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8.19 Enteral feeding tubes: administration of medication

Essential equipment

  • Personal protective equipment
  • 60 mL ENfit enteral syringe
  • 5 mL, 10 mL and 20 mL ENfit syringes (if required)
  • 10 mL oral syringe (if required)
  • Mortar and pestle or tablet crusher if tablets are being administered (BAPEN [13])

Optional equipment

  • Freshly drawn tap water for patients who are not immunosuppressed, and either cooled freshly boiled water or sterile water from a freshly opened container for patients who are immunosuppressed (NICE [119]) (keep water covered)

Pre‐procedure

ActionRationale

  1. 1.
    Check whether the patient can take medication orally, whether medication is necessary or whether it can be temporarily suspended.
    If the patient can take medication orally this reduces the risk of tube blockage (BAPEN [13], C).
  2. 2.
    Consider whether an alternative route can be used, for example buccal, transdermal, topical, rectal or subcutaneous.
    If the patient can take medication via an alternative route this reduces the risk of tube blockage (BAPEN [13], C).
  3. 3.
    Check the drug is absorbed from the site of delivery.
    Some drugs may not be absorbed directly from the jejunum (BAPEN [13], C).
  4. 4.
    Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
    To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [126], C).
  5. 5.
    Clean hands with soap and water or alcohol‐based handrub and apply personal protective equipment.
    To minimize the risk of cross‐infection and protect the practitioner from gastric/intestinal contents ([115], C).

Procedure

  1. 6.
    Stop the enteral feed and flush the tube with at least 30 mL of water (sterile water for jejunostomy administration), using an enteral syringe.
    Next, where there is an absolute contraindication for medicine to be taken with feed, follow steps 7 and 8. If not, skip to step 9.
    To clear the tube of enteral feed as this may cause a blockage or interact with medications. Sterile water should be used for jejunostomy tubes as the water is bypassing the protective acidic environment of the stomach. E
  2. 7.
    Stop the feed 1–2 hours before and leave the feed off for up to 2 hours after administration (this will depend on the drug); for example, for phenytoin administration, stop feed 2 hours before and for 2 hours after.
    To avoid interaction with enteral feed. E
  3. 8.
    Consult with the dietitian to prescribe a suitable feeding regimen.
    To ensure that the patient's nutritional requirements are met in the time available around medicine administration (BAPEN [13], C).
  4. 9.
    Prior to preparation, check with the pharmacist which medicines should never be crushed.
    Some medications are not designed to be crushed. These include:
    • modified‐release tablets: absorption will be altered by crushing, possibly causing toxic side‐effects
    • enteric‐coated tablets: the coating is designed to protect the drug against gastric acid
    • cytotoxic medicines: crushing will risk exposing the practitioner to the drug (BNF [23], C).
  5. 10.
    Prepare each medication to be given separately. Volumes greater than 2.5 mL may be drawn up in a 5 mL, 10 mL, 20 mL or 60 mL ENFit syringe according to the volume required and administered via the tube. Always choose the smallest syringe that will accommodate the volume of drug. For smaller volumes (less than 2.5 mL) follow step 13.
    Either:
    • Soluble tablets: dissolve in 10–15 mL water.
    Or:
    • Liquids: shake well. For thick liquids mix with an equal volume of water.
    Or:
    • Tablets: crush using a mortar and pestle or tablet crusher and mix with 10–15 mL water.
    To avoid interaction between different medications and to ensure solubility (BAPEN [13], C).
    To improve accuracy of measurement of the drug. E
  6. 11.
    Never add medication directly to the enteral feed.
    To avoid interaction between medicines and feed (BAPEN [13], C).
  7. 12.
    Administer the medication through the tube via a 60 mL ENFit enteral syringe.
    To ensure the whole dose is administered (BAPEN [13], C). To ensure that intravenous syringes are not connected to an enteral feeding system (NHSI [117], C).
  8. 13.
    Rinse the tablet crusher or mortar with 10 mL water, draw the water up in a 60 mL ENFit syringe, and flush this through the tube.
    To ensure the whole dose is administered (BAPEN [13], C).
  9. 14.
    If volumes of less than 2.5 mL are required, the dose should be measured in a 10 mL oral syringe – not an ENFit syringe. The plunger of a 60 mL ENfit syringe should be removed and the 60 mL ENfit syringe connected with the enteral tube. The dose should then be administered into the barrel of the 60 mL ENFit syringe and the 10 mL syringe rinsed with water, and this water should also be administered via the barrel of the 60 mL ENFit syringe.
    To avoid interactions between medicines (BAPEN [13], C).
    To ensure that the whole dose is administered. E
  10. 15.
    Flush the tube with at least 30 mL of water between administrations of different drugs and following the administration of the last drug.
    To avoid medicines blocking the enteral tube (BAPEN [13], C).
  11. 16.
    If the patient is on fluid restriction or for a paediatric patient, consult the dietician and pharmacist about the quantity of water to be given before and after medication.
    To ensure that the patient does not exceed their fluid restriction or requirements (BAPEN [13], C).

Post‐procedure

  1. 17.
    Remove and dispose of any equipment.
    To reduce the risk of cross‐infection. E
  2. 18.
    Record the administration on the prescription chart. Record fluid intake on the fluid chart if applicable.
    To maintain accurate records (NMC [126], C).
    To ensure accuracy of fluid balance monitoring. E
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