PEG Tube Feeding - Checking Residual

[cara519]

Hi, I am a first semester nursing student and we are learning about nutrition/tube feedings right now. I have a worksheet I am working on, but the book does not seem to be very helpful in that is only gives descriptions, but not specific actions to take.

The question I need clarification on is: "A patient is receiving PEG tube feeding at 60mL/hr. The nurse checks the residual and aspirated 150cc or undigested feeding. What action should the nurse take next?"

My problem is that my book only talks about what PEG tube feeding is, but does not give an explanation as to what is an acceptable volume for gastric residuals. I have tried using Google to get some help and have gotten a few different answers. The first approach was to multiply the amount given by 2 (60x2=120), and what would be used as a guideline. Or I have also been reading that anything below 250cc is acceptable.

So, in the case of my question, would 150cc be an acceptable amount since it's below 250, or does that value need intervention since it is above 120?

And if it does need intervention, is stopping the feeding the an appropriate action?

Any clarification would be helpful! :)

[Sun0408, ASN, RN]

You would return the residual and resume the TF and recheck for residuals again in 4 hours.. Residual checks are standard q4h in most places.. The hold/not hold is a specific question that is facility based. Usually anything under 250 is fine to continue the TF while anything over would be cause to hold the TF because the pt is not tolerating it..

My answer is based on practice. You instructor may have an article or some other educational information she/he is basing this lesson off of. Was this not mentioned in class since the book is of little help??

[cara519]

I will probably stick with 250 as my frame of reference, since I seem to be seeing that a fair amount. Thanks for your help!

And we were assigned the reading for this chapter and given a worksheet to answer, but lecture is not until Tuesday. So, it is a a little backwards

[morte, LPN, LVN]

The book can't get too specific because these things are per doctor's order/facility protocol; hence will vary by where you practice.

[Double-Helix, BSN, RN]

A healthy stomach should be continuously digesting what is put into it. The patient is getting 60mL/hr of tube feed and you've found a residual of 150mL. That means that in 2.5 hours, nothing has left the stomach. This could be a sign that the patient is having problems with GI motility. My first action would be to return the residual, stop the tube feed and assess the patient. Are bowel sounds present? Does the abdomen fell soft/hard? Tender? Appear distended? I would notify the physician of the residual and my assessment findings. Most likely, at that point I would hold the tube feeding for an hour and recheck the residual at that point. You would not want to continue to feed the patient, as over-filling of the stomach can cause distention and reflux, increasing the risk for aspiration.

Of course, that's my facility. It's important to know your facility's policy regarding residual volumes. I work with pediatrics, so we do not have a standard XmL residual is acceptable. Generally any residual greater than the volume of two hours of feeds would be cause for concern and notification of the MD.

[hodgieRN]

Our facility is to continue anything under 200 ml. As people stated before, you return it and check residual in 4 hrs to see how much they absorbed. It's a mock bolus feeding.

One of the reasons a pt has residuals is because the stomach doesn't exactly empty at a continuous rate. The stomach is a mixing chamber...nothing more. Tube feedings need little digestion and it should pass relatively quick, but the stomach is at the mercy of the pyloric sphincter and the vagus nerve. So here it the kicker.....the activity of the pylorus is related to the stretching of the stomach wall (among other things). Some people need a certain amount of food in the stomach before the pylorus can expand larger enough to pass feedings. So it goes build, build, build, empty...build, build, build, empty. As a matter of fact, most pts have some type of residual with gastric feedings. If they have no residual, that's great. They have great motility. But, some need a little volume before the sphincter can open. That's why residuals are allowed. The stomach was made to hold food, break it down, churn it, and then pass it. Now, the pylorus isn't completely closed off and tube feedings can pass very quickly (because there's really nothing to digest) but, in some pts, the pylorus may only be open enough for a few drops to pass a second. And that may be enough to build over time. If a pt has no residuals with gastric feedings on the chart, I'm either surprised or I assume the prior nurse never checked residuals and just charted zero.

There is on quick thing you can do from a nursing stand point. Put the pt on their right side. The pylorus is down and to the right. If the pt is completely on their left side, there is delayed emptying. What doesn't pass by peristalsis will stay in the stomach and build. Residuals don't count unless you've mobilized the pt a bit and put them on the right side. Give them a chance to empty. When they are on the right side, all the tube feeding (which has been pooling in the greater curvature of the stomach) will pool above the pylorus, causing stretch and emptying. You basically stimulate the parasympathetic response by manipulating the feedings. If that doesn't work, then they aren't tolerating.

Consider giving them Reglan. Reglan increases motility. If a pt is having high residuals, it often fixes the problem. And then, hello poo! Nurses have a love/hate relationship with Reglan.

[RNhelenwheels16]

Residuals less than 250 ml per most facility policies is acceptable. However if something is amiss, I think you've gotten some great advice on this forum.