

Altering the medications form can either decrease or increase a drug’s

absorption, affect, interaction, and availability and has caused death. Nurses

who routinely administer oral medication in an altered form through an enteral

feeding tube should receive additional pharmacological training in an attempt to

decrease complications related to the inappropriate administration of medication.

Implementation Plan

Various obstacles present themselves to any change. Regardless of the

depth or brevity of change, obstacles can be overcome with proper planning and

implementation. Successful planning and implementation will require the

identification of barriers, whatever they may be, and identification of actions

aimed at overcoming them. It should be noted that according to Phillips and

Endacott, only 40.9% of respondents stated that hospital procedures guided their

administration of medication through an enteral feeding tube, but that 80% relied

primarily on their practice experience (Phillips & Endacott, 2011, p. 2590). Kurt

Lewing theorized that change required the rejection and replacement of old

knowledge a process that may prove difficult when confronted with years of

practice experience (Kritsonis, 2005).

Prior to implementing a comprehensive educational and training program

related to the safe administration of medication through enteral feeding tubes and

changes to hospital procedures, the hospital’s various department heads must

approve the concept allowing for the review of current procedures. Proposed


changes must be based on best practice and solid science. Change to hospital

procedures can be a difficult and long process often governed by individuals no

longer practicing at the bedside. What is seen in the patient population today

may not be what was seen in the past.

Permission to evaluate procedure in the facility begins with the education

department and is forwarded for approval through the nursing department,

pharmacy, executive staff, and can require ethics review when necessary. An

alteration to the current policy is believed necessary, based in part, on observed

improper techniques. Because the intended change includes the database

development of medication commonly altered for administration via an enteral

feeding tube, drug properties, intended absorption site, and common interactions

by the Pharmacy any implementation could include the added dynamic of

resistance from staff outside the nursing department. Change occurs when the

driving force of change is greater than the force of resistance to change;

however, for lasting change vigilance in the adherence to new policy is required.

The availability of a Clinical Competency Coordinator in the facility to monitor the

adherence to new practice skills is imperative.

With the growing number of medications in use today, clinicians require a

greater knowledge base of drug interactions in general, but even more so when

faced with a need to alter the state of medication to administer it through an

enteral feeding tube. Medication administration by a clinician should follow the

patient’s five rights of administration. Notably, medications intended for oral

administration, when altered for administration through an enteral tube, do in fact


violate the “right route” precept. Clinicians understand that this change can be

dangerous, however in a recent study 80% percent of medications administered

through an enteral feeding tube are altered (Cursano et al., 2012).

Often time medication administration through an enteral feeding tube not

only alters form and route, but also alters the bioavailability of medication and in

doing so creates unintended effects and often times a life-threatening situation

(Boulatta, 2009). Drug formulation has become a highly complex science.

Highly soluble medications with high permeability are of least concern in that they

are expected to be available early in the gastrointestinal tract, however

medications that have low permeability and low solubility should not be altered

for administration through a feeding tube (Boulatta, p. 38).

Adherence to current policy requiring the separate preparation and

administration of medication through an enteral feeding tube is often times

lacking. Procedures detailing the appropriate preparation and delivery are not

available. Current policy does not require a review of medication properties,

effect of changing medication form, or a review of common interactions.

According to Best and Wilson, a full review of medication should be performed

prior to the administration (Best & Wilson, 2011). Further, current policy does not

allow for a Pharmacist to dispense appropriate alternative suspensions, when

available, without a written order. Nursing procedures are as unique as the

individual performing the procedure. However, each procedural variation can be

associated with unique adverse events and risk for patient safety (Kenny &

Goodman, 2010, p. S23). Solutions proposed include: the institution of new


policies directing the design and completion of a database of all medication

available for oral administration within the hospital, policies regarding the

identification of all non-crushable medications dispensed by the pharmacy, and

nursing team competency evaluation and training.

Design of the medication database should be sufficient to provide answers

to important questions regarding medication administration. Information that

includes drug properties, intended absorption site, drug form alternatives for

administration through enteral feeding tubes, common drug interactions, drug

bioavailability changes when crushed, if the drug can be crushed, as well as

preferred preparation and administration techniques (Gonzaga do Nascimento,

Moreira Reis, Wick, & Ribeiro, 2012). Preferred preparation and administration

techniques should include wait times between multiple medications being

administered and between medication administration and resumption of feeding.

Nursing competency, key in the safe administration of medication through

an enteral feeding tube, should be evaluated and appropriate training undertaken

to reinforce and remediate approved technique. Recent studies indicate that

nurses often times used one to three different inappropriate techniques in the

administration of medication through enteral feeding tubes (Boulatta, 2009).

Philips and Endacott statistically detail multiple administration practices across a

random sample of 181 Registered Nurses at two large metropolitan hospitals.

They concluded, “Enteral medication administration practices are inconsistent.

Some nurses are using unsafe practices and may therefore compromise patient

care” (Phillips & Endacott, 2011, p. 2586). Prior to the administration of


medication through an enteral feeding tube nurses should review the medication

database for each medication being administered to identify potential

complications or interactions. Medications should be prepared with purified

water and administered separately and liquid doses should be given when

available (Yantis & Velander, 2011). Enteral feeding tubes should be flushed

with water prior to the administration of medications, in between each

medication, and after the last medication is administered (Phillips & Nay, 2008).

Hospitals present unique difficulties to implementing new procedures in

that long shifts, varied days, and 24-hour staffing make a uniformed role out of a

new procedure difficult to achieve. Through the use of the Clinical Competency

Coordinator and Nurse Educator training, evaluation, and remediation if

necessary can be initiated prior to the role out of new procedures. The hospital

Nurse Educator can assist in the development of training materials related to the

new procedures and Nurse Executives assist in the development of the new

protocols, staff motivation, agency commitment to change an oversee the

implementation process.

Prior to the implementation of the new procedures an evaluation of current

practice should be completed. Development of a staff survey in which questions

regarding current medication preparation practices for medication administered

through an enteral feeding tube are determined can be instrumental in the

development of training material geared at replacing old practices with those

based in evidence. The Nurse Educator, as a baseline comparison for education

effectiveness, should complete development of the staff survey. In subsequent


competency checks the same survey can be completed to determine the

adherence to the new facility procedures.

Resource required to effect a shift in procedures should include the

development of education materials include handouts detailing the procedure

change, the evidence used to develop the new procedure and the intended

benefit of the procedure change. Classroom training should be enhanced with

Power-Point presentations and printed material. Being multi-facility health care

company aids in the development of affective training material including the

development of core competency training and evaluation material and the

deployment of those materials across the corporate network infrastructure for

uniformed education. By doing so funding can be held to a minimum and

generally covered by the educational budget.

After the initiation of change a system to oversee and evaluate that

change is need to ensure continue practice. Although the initial role out of a new

procedure is intensive the evaluation of practice based on those procedure

should be relatively effortless. Evaluation of core competency already fall to the

Clinical Competency Coordinator to complete and the addition of core

competencies regarding the safe administration of medication through an enteral

feeding tube can be observed and evaluated at the bedside.

Although different techniques for the administration of medication through

an enteral feeding tube are used in current clinical practice some nurses are

using unsafe practices that can alter patient outcomes. Development of the

foregoing procedures couple with a single source of information regarding drug


properties, intended absorption site, drug form alternatives for administration

through enteral feeding tubes, common drug interactions, drug bioavailability

changes when crushed, if the drug can be crushed, as well as preferred

preparation and administration techniques can reduce errors and negative

patient outcomes. Negative outcomes that could prove to be more costly than the

expenses incurred in developing and implementing new policies and procedures

regarding medication administration through and enteral feeding tube.

Evaluation Plan

As the nursing process is cyclical in nature so is the process in which

evidence based practice is implemented. Evaluation may appear to be the last of

many steps in the implementation of evidence based practice, however, it is only

a single step in a cyclical process. Should one determine through evaluation that

additional implementation is necessary, the process continues. Evaluation

includes determining the impact of change as well as the level of compliance with

newly developed procedures.

Hospital Procedure (Appendix A) details newly implemented steps for the

safe administration of medications through an enteral feeding tube. Individual

nurses are responsible for the safe administration of medications. Through

group training session, an individual nurse will be familiarized with the procedure

changes, gain understanding of the science behind the change in procedures,

and develop new skills in the preparation and administration of medications

through and enteral feeding tube. Procedures include holding enteral feeding for

30 minutes, identifying medications that cannot be crushed, proper preparation of


medication, dilution of medication, administration, flushing between individual

medication administration, and flushing after all medication have been

administered. Uniformed teaching material (Appendix B), in the form of a

PowerPoint presentation will be utilized during training sessions. Slides include

individual procedures and the science behind the change.

Individual clinicians will be provided with a flow sheet (Appendix C) of the

appropriate steps in administering medications through and enteral feeding tube

(Cursano, et al., 2012). Additional handouts will include the Hospital Procedure

(Appendix A), copies of the teaching material (Appendix B), and a pocket card

listing medication types that should not be administered through an enteral

feeding tube (Appendix D). Medication that should not be administered through

an enteral feeding tube including: enteric-coated, extended-release, time-release,

sustained-released or medication for which a suitable alternative is available

through the facility pharmacy, i.e. ferrous sulfate suspension for ferrous sulfate

oral tablet.

Post training knowledge will be evaluated by questionnaire (Appendix E)

comprised of knowledge questions developed from the procedures being

implemented. Nurses have the skill set necessary to implement this change and

basic knowledge will be tested through the questionnaire. However, the

evaluation process does not end after the training. Long-term evaluation

includes competency qualification annually and periodically to reinforce

compliance with new policy. The included Competency Evaluation form

(Appendix F) is to be utilized during periodic and annual competency evaluation.


Members of the Nursing management team, along with Pharmacist,

should review medical records quarterly to determine if administration of any of

the non-crushable medication though an enteral feeding tube has occurred.

Additional training and remediation should be undertaken with individual nurses

identified as having administered through an enteral feeding tube a medication

listed as a drug not to be administered through an enteral feeding tube.

Evaluation is only a single step in the implementation of change. Additionally,

input from nursing and pharmacy staff may assist in the successful

implementation of change, input that should be actively solicited.

Dissemination Plan

Dissemination of information to an individual or group can be difficult.

Getting the individual or group to participate in change can prove even more

difficult. When attempting to disseminate information to nursing and pharmacy

staff, the end result is to create enough driving force of change that the new

policy and procedure will become ingrained as the norm.

Throughout the hospitals three departments, Intensive Care, Intermediate

Intensive Care, and Medical-Surgical, nurses are assigned to a 72-block

schedule. With approximately 11 nurses on schedule each shift, training

sessions would consist of two or three nurses, and completion of the

Dissemination Plan will require several weeks. Training sessions will include:

presentations through information boards, PowerPoint presentations, and

individual handouts. Further, informational posters will be placed in medication

preparation areas as well as medication storage cabinets, and throughout the


units. Warning cards listing medications not to be crushed and administered

through and enteral feeding tube will also be placed in medication preparation

areas and storage cabinets. Medications that include: extended release

formulas, enteric-coated medications, and medication for which a suitable

alternative is available through the pharmacy.

Prior to the implementation of the new policies and procedures regarding

the administration of medication through an enteral feeding tube, pharmacy staff

has identified medication administered within the hospital and has developed a

reference database regarding each medication properties, guidelines regarding

their administration through an enteral feeding tube, and suitable alternatives.

Through the use of the medication database, procedures have been adopted on

the proper administration of medication. Hospital procedures (Appendix A)

contain detailed medication administration procedures, which will be discussed

during group training. Further, training includes a review of the research that

forms the foundation for the change in procedure.

Handouts containing the new procedure for administration of medication

through an enteral feeding tube, along with handouts containing a list of

medication not to be administered through the enteral feeding tube will be given

to each clinician during their training session.

Clear evidence exists supporting the implementation of new procedures

regarding the administration of medication through an enteral feeding tube. The

purposes behind the dissemination plan are to provide practicing clinicians with

guidelines for the safety of their patients receiving medication altered for


administration through an enteral feeding tube. Clinicians have the skill level to

understand and implement the change in procedures. The effectiveness of the

dissemination plan will be evaluated at the end of the implementation period.

Literature Review Best, C., & Wilson, N. (2011). “Advice on safe administration of medications via

enteral feeding tubes.” British Journal of Community Nursing, S6-S10.

Review of this article reveals that although not a research article, in that it

does not contain statistical information, its benefits to Nursing and patient care

are evident. Carolyn Best and Neil Wilson detail nursing responsibilities

providing well documented nursing standards regarding medication

administration. Standards that include proper preparation of medication, enteral

tube access, access devices, and well as discussion of drug interactions and

drug absorption.

Although alteration of medication formulations by crushing, opening or

mixing, and the administering them through and enteral feeding tube is a

common practice, a full review of medication should be performed prior to

administration (Best & Wilson, 2011). Further, detailed procedures to reduce the

risk of tube blockage and medication binding with the tube material are offered

for consideration by the reader. Significant lose of medication is notable, when

administering medications such as carbamazepine undiluted through PVC

enteral feeding tube (Best & Wilson).


Boulatta, J. I. (2009). “Drug administration through an enteral feeding tube The

rationale behind the guidelines.” American Journal of Nursing, 109(10), 34-42.

When faced with administering medication through enteral feeding

tubes, clinicians often make poor administration choices based on long standing

practices. In a survey conducted in 1988, 97% of participants believed their

techniques were appropriate and effective. “In a more recent study respondents

used one to three inappropriate techniques” (Boulatta, 2009, p. 36). Boulatta

provides a comprehensive review of the American Society for Parenteral and

Enteral Nutrition’s Guidelines for Administering Medication Through an Enteral

Feeding Tube. A review of literature reveals that 57% of nurses surveyed do not

routinely flush the tube before administration of medication. Medication

combined with enteral feeding can cause tube-clogging, interaction with the

feeding, and change the medication’s bioavailability. Provided as a continuing

education credit Boulatta makes sense of the guidelines and makes a case for a

multidiscipline approach to medication administration.

Cursano, R., Noe, D., Albrecht, M., Lanzi, P., Bargiggia, A., & Piacentini, P.

(2012). Drug risk/benefit ratio assessment in patients receiving enteral nutrition

Internal guidelines by a nutrition team. Nutritional Therapy & Metabolism, 30(4),

208-216.

Italian researchers, in their research article, Drug risk/benefits assessment

in patients receiving enteral nutrition: internal guidelines by a nutrition team

addresses the problem from a multidiscipline team approach. Using information


from over 100 patients, they developed comprehensive guidelines to assist the

Nurse in decision-making when faced with altering medication form for

administration through an enteral feeding tube (Cursano et al., 2012).

Analysis of medical records retrospectively and prospectively combined

with personnel interviews were employed to investigate current practices and

related problem as they pertain to the administration of medication through

feeding tubes was the focus of research in a Milan hospital. The study aimed to

assess the impact of the clinical pharmacist within the multidisciplinary team as

well as determine the risk to benefit ration of medication administration through

an enteral feeding tube.

Results reflected that 80% of the time administration of medication

through an enteral feeding tube involved a change in pharmaceutical form.

Further the results were used in the development of a decision algorithm for

administering medication through an enteral feeding tube (Cursano, et al., p.

212).

Fletcher, J. (2011). Nutrition Safe practice in adult enteral tube feeding. British

Journal of Nursing, 20, 1234-1239

Although Jane Fletcher’s article Nutrition: safe practice in adult enteral

tube feeding concentrates on the safe use of feeding tubes, details regarding

standards for assessing tube placement while at bedside are important in

developing additional educational materials for the nurse. Details regarding pH

testing of aspirated gastric fluid will be helpful in determining the likelihood of


alter medication availability and “promoting safer measurement and

administration of liquid medicines” (Fletcher, 2011, p. 1234). Gastric pH levels

can directly influence medication bioavailability.

Not research in nature; the significance of Jane Fletcher’s article to

nursing and patient care is significant. Fletcher provides best practice

recommendations for safe use of enteral feeding tubes for both feeding and

medication administration.

Gonzaga do Nascimento, M. M., Moreira Reis, A. M., Wick, J. Y., & Ribeiro, A.

Q. (2012). Drug administration through feeding tubes An integrated qualification

program. Nutricion Hospitalaria, 27, 1309-1313

The original research article Drug administration through feeding tubes:

and integrated qualification program goes further than any other article herein

and provides direct research into methods of change. Detailing instruction of

specific medication recommendations and formal training regarding drug

administration through feeding tubes (Gonzaga do Nascimento, Moreira Reis,

Wick, & Ribeiro, 2012). Describing the implementation process and results of an

integrated program to improve drug administration this article supports the

conclusion that comprehensive training regarding administration of medications

through an enteral feeding tube are necessary and effective.

A descriptive study centered on the implementation of four steps. Those

being: the design of a database with technical characteristics of oral medications,

identification of non-crushable medications, nursing team knowledge and


evaluation, and prescription evaluation. Results noted that with the development

of a single source of consultation, nurses could form an integrated program with

multiple strategies to improve the process of administering medication through

feeding tube (Gonzaga do Nascimento, Moreira Reis, Wick, & Ribeiro, 2012).

Idzinga, J. C., De Jong, A. L., & Van den Bemt, P. M. (2009). The effect of an

intervention aimed at reducing errors when administering medication through

enteral feeding tubes in an institution for individuals with intellectual disability.

Journal of Intellectual Disability Research, 53, 932-938.

Additional research is available in the article the effect of an intervention

aimed at reducing errors when administering medication through enteral feeding

tubes in an institution for individuals with intellectual disability. Idzinga & Jong, et

al. concludes that programs instituted in tertiary hospitals to reduce errors in

administering medication through and enteral feeding tubes are equally effective

in institutions for individual with intellectual disability (Idzinga, de Jong, & van den

Bemt, 2009). In doing so, their research supports this writer’s contention that

additional pharmacologic training is necessary to administer medications safely

through an enteral feeding tube.

Designed as an observational, prospective study with pre- and post-

intervention study (Idzinga, de Jong, & van den Bemt, 2009). Its significance to

nursing and patient care is in information obtained through observation of

medication errors relating to administration through an enteral feeding tube.


Kenny, D. J., & Goodman, P. (2010). Care of the patient with enteral tube

feeding An evidence-based practice protocol. Nursing Research, 59 (1S), S22-

S31.

Noting that care practices can vary widely Kenny & Goodman developed

and evidence based practice protocol regarding the care of the patient with

enteral tube feeding (Kenny & Goodman, 2010).

This is an evidence-based implementation project where date was

collected through pretest and posttest measures. This article will be used to

develop additional evidence based practices in relation to the administration of

medication through enteral feeding tubes.

Kirkevold, O., & Engedal, K. (2010). What is the matter with crushing pills and

opening capsules. International Journal of Nursing Practice, 16, 81-85.

In the original research study, What is the matter with crushing pills and

opening capsules researchers detail statistical occurrence of medication altering.

Although specifically regarding medication for oral administration, the study

detailed the effects on medication efficacy and the extent of malpractice

regarding one aspect of medication administration (Kirkevold & Engedal, 2010).

Research methods included data sheets used to collect patient

demographics as well as detailed information regarding medication

administration. The results indicated that nearly a quarter of the patient received

medications in altered states and frequently those medications should not to be

altered.


Nissen, L. M., Haywood, A., & Steadman, K. J. (2009). Solid medication

dosage form modification at the bedside and in the pharmacy of Queensland

hospitals. Journal of Pharmacy Practice and Research, 39(2), 129-134.

Research detailing the occurrence of bedside medication form altering

through self-reporting survey of 97 hospitals revealed that not only were

medications being altered at the beside, but included medication for which

serious adverse effects may arise from the delivery of toxic or sub-therapeutic

doses (Nissen, Haywood, & Steadman, 2009, p. 129).

Method employed included a survey of open-ended questions distributed

to 97 facilities used to identify commonly altered medication at the bedside and

the reason those medications were altered. Results indicate that medications

altered at the bedside can result in medication errors and the methods used to

determine which medication were crushable were as varied as the survey

participants.

This articles relevance is in evidence of the need for a comprehensive

program of education to prevent medication error, increase morbidity, and even

mortality.

Phillips, N. M., & Endacott, R. (2011). Medication administration via enteral

tubes A survey of nurses’ practices. Journal of Advanced Nursing, 2586-2592

In the original research article Medication administration via enteral tubes:

a survey of nurses’ practices, researchers Phillips and Endacott statistically detail


multiple administration practices across a random sample of 181 Registered

Nurses at two large metropolitan hospitals. They conclude, “Enteral medication

administration practices are inconsistent. Some nurses are using unsafe

practices and may therefore compromise patient care” (Phillips & Endacott, 2011,

p. 2586). The available statistical data will assist in the formulation of solutions

as well as detail practices that are most likely unsafe.

Phillips, N. M., & Nay, R. (2008). A systematic review of nursing administration

of medication via enteral tubes in adults. Journal of Clinical Nursing, 17, 2257-

2265.

Philips & Nay performed a systematic review aimed to determine the best

available evidence regarding the effectiveness of nursing interventions in

minimizing the complications associated with administering medication via

enteral tubes in adults (Phillips & Nay, 2008, p. 2257). In their article, A

systematic review of nursing administration of medication via enteral tubes in

adults, they identify and catalog best evidence practices. These practices will be

used in the support of the development of comprehensive training for nurses who

administer medication through enteral feeding tubes and support the proposed

changes.

Prohaska, E. S., & King, A. R. (2012). Administration of antiretroviral

medication via enteral tubes. American Journal of Health-System Pharmacy, 69,

140-146.


In a study published by Prohaska & King in the American Journal of

Health-System Pharmacy titled, Administration of antiretroviral medication via

enteral tubes, discussion on the direct effect of crushing medication and

administering through an enteral feeding tube in regard to specific medication.

That discussion includes absorption of first-pass hepatic metabolism, variations

in pH, disintegration and dissolution of medications (Prohaska & King, 2012, p.

2140). This article demonstrates the gravity of the issue and offers suggestions

for best practice.

Toedter Williams, N. (2008). Medication administration through enteral feeding

tubes. American Journal of Health-System Pharmacy, 65, 2347-2357

Nancy Williams details specific medication administration concerns

through an enteral feeding tube. In her article Medication administration through

enteral feeding tubes, she provides “an overview of enteral feeding tubes, drug

administration techniques, considerations for dosage form selection, common

drug interactions with enteral formulas, and methods to minimize tube occlusion”

(Toedter Williams, 2008, p. 2347). This overview is significant to nursing and

patient care in that it provides reference to best practice for reduction of

complications when administering medication through tube feeding.

Yantis, M. A., & Velander, R. (2011). Untangling enteral nutrition guidelines.

Nursing2011, (), 33-38


Yantis & Velander, in their article Untangling Enteral Nutrition Guidelines,

note special precautions are required when administering oral medications

through a enteral feeding tube including the preparation and separate

administration of each medication (Yantis & Velander, 2011). Though this article

does not provide statistical information it does offer recommendations from the

American Society for Parenteral end Enteral Nutrition relating to the appropriate

procedures for administering medication through an enteral feeding tube and

generally supports the intervention of providing additional training to nurses who

administer medication via this route.

Zhu, L. L., Xu, L. C., Wang, H. Q., Jin, J. F., Wang, H. F., & Zhou, Q. (2012).

Appropriateness of administration of nasogastric medication and preliminary

intervention. Therapeutics and Clinical Risk Management, 8, 393-401.

Chinese researchers in utilization study titled; Appropriateness of

administration of nasogastric medication and preliminary intervention separated

medication into two groups. In one group were medications with a package

insert that noted the medication should not be crushed or opened and in the

other medication that did not have a specific recommendation discouraging

altering dosage, but that evidence showed they should not. The awareness of

evidence that those medications in the second group should not be crushed was

zero. Through instituted intervention, knowledge of which medications could not

be crushed was significantly raised through team cooperation and effort (Zhu et

al., 2012, p. 393).


Statistical information was garnered through descriptive analysis from data

collected in a 2200-bed tertiary care hospital. Specifically this article supports

the proposed change and details the quality and effectiveness of a preliminary

intervention similar to the one being proposed.

In-depth analysis of the forgoing 15 articles identified nine research study

findings and six articles of either Meta analysis or incorporation of best practice

review. Sufficient knowledge can be obtained from the included research studies

to identify areas of concern in regard to medication administration through enteral

feeding tubes along with sufficient data to assist in the development of a program

aimed at reducing the effects of medication administration through a enteral

feeding on patient safety.


Appendix A

Kindred Health Care System Wide

Policy and Procedure Manual Nursing Department

Chapter

Z

Section

2

Subject: ADMINSTRATION OF

MEDICATION THROUGH AN ENTERAL FEEDING TUBE

Date Issued

02/09/2013

Date Revised

Page

1 of 2

I. PURPOSE The purpose of this policy is to direct the safe alteration of

medication and subsequent safe administration through an enteral feeding tube.

II. POLICY STATEMENT

The goal of KHC is to provide high quality patient care. Care that includes the safe administration of medications.

III. DEFINITIONS ALTERATION: any change in the original structure of a medication to facilitate its administration through an enteral feeding tube ENTERAL FEEDING TUBE: A tube designed for the administration of enteral

feeding including, Nasogastric Tube (NGT), Percutaneous endoscopic gastrostomy tube (PEG), Dubhoff, or any other tube placed at bedside or through surgical procedure intended for use in the delivery of enteral feeding.

IV. PROCEDURE A. Determine if any medication to be administered is

incompatible with enteral formula. a. If a medication is incompatible with enteral

formula hold tube feeding for 30 minutes. B. Determine if medication can be crushed

b. Do not crush enteric-coated medications. c. Do not crush time-delayed medications including:

extended-release or sustained-released medication.

i. Request alternatives for all time-delayed medications.

C. Preparation of medications d. Tablet – crush and mix tablet individually with 10

-15 mL of drinking water. e. Capsules – open capsules and mix contents

individually with 10 – 15 mL of drinking water. f. Liquids – shake well and dilute correct dose with

10 -15 mL of drinking water.


D. Administer medication individually g. Using a 60 mL catheter tip syringe administer

each medication separately. h. Rinse syringe and administer solution through the

tube. i. Flush after each medication with 30 mL of

drinking water and before restarting feeding. E. Restart feeding.


Appendix B

TEACHING MATERIALS


Appendix C

PROCEDURE FOR THE ADMINSTRATION OF MEDICATION THROUGH AN ENTERAL FEEDING TUBE

Stop the tube feeding

Prepare medications separately

TABLETS Crush and mix with 10 – 15

mL water

CAPSULES Open and mix

with 10 - 15 mL water

Liquids Shake and

dilute in 10 – 15 mL water

Hold for 30 minutes and flush with 30 mL

of water for medication requiring to be administered

on an empty stomach

Hold for 1 hour a flush with 30 mL of

water for medications

determined to be incompatible with enteral feeding

Flush enteral tube with 30 mL water

before administering medications that do

not requiring an empty stomach or

that are not

Use a 60 mL catheter tip syringe

Administer medication individually through enteral feeding tube

Rinse syringe and administer through tube

Flush tube between medications and before restarting enteral feeding with 30 mL of water

RESTART ENTERAL TUBE FEEDING


Appendix D

MEDICATIONS NOT TO BE ADMINISTERED THROUGH AN ENTERAL

FEEDING TUBE

MEDICATION NOT TO BE ADMINSTERED THROUGH AN ENTERAL FEEDING TUBE

Sustained Release

Medications with suitable

substitute

Enteric Coated

Timed Release

Extended Release


Appendix E

Kindred Hospital Medication Administration through Enteral Feeding Tube

Post training questionnaire

1. Medication administered through an enteral feeding tube can be administered all at once.

True False 2. Holding tube feeding prior to administration of

medication is only required when medication is deemed to be incompatible with enteral feeding formula. True False

3. Enteric-coated medication cannot be administered through an enteral feeding tube. True False

4. It is not necessary to flush the enteral feeding tube after the administration of all medications. True False

5. Evidence suggests that medications should be administered only by gravity. True False

6. Medication should be mixed with enteral feeding formula to prevent clogging of the enteral feeding tube. True False

7. Medication can be prepared together with other medications True False

8. Liquid medications should be diluted in 10 – 15 mL of drinking water before being administered through an enteral feeding tube. True False

9. Medications should be prepared with 10 – 15 mL of drinking water before being administered through an enteral feeding tube. True False

10. Administering and flushing medication by bolus is preferred because it creates sufficient turbulence at the distal end of a feeding tube to debride the feeding tube. True False


Appendix F

KINDRED HOSPITAL

MEDICATION ADMINSTRATION THROUGH AN ENTERAL

FEEDING TUBE COMPETENCY EVALAUATION

Not observed

Sufficient

Insufficient

Skill 1. Nurse correctly identified medications that cannot be

administered through an enteral feeding tube.

2. Nurse held enteral tube feeding for 30 minutes if medication being administered required medication is administered on an empty stomach or 1 hour if a medication is incompatible with enteral feeding formula.

3. Medications were crushed and prepared individually.

4. Medications were individual mixed with 10 – 15 mL of drinking water.

5. The enteral feeding tube was flushed with 30 mL of drinking water before the administration of any medication.

6. Nurse flushed the enteral feeding tube with 30 mL of drinking water between each medication.

7. Nurse used a 60 mL catheter tip syringe for the administration of medication.

8. The syringe was rinse with drink water between each medication and administered through the feeding tube.

9. Nurse flushed the enteral feeding tube with 30 mL of drinking water after all medications were administered.

10. Nurse restarted tube feeding after the administration of all medications.


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