58 AJN ▼ March 2005 ▼ Vol. 105, No. 3 http://www.nursingcenter.com

Deanna L. Reising is an assistant professor at the Indiana University School of Nursing, Bloomington, andRonald Scott Neal is a staff nurse on the critical care unit, Columbus Regional Hospital, Columbus, IN. Theproject the authors describe was funded by a grant from the Indiana University Undergraduate Research andCreative Activity Partnership. Contact author: Deanna L. Reising, dreising@indiana.edu. The authors of this arti-cle have no ties, financial or otherwise, to any company that might have an interest in the publication of this edu-cational activity.

By Deanna L. Reising, PhD, APRN,BC, and Ronald Scott Neal, BSN, RN

What you think are the best practices may not be.

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Flushing an enteral tube (in other words, keeping it free of buildup) is essen-tial because unclogging one wastes time, effort, and resources. And tubesthat can’t be unclogged have to be replaced, taking up even more nursingtime, not to mention those resources—the new tube, the X-ray to confirmtube placement—that can cause the patient discomfort or injury and, of

course, interrupt the delivery of crucial nutrition.Water is generally considered to be the best liquid for flushing, but there is little

agreement on how much fluid to use, how often tubes should be flushed, or howto flush when administering medication. In order to shed some light on the bestmethods of flushing enteral tubes, we reviewed the available literature and currentpractices.

DATA COLLECTIONWe took several approaches to examining the evidence. We contacted nursing edu-cation departments at 19 hospitals in Indiana to determine what, if any, practiceswere mandated at these institutions. We also conducted a search of nursingresearch and other review articles published between 1982 and 2002; for this weused the Cumulative Index to Nursing and Allied Health Literature. UsingMedline, we searched medical and allied health research and nonresearch articlespublished in the same period; ultimately, we reviewed 21 articles. Finally, wesearched for recommended practices in textbooks by major publishers that were

used in nursing courses—medical–surgical nursing,fundamentals, nursing pharmacology, and nursingnutrition. Nineteen textbooks were reviewed. Wefocused on routine and special flushing procedures,including those used to relieve occlusions, forpatients receiving nutrition or medication throughenteral tubes.

WHAT ARE NURSES DOING?As enteral tube flushing is under the clear purview ofnursing, it’s important to understand how it is gener-ally accomplished. The results of our review reflectthe variety of techniques nurses use in their practice.

Nursing practices. In 1996 Mateo published theresults of a study investigating nurse managementof enteral tubes.1 This research identified the mainpractices that nurses use when caring for patientswith enteral tubes. Of the 180 nurses whoresponded to the 43-item questionnaire, 94%reported regularly flushing enteral feeding tubes;29% of these flushed before feedings; 43% of themflushed after feedings; and 59% of them flushedevery four hours. Nurses also flushed when admin-istering medication: 47% of respondents reportedflushing before giving medications, 95% flushedafter giving medications, and 38% did so betweenmedications. Respondents reported using tap water,sterile water, and sterile normal saline as fluids forroutine flushing. Fluids used to unclog enteral tubesincluded carbonated beverages (81%), sterile water(49%), papain solution (46%; papain is a papayaextract used in meat tenderizers that acts as a pan-creatic enzyme, breaking down proteins), and tapwater (42%).

Although experts routinely emphasize the impor-tance of flushing before and after medication admin-istration, a study reported that only 69% of nursesflushed before medication administration throughenteral tubes; 98% of nurses flushed the enteral tube after administering medication.2 This variancein practice may or may not contribute to cloggedenteral tubes—there is no research in this area.

Institutional practices. When we contacted the 19Indiana hospitals to ascertain their policies and pro-cedures concerning enteral tube flushing, we foundthat institutions address this subject in a variety ofways. Of the hospitals surveyed,• 10 had no formal policy on flushing enteral

tubes.• three followed flushing procedures outlined in

the textbook Nursing Procedures (published bySpringhouse).

• two required a clinician’s orders for fluids andvolumes.

• one required the use of sterile water but had novolume standard.

• one had no written standard, but the educatorrecommended 60 mL of tap water for flushes.

• one required 150 mL of water to be administeredbefore and after feedings or medications beingpassed through the tubes.

• one specified 30 to 50 mL of water to be givenevery four hours.

A REVIEW OF THE LITERATURE How do these reported practices reflect what’s inthe literature?

Flushing during enteral tube feedings. Twoimportant studies established water as the acceptedflushing fluid and deemed cranberry juice ineffec-tive.3, 4 Water was also the flushing fluid most oftensuggested in textbooks; only two didn’t recommenda specific fluid.5, 6

Recommendations on the amount of fluid usedand the frequency and timing of flushing vary. Inpatients receiving continuous feedings, the amountof fluid recommended for flushing ranged from 20to 100 mL, and the suggested frequency of flushingranged from every four hours to every eight hours.In patients receiving intermittent or bolus feedings,the amount of fluid recommended ranged from 15to 100 mL, and sources recommended flushing bothbefore and after feeding. While a determination ofthe amount of fluid used, also called the “flush vol-ume,” must take into account the patient’s needs andrestrictions, nurse expert Norma Metheny pointedout in a personal communication that “the larger the

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Two important studies

established water as the

accepted flushing fluid

and deemed cranberry

juice ineffective.

ication.10, 11 Scanlan and Frisch found that the num-ber of enteral tube occlusions was greatly reducedby flushing with water before and after medicationadministration.10 While all the literature examinedrecommended flushing with water between enteralmedication administrations, there are differences of

flush volume, the more likely the tube is to remainpatent.” Finally, many sources specified that the fluidused to flush should be warm or tepid.6-9

Flushing between enteral medication administra-tions. Research and review articles have linkedenteral tube clogging to the administration of med-

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X Entry Site

StomachDuodenum

Gastrostomybutton

Gastrostomy tube

Abdominalwall

Gastrojejunostomy(through-the-stomachjejunostomy) tube

Jejunum

opinion as to the amount of water to use and whenthe flushing should be done.

Special considerations for small-bore enteraltubes. Most resources we consulted didn’t distinguishbetween large- and small-bore tubes. But Perry andPotter specified that a small-bore tube required 30 mLof normal saline or tap water for flushing, while large-bore tubes required 5 to 15 mL more than that.12, 13

Kohn-Keeth emphasized that small-bore tubes shouldbe flushed with water every four hours.14 We found noresearch conducted on this topic.

Checking feeding residual has been shown toincrease the incidence of tube clogging.15 When someenteral formulas, such as protein formulas, mix withlow-pH gastric juices, sediment may form and collectin tubes, possibly leading to occlusions; as a result,the practice of flushing after checking for feedingresiduals is gaining wider acceptance.7, 9, 12, 14, 16-19 It

should be emphasized that nurses should not stopchecking for residuals—frequent flushing withwater has been shown to prevent tube occlusionafter this important procedure.

Flushing fluids were compared in two now-classicstudies published in the 1980s. Both sought to deter-mine which fluids were the most effective in prevent-ing occlusion. Metheny and colleagues comparedwater, Coca-Cola, and cranberry juice.3 They foundthat water and Coca-Cola were superior to cran-berry juice. Wilson and Haynes-Johnson comparedthe efficacy of water and cranberry juice, ultimatelyconcluding that water was “a more effective irrig-ant.”4 In that study, 73% of the tubes flushed withcranberry juice became occluded, while none of thetubes flushed with water did. The influence of thesetwo studies has been enormous: their recommenda-tions are reflected in almost all of the resources sur-

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Enteral TubesThe three most commonly placed tubes.

Enteral tube feeding may be indicated when apatient cannot receive adequate nutrition orally.

This inability can result from trauma, congenitaldysphagia, impaired swallowing caused by neuro-logic conditions, or obstruction or tissue destructioncaused by neoplasms. Metabolic disorders orabsorption problems may necessitate enteral feed-ing, as well.

Short-term feeding (of less than four weeks’ duration)can be managed with a nasogastric tube. The mostcommonly used tubes for long-term feeding are picturedat left: the gastrostomy tube, the gastrostomy button,and the gastrojejunostomy tube. A number of factorsdictate the choice of tube, including the expected dura-tion of feeding, the condition necessitating the feeding,concomitant conditions, and clinician preference.

Percutaneous endoscopic gastrostomy (PEG) isthe most common method of tube insertion becauseof its safety and effectiveness; it’s associated with lowrates of morbidity and mortality and decreased costsbecause surgery and general anesthesia aren’t nec-essary for tube insertion. The tube is placed underdirect endoscopic visualization through an abdomi-nal incision and anchored in place with an outerflange and an inner bumper or balloon.

The gastrostomy tube feeds directly into the stom-ach and poses fewer risks of serious adverse effectsthan the gastrojejunostomy tube.

The gastrojejunostomy tube, the through-the-stomach jejunostomy tube, delivers its contents into the

jejunum and is indicated in patients with recurrentaspiration, upper gastrointestinal obstruction or fistula,gastroparesis, and gastroesophageal reflux. It cannotbe used in patients with small-bowel disease becauseit can cause enterocutaneous fistulae. And becausethese are smaller-bore tubes they tend to clog moreoften than gastrostomy tubes, requiring more frequenttube flushing or replacement.

The gastrostomy button came along in 1984 in aneffort to prevent some of the chronic complications ofgastrostomy tubes—clogging, leakage, and skin irri-tation. The button is skin level and out of site whenthe patient is dressed. It usually replaces a gastros-tomy tube four weeks after initial PEG (this periodensures a mature tract). Recent advances haveallowed for primary button insertion if gastropexy(attachment of the stomach to the abdominal wall) isalso performed at the time of insertion; long-termresults of this procedure aren’t known.

Patients with any type of tube placement must beassessed for leakage (high abdominal pressure, asoccurs with sneezing or coughing, often causes somenormal leakage), skin irritation, infection, and forma-tion of granulation tissue. Nutrition and hydration sta-tus, and signs or symptoms of aspiration, pneumonia,or gastrointestinal complications such as bleeding orperitonitis, must be assessed as well. Time spent withthe patient while flushing and assessing tubes is anexcellent opportunity for educating patients and care-givers on care of the gastrostomy tube. It’s alsoimportant to offer support as patients adjust tochanges in body image and the loss of the pleasuresof eating.—Karen Roush, MSN, NP, clinical editor

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veyed in this review, with the exception of one.While McKenry and Salerno suggest cranberry juiceas a flushing fluid,20 it’s important to note that thisrecommendation isn’t supported by research anddoes, in fact, contradict other research findings.

Unclogging occluded enteral tubes is covered invarious studies and textbooks. The findings of threestudies support the use of certain pancreatic en-zymes to remove obstructions if water or a carbon-ated beverage has failed.17, 21, 22 One study alsodemonstrated the effectiveness of administeringpancreatic enzymes in preventing tube obstruc-tion.23

Of the textbooks that specify how to treat aclogged enteral tube, two suggest water alone as theremedy,6, 24 and two recommend water alone orwater in combination with a carbonated beverage.5,

25 Ignatavicius and Workman state that cranberry

juice should not be used.25 Craven and Hirnle recom-mend intervention as soon as there is “difficulty”flushing an enteral tube.8 The intervention recom-mended is flushing with water and, if water is inef-fective, using 30 to 50 mL of a carbonated beverage.

Finally, it’s important to note that pancreaticenzymes must be activated before use. Typically, atablet of the pancreatic enzyme and a 324-mg tabletof sodium bicarbonate are dissolved in 5 mL ofwarm water just before instillation into theoccluded tube.26

Syringe size for flushing. Both Guenter and Lord,two experts in the field who associate tube rupturewith syringe size, say a syringe of 30 mL or greater isneeded to prevent rupture; other experts come to thesame conclusion.7, 9, 16 Two textbooks also support thispremise.19, 25 Although Lilly and Aucker recommend a10- to 20-mL syringe for flushing small-bore tubes,27

these smaller syringe sizes are believed to cause tuberupture because they generate considerable pressure.We found no research on appropriate syringe size forflushing; the only recommendations we found werefrom sources that weren’t researched based.

DISCUSSIONWhile there is some overlap in many of the recom-mendations in the literature, there is also significantvariance—possibly caused by conflicting evidencein the nursing literature. According to a personalcommunication from Norma Metheny, “the greatvariability in the information presented in text-books demonstrates that practical experience isproblematic. Standards should be written byexperts.”

In fact, more research is needed to determine thebest practices for routine enteral tube flushing. Stu-dies to determine the preferred tube (large or smallbore) must also be performed. Essential to thisresearch will be determining the minimum amount offluid necessary to maintain tube patency. ▼

REFERENCES1. Mateo MA. Nursing management of enteral tube feedings.

Heart Lung 1996;25(4):318-23. 2. Seifert CF, et al. A nursing survey to determine the charac-

teristics of medication administration through enteral feed-ing catheters. Clin Nurs Res 1995;4(3):290-305.

3. Metheny N, et al. Effect of feeding tube properties and threeirrigants on clogging rates. Nurs Res 1988;37(3):165-9.

4. Wilson M, Haynes-Johnson V. Cranberry juice or water? A comparison of feeding-tube irrigants. Nutr Support Serv1987;7(7):23-4.

5. Kee JL, Hayes ER. Pharmacology: a nursing processapproach. 4th ed. Philadelphia: Saunders; 2003.

Complete the CE test for this article byusing the mail-in form available in thisissue or visit NursingCenter.com’s “CE Connection” to take the test and find other CE activities and “My CE Planner.”

The following are some conclusions we havedrawn from our review.

Do

• flush at least every four hours: before,between, and after medication administration;before and after bolus feedings; and beforeand after checking for gastric residuals.

• use a syringe that holds at least 30 mL offluid.

• flush with at least 30 mL of warm water.• administer liquid forms of medications when-

ever possible.• try pancreatic enzymes to unclog an occlud-

ed tube.• develop a standard operating procedure on

tube flushing for nurses in your institution.

Don’t

• force or apply excessive pressure whenflushing the tube.

• use a syringe that holds less than 30 mL.• flush with cranberry juice.• crush sustained-release or enteric-coated

medications.• fail to activate pancreatic enzymes before

instillation into the tube.• assume that all nurses are flushing tubes

correctly or consistently.

In Conclusion

6. Springhouse Corporation. Nursing procedures. 3rd ed.Springhouse, PA: Springhouse Corp.; 2000.

7. Lord LM. Enteral access devices. Nurs Clin North Am1997;32(4):685-704.

8. Craven RF, Hirnle CJ. Fundamentals of nursing: humanhealth and function. 4th ed. Philadelphia: LippincottWilliams and Wilkins; 2003.

9. Bowers S. All about tubes: your guide to enteral feedingdevices. Nursing 2000;30(12):41-7; quiz 48.

10. Scanlan M, Frisch S. Nasoduodenal feeding tubes: preven-tion of occlusion. J Neurosci Nurs 1992;24(5):256-9.

11. Petrosino BM, et al. Implications of selected problems withnasoenteral tube feedings. Crit Care Nurs Q 1989;12(3):1-18.

12. Perry AG, Potter PA. Clinical nursing skills and techniques.5th ed. St. Louis: Mosby; 2001.

13. Potter PA, Perry AG. Fundamentals of nursing. 5th ed. St. Louis: Mosby; 2001.

14. Kohn-Keeth C. How to keep feeding tubes flowing freely.Nursing 2000;30(3):58-9.

15. Powell KS, et al. Aspirating gastric residuals causes occlusionof small-bore feeding tubes. JPEN J Parenter Enteral Nutr1993;17(3):243-6.

16. Guenter P. Mechanical complications in long-term feedingtubes. Nurs Spectr (Wash D C) 1999;9(12):12-4.

17. Marcuard SP, Perkins AM. Clogging of feeding tubes. JPENJ Parenter Enteral Nutr 1988;12(4):403-5.

18. Peckenpaugh NJ, Poleman CM. Nutrition essentials and diettherapy. 8th ed. Philadelphia: W. B. Saunders; 1999.

19. Smeltzer S, Bare B. Brunner and Suddarth’s textbook ofmedical–surgical nursing. 9th ed. Philadelphia: LippincottWilliams and Wilkins; 2000.

20. McKenry LM, Salerno E. Mosby’s pharmacology in nursing.21st ed. St. Louis: Mosby; 2001.

21. Marcuard SP, et al. Clearing obstructed feeding tubes. JPENJ Parenter Enteral Nutr 1989;13(1):81-3.

22. Nicholson LJ. Declogging small-bore feeding tubes. JPEN J Parenter Enteral Nutr 1987;11(6):594-7.

23. Sriram K, et al. Prophylactic locking of enteral feeding tubeswith pancreatic enzymes. JPEN J Parenter Enteral Nutr1997;21(6):353-6.

24. Grodner M, et al. Foundations and clinical applications ofnutrition: a nursing approach. 2nd ed. St. Louis: Mosby;2000.

25. Ignatavicius DD, Workman ML. Medical–surgical nursing:critical thinking for collaborative care. 4th ed. Philadelphia:W. B. Saunders; 2002.

26. Marcuard SP, Stegall KS. Unclogging feeding tubes with pan-creatic enzyme. JPEN J Parenter Enteral Nutr 1990;14(2):198-200.

27. Lilley LL, Aucker RS. Pharmacology and the nursingprocess. 2nd ed. St. Louis: Mosby; 1999.

ajn@lww.com AJN ▼ March 2005 ▼ Vol. 105, No. 3 63

GENERAL PURPOSE: To examine current practice andthe recommended methods for keeping enteral feed-ing tubes free of buildup and functioning optimally.

LEARNING OBJECTIVES: After reading this article andtaking the test on the next page, you will be able to

• discuss previous research about enteral tube flush-ing techniques.

• list appropriate evidence-based recommendationsfor routine flushing of enteral feeding tubes.

• outline evidence-based recommendations fordeclogging enteral feeding tubes.

To earn continuing education (CE) credit, follow these instructions:

1. After reading this article, darken the appropriate boxes(numbers 1–15) on the answer card between pages 48and 49 (or a photocopy). Each question has only onecorrect answer.2. Complete the registration information (Box A) and helpus evaluate this offering (Box C).*3. Send the card with your registration fee to: ContinuingEducation Department, Lippincott Williams & Wilkins, 333Seventh Avenue, 19th Floor, New York, NY 10001. 4. Your registration fee for this offering is $19.95. If you taketwo or more tests in any nursing journal published byLippincott Williams & Wilkins and send in your answers toall tests together, you may deduct $0.75 from the price ofeach test.

Within six weeks after Lippincott Williams & Wilkinsreceives your answer card, you’ll be notified of your testresults. A passing score for this test is 11 correct answers(73%). If you pass, Lippincott Williams & Wilkins willsend you a CE certificate indicating the number ofcontact hours you’ve earned. If you fail, LippincottWilliams & Wilkins gives you the option of taking thetest again at no additional cost. All answer cards for thistest on “Enteral Tube Flushing” must be received by March31, 2007.

This continuing education activity for 3 contact hoursis provided by Lippincott Williams & Wilkins, which isaccredited as a provider of continuing nursing educa-tion (CNE) by the American Nurses CredentialingCenter’s Commission on Accreditation and by theAmerican Association of Critical-Care Nurses (AACN00012278, category A). This activity is also providerapproved by the California Board of RegisteredNursing, provider number CEP11749 for 3 contacthours. Lippincott Williams & Wilkins is also anapproved provider of CNE in Alabama, Florida, andIowa, and holds the following provider numbers: AL#ABNP0114, FL #FBN2454, IA #75. All of its homestudy activities are classified for Texas nursing continu-ing education requirements as Type 1.*In accordance with Iowa Board of Nursing administrativerules governing grievances, a copy of your evaluation of thisCNE offering may be submitted to the Iowa Board of Nursing.

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