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A client admitted to the ICU due to unresponsiveness is diagnosed with cerebrovascular accident (CVA) and started on nasogastric tube feedings. As the nurse checks tube placement to prepare for the next feeding, which of the following should be performed for gastric residual greater than 100mL?

Explanation

• Ensuring the patient is in a semi-Fowler's position enhances the gravitational flow of the solution, and lowers risk for aspiration of gastric contents into the lungs.

• The entire gastric contents are removed and measured before every intermittent feeding (or every 8 hours for continuous feedings) to monitor for delayed gastric emptying. Acceptable residual amounts are according to the provider’s guideline or institution policy; however, typically residuals should not be greater than one-half the amount of the last feeding.

• If there is more than 100ml gastric residual, the feeding should be withheld and the residual reassessed after an hour.  The provider should be notified of suspected delayed gastric emptying AFTER the nurse has re-evaluated residuals.

• Any measured residual fluid should be documented and replaced into the patient’s stomach to prevent fluid, electrolyte, and nutrient loss.

• 4-6 hourly removal and wasting of the contents could disturb the client's electrolyte balance.

• Check tube placement every 8 hours for continuous feedings according to facility policy, and prior to each intermittent feeding or medication administration via tube. The pH of the removed gastric content is tested first, before the total gastric residual is removed, in order to confirm placement of the tube. The pH of gastric contents should be less than 5.5 and be green, tan, or white. If the patient takes an acid-inhibiting medication, less than 6.0 is normal. The fluid in the small intestines is yellowish or brown-green and thicker, and the pH is 6 or higher. If the pH is over 7, it indicates respiratory fluid, and an x-ray would be needed to check placement.

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