Tube-feeding schedule, giving the feed safely, and hygiene
Give tube feeds on a fixed schedule with the head raised, flush with water before and after, build up slowly, and keep strict hygiene to prevent diarrhoea and aspiration.
Aim and principles
Aim: To plan a feeding schedule for Mr. S (six 300 mL bolus feeds a day), describe how to give a feed safely, and plan his water. Principles: Feeds are given at fixed times, so that the day's volume, energy and water are actually delivered. Bolus feeding (about 200-300 mL by syringe or gravity over 15-30 minutes, 5-8 times a day) is simple and suits blenderised feeds through a nasogastric or PEG tube in stable patients. Continuous feeding by pump (for example 1800 mL over 20 hours = 90 mL per hour) is used in the ICU, for jejunal tubes and when bolus feeds are not tolerated; it needs commercial feeds. Feeding is built up slowly over 2-3 days, especially in malnourished patients, who are at risk of refeeding syndrome (sudden falls in phosphate, potassium and magnesium). The patient sits with the head raised 30-45° during and after feeds to prevent aspiration into the lungs. The tube position is checked before each feed as the hospital protocol says. The tube is flushed with about 30 mL water before and after every feed and medicine to prevent blockage, and extra water is given to meet the fluid need. Hygiene (hand washing, boiled water, clean equipment, fresh feeds) prevents diarrhoea and infection. The patient is monitored daily for volume taken, vomiting, abdominal distension, stools and hydration, with weight checked weekly and blood sugar and electrolytes as the doctor advises.
Feeding prescription: Mr. S, 60 kg, Ryle's tube
| Item | Plan | Basis |
|---|---|---|
| Feed | 1800 mL a day (Feed A × 3, Feed B × 3), about 1 kcal/mL | 1800 kcal, 65-70 g protein |
| Method | Bolus by 50 mL syringe or gravity; 300 mL over 20-30 minutes | Stable patient; wide Ryle's tube |
| Frequency | 6 feeds, every 3 hours, 6 am to 9 pm | Night rest for the stomach |
| Flushes | 30 mL water before and after each feed (360 mL a day) | Prevents blockage; adds water |
| Extra water | 2 × 115 mL between feeds (about 230 mL) | Makes total water about 2100 mL |
| Build-up | For example 100 mL per feed on day 1, 200 mL on day 2, 300 mL on day 3 | Slower if malnourished or not tolerated |
Do's and don'ts while tube feeding
| Do | Don't |
|---|---|
| Wash hands and wear clean gloves | Touch the tube tip or the feed with bare hands |
| Raise the head 30-45° and keep it raised for 30 minutes after | Feed a patient who is lying flat |
| Check the tube position before each feed, as per protocol | Feed if the patient coughs, chokes, or the tube seems to have moved |
| Give the feed at room temperature, slowly, over 20-30 minutes | Push the feed fast or give it cold from the fridge |
| Flush with 30 mL water before and after feeds and medicines | Mix medicines into the feed |
| Use fresh feed and discard leftovers after about 2 hours | Keep feed at room temperature for later |
| Record every volume on the intake chart | Skip feeds without telling the dietitian |
Sample one-day feeding schedule (Mr. S)
| Time | Feed or water | Volume |
|---|---|---|
| 6.00 am | Flush, Feed A, flush | 30 + 300 + 30 mL |
| 9.00 am | Flush, Feed B, flush | 30 + 300 + 30 mL |
| 10.30 am | Extra water | 115 mL |
| 12.00 noon | Flush, Feed A, flush | 30 + 300 + 30 mL |
| 3.00 pm | Flush, Feed B, flush | 30 + 300 + 30 mL |
| 4.30 pm | Extra water | 115 mL |
| 6.00 pm | Flush, Feed A, flush | 30 + 300 + 30 mL |
| 9.00 pm | Flush, Feed B, flush | 30 + 300 + 30 mL |
| Total | 6 feeds, 12 flushes, 2 water feeds | 1800 + 360 + 230 = 2390 mL given |
How to give a bolus feed
- 1★Wash hands, wear clean gloves and explain to the patient.
- 2Raise the head of the bed to 30-45°.
- 3★Check the tube position as the hospital protocol says (for example the length mark at the nose and the pH of the aspirate); do not rely on the 'whoosh' air test.
- 4Flush with 30 mL of boiled, cooled water using a 50 mL syringe.
- 5Give the feed at room temperature by gravity or slow syringe push over 20-30 minutes; stop if the patient coughs, vomits or looks distressed.
- 6Flush with 30 mL water, close the tube and record the volume on the chart.
- 7Keep the patient sitting up for at least 30 minutes; give mouth care.
★ one-way, controls the pace
Worked calculation: water and feeding rate
Mr. S (60 kg) receives 1800 mL of a 1 kcal/mL feed as six bolus feeds. Plan his water to reach 35 mL/kg, and find the pump rate if the same feed were given continuously over 20 hours.
- Water needed = 35 mL/kg × 60 kg = 2100 mL.
- Water from the feed: standard 1 kcal/mL commercial feeds are about 84% water, and a rough check of Feed A and Feed B gives a similar 83-86%, so use 84% as an estimate: 1800 × 0.84 = 1512 mL.
- Flushes: 30 mL before and after each of 6 feeds = 6 × 2 × 30 = 360 mL.
- Water still needed = 2100 − 1512 − 360 = 228 mL, about 230 mL, given as two extra water feeds of about 115 mL.
- Total water = 1512 + 360 + 230 = 2102 mL, about 2.1 L.
- Continuous feeding: 1800 mL ÷ 20 hours = 90 mL per hour by pump.
- Build-up: day 1, 6 × 100 mL = 600 mL; day 2, 6 × 200 mL = 1200 mL; day 3, 6 × 300 mL = 1800 mL.
Six 300 mL feeds (about 1512 mL water) + 360 mL flushes + about 230 mL extra water give about 2.1 L water a day; a pump would run at 90 mL per hour for 20 hours.
Complications, monitoring and result
- Diarrhoea: check hygiene, feed temperature, speed, sugar and medicines before stopping the feed.
- Aspiration: keep the head raised, feed slowly, and stop if the patient coughs or vomits.
- Tube blockage: strain feeds, flush before and after, and never mix medicines into the feed.
- Refeeding syndrome: in malnourished patients start low, build up over 2-3 days, and check electrolytes as advised.
- Monitor: volume given, vomiting, distension, stools and urine output daily; weight weekly.
- Result: Mr. S receives six 300 mL feeds at fixed 3-hourly times with 30 mL flushes and two extra water feeds: about 1779 kcal, 69 g protein and 2.1 L water a day, given safely with the head raised.
In the diet kitchen, the feeding schedule decides the cooking schedule: each 3-hourly feed is made or portioned fresh, labelled and sent with the right volume. The ward and the kitchen share one feed chart, so a missed or refused feed is noticed the same day.
Short answer: “Why is the head of the bed raised during tube feeding?” To reduce reflux and aspiration of feed into the lungs; keep it at 30-45° during feeds and for at least 30 minutes after.
Short answer: “Why is the tube flushed with water?” To clear feed or medicine so the tube does not block, and to add water to the day's fluid; about 30 mL before and after each feed.
Structured question: “Describe the method of giving a bolus tube feed and list its complications.” Wash hands, raise the head 30-45°, check tube position, flush 30 mL, give 200-300 mL at room temperature over 20-30 minutes, flush 30 mL, keep upright 30 minutes, record. Complications: diarrhoea, aspiration, vomiting and distension, tube blockage or displacement, dehydration, refeeding syndrome, high blood sugar.
Wash, Raise, Check, Flush, Feed, Flush, Sit: the seven steps of every bolus feed.