Procedure for Gavage Feeding (Pediatric)

Definition: Gavage feeding is a means of providing food via a catheter passed through the nares or mouth, past the pharynx, down the esophagus, and into the stomach, slightly beyond the cardiac sphincter. Objectives: a.To provide a method of feeding or administering medication that requires minimal patients effort, when the infant is unable to suck or swallow. b.To provide a route that allows adequate calories or fluid intake. c.To prvent fatigue or cyanosis that is apt to occur from nipple feeding. d.To provide a safe method of feeding a limp and listless patient. Contraindication: Absent bowel sounds Nursing Alert: Tube feeding are contraindicated to patients without bowel sounds. Administration of feeding solution into an improperly placed tube may cause aspiration of the feeding into the lungs. Charting: a.Accurately describe and record procedure, including time of feeding, type of gavage feeding type and amount of fluid given, amount retained or vomited, how the patient tolerated feeding, and activity before, during and following feeding. b.Observe for readiness of the infant to feed by nipple note sucking activity and sleep-wake cycle in relation to feeding. Equipment: Sterile rubber or plastic catheter, stethoscope, tape, feeding fluid, rounded tip, size 5-10 french clear calibrated reservoir for feeding fluid, syringe, water for lubrication, hypoallergenic, pacifier ACTIONS: 1.Position the infant on his side or back with a diaper roll placed under his shoulder, a mummy restraint may be necessary to help maintain this position. Rationale: This position allows for easy passage of the catheter, facilitates observation, and helps avoid constriction of the air way. 2.Measure feeding catheter and mark with tape; measure distance from tip of nose to ear to xiphisternum. Rationale: Premeasuring the catheter provides a guideline as to how far to insert the catheter. 3.have suction apparatus readily available. Rationale: Suctioning clears the air way and prevent aspiration if vomiting occurs.

4.Lubricate catheter with a sterile water or saline. Rationale: Do not use oil because of danger of aspiration.. 5.Stabilize the patients head with one hand; use the other hand to insert catheter. Rationale: This direction will follow the nares passage way into the pharynx. Do not direct the catheter upward. Positioning in nares may cause partial airway obstruction, therefore, observe for respiratory distress. Avoid this route if there is critical airway compromise. Push nose up to widen nostril. a.Insertion through nares slip the catheter into nostril and 6.If the patient swallows, passage of the catheter may be synchronized with swallowing. Do not push against resistance. Rationale: Swallowing motion will cause esophageal peristalsis which opens the cardiac sphincter and facilitates passage of the catheter. 7.If theres no swallowing, insert the catheter smoothly and quickly. Rationale: Because of cardiac sphincter spasm, resistance may be met at this point, pause a few seconds, then proceed. 8.In the infant, especially, observe for vagal stimulation (i.e. bradycardia and apnea) Rationale: The vague nerve pathway lies from the medulla through the neck and thorax to the abdomen. Above the stomach, the left and right branches unite to form the esophageal plexus. Stimulation of the nerve branches with the catheter will directly affect the cardiac and pulmonary plexus. 9.Once the catheter has been inserted to the premeasured length, tape the catheter to the patients face. Rationale: This prevents movement of catheter from the premeasured, preestablished correct position. Alternative method loop narrow cloth tape amount tube just below the nostril, then secure it above tip or nose with tape. Some movement of tube may be seen with swallowing. 10.Test for the correct position of the catheter in the stomach. a. Inject 5.5 ml air into the catheter and the stomach. At the same time listen to the typical growing stomach sound with a stethoscope placed over the epigastric region. Rationale: Aids in ensuring proper location of catheter. b.Aspirated injected air from the stomach. Rationale: This prevents abdominal distention. c.Aspirate small amount of stomach content and test acidity by pH tape. Rationale: Failure to obtain aspirate does not indicate improper placement; there may be any stomach content or the catheter may not be in contact with the fluid.

d.Observe and gently palpate abdomen for the tip of the catheter. Avoid inserting catheter into the infants trachea. Rationale: If improper placement occurs and the catheter inserts the trachea the patient may cough, fight and become cyanotic. Remove the catheter immediately and allow the patient to rest before attempting intubation again.i 11.The feeding position should be right side-lying with head and chest slightly elevated. Attached reservoir to catheter and fill with feeding fluid. Allow infant to suck during feeing. Hold infant if possible. Rationale: This position allows the flow of fluid to be aided by gravity. The use of the pacifier will relax the infant, allowing for easier flow of fluid as well as provide for normal sucking needs. Sucking will help develop muscles and provide a positive association between sucking and relief of hunger. 12.Aspirate tube before feeding begins. a.If over the previous feeding is obtained, withhold the feeding. b.If small residual of formula is obtained, return it to stomach and subtract that amount from the total amount of the formula to be given. Rationale: This is done to monitor for appropriate fluid intake, digestion time, and over feeding that can cause distention. Note an increase in gastric residual content. 13.The flow of feeding should be slow. Do not apply pressure. Elevate reservoir 15-20cm, above the patients head. Rationale: The rate of flow is controlled by the size of feeding catheter: the smaller the size, the lower the flow. If the reservoir is too high the pressure of the fluid itself increases the rate of flow. 14.Food taken too rapidly will interfere with peristalsis, causing abdominal distention and regurgitation. Rationale: The presence of food in the stomach stimulates peristalsis and causes the digestive process to begin. Also, when tube is in place, incompetence of the esophageal-cardiac sphincter may result in regurgitation. 15.Feeding time should last approximately as long as when a corresponding amount is given by nipple 5ml/5-10 minutes or 5-20 minutes total time. 16.When the feeding is completed, the catheter may be irrigated with clear water. Before the fluid reaches the end of the catheter clamp it off and withdraw it quickly. Rationale: Clamp the catheter before air enters the stomach and causes abdominal distention. Clamping also prevents fluid from dripping from the catheter into the pharynx, causing the patient to gag and aspirate. 17.Discard feeding tube and any feeding solution.

Note: Intermittent gavage is often preferred to indwelling gavage feeding. An indwelling catheter may coil and know, perforate the stomach, and cause nasal airway obstruction, ulceration, irritation of the mucous membrane, incompetence and esophageal-cardiac sphincter, and epistaxis. However, if intermittent intubation is not well tolerated and the indwelling method is used, the catheter should be clamped to prevent loss of feeding or entry of air and changed every 48-72 hours (use alternate side of the nares. Constant alertness to the above problem should be stressed. Indwelling method may be preferred with older infant or child. FOLLOW-UP PHASE: 1.Burp the patient. Rationale: Adequate expulsion air swallowed or ingested during feeding will decrease abdominal distention and allow for better tolerance of feeding. 2.Place the patient on right side or on abdomen for at least 1 hour. Rationale: To facilitate gastric emptying and minimize regurgitation and aspiration. 3.Observe condition after feeding: bradycardia and apnea may still occur. Rationale: Because of vagal stimulation as mentioned above. 4.Note any vomiting or abdominal distention. Rationale: Due to over feeding or too rapid feeding. Regurgitation of 1-2ml may occur in the premature infant as the musculature of the sphincter of the GIT is relaxed and allow for easy reflux. 5.Note infants activity. Rationale: Fatigue or peaceful sleep.

Tepid Sponge Bath

1 Assess the condition of your patient. This data will serve as a basis in evaluating the patient's response to the treatment. 2 Explain the method to the patient or the watcher. By providing them some information about the procedure, it will be much easier for them to cooperate. 3 Bring all equipments and set them on the area near the bed. Carefully check all of your materials to make sure everything is there. 4

Wash hands thoroughly before starting the procedure. 5 Close the door or the partition sheets (if at the ward) to provide privacy. 6 Adjust the patient's bed on a certain height that is accessible for working. This is beneficial on your side as it protects you from straining your back. 7 Place the bed protector or rubber sheet on patient's bed to protect bed linens. 8 Put on your working gloves. This prevents transmission of contaminants. 9 Carefully remove patient's clothing and place the bath blanket on top of him to ensure privacy. 10 Fill in your basin with cold water and mixed it up with hot water. Make sure to check its temperature. It should be neither too hot nor too cold. Appropriate temperature is 27 to 37 degrees C. 11 Immerse or dip small towels in the lukewarm water. Squeeze it to avoid dripping, and gently apply on the forehead, the axilla or armpits and the groin area. Do this for about 20 to 30 minutes and repeat if necessary. Heat transfer is much more effective when compresses are applied on areas with large superficial blood vessels such as the axillary and groin areas. 12 Carefully wipe the patient's extremities for about five minutes. Then proceed with back area and buttocks for about five to 10 minutes. Abdomen and chest areas are usually not included. 13 Monitor the patients' response to the treatment by checking his temperature. If it is slightly above normal, discontinue the procedure. 14 Replace the patients' clothing and cover him with a light sheet. As much as possible, avoid letting your patient wear heavy clothing or excessive sheet covering as it will only elevate his temperature. 15

Now begin after care by doing the following: change bed linens and remove the equipments away from the bed to prevent transmission of microorganisms, lower the patient's bed back to a safer height, Remove gloves, and wash your hands thoroughly. 16 Document the procedure done, along with the patient's vital signs, response to treatment, and complications if any.