Preparing and Administering Enteric Tube Medications

Preparation

1. Enteral tube medication administration considerations (review in the room, with the patient).

1. Upon first entering the patient's room, disinfect your hands by washing them with soap and warm water, applying vigorous friction for at least 20 s. Hand sanitizers may be used if the hands are not visibly soiled, but vigorous friction should also be applied.
2. At the bedside computer, log into the patient's electronic health record and review the patient's medical history and previous administration times. Verify with the patient any medication allergies and discuss his/her physical allergic responses and reactions.
3. At the bedside computer, pull up the Medication Administration Record (MAR).
   1. Review the medications that are due to be administered, and clarify with the patient if he/she has a preference or concerns prior to acquiring and preparing the medication. Some patients are sensitive to large volumes of fluid administered through the enteral tube or request fluids and medications to be administered slowly to avoid nausea.
   2. Review the medications that are scheduled to be given via the enteric tube. Medications that are provided in tablet form will need to be crushed, while capsules will need to be opened to release the powder or granules. Before crushing a tablet or opening a capsule, you must ensure that that it is safe to do so. Enteric-coated medication and extended/sustained-release medications should never be crushed.
   3. There are many medications that can be provided in a liquid form; this is preferred for enteric tube administration to decrease the likelihood of clogging the tube. Consult with a pharmacist to determine liquid preparation availability.
4. Leave the patient's room and wash hands, as described above (step 1.1)

2. Go to the medication preparation area (this area may be in a secured room or in a secured portion of the nurses' station) and complete the first safety check using the five "rights" of medication administration. Refer to the "Safety Checks and Five Rights of Medication Administration for Acquiring Medications from a Medication Dispensing Device" video.

1. The nurse must now maintain a distraction/disruption-free environment while dispensing and administering medications to prevent medication errors.
2. Acquire the enteric tube medications from the medication dispensing device, using the five "rights" during the first safety check.

3. In the medication preparation area, prepare the enteric tube medication as indicated in the MAR, pharmacy instructions, and nurse drug guide and according to best practices and institutional policies/procedures. Be mindful of preparing the medications in a manner that will allow you to correctly identify the medication.

1. Open the oral medication packaging and prepare for medication preparation.
2. For tablets, use a pill mortar and pestle or pill crusher to crush the tablet into a powder. Ensure that you create a fine powder to decrease the likelihood of clogging the enteric tube. Empty the contents of the mortar or pill crusher into a medication cup. If two or more drugs must be administered, they should never be crushed and mixed together.
3. For capsules, empty the contents of the capsule by grasping both ends of the capsule, twisting, and gently pulling. Empty the contents into a medication cup. Be careful not to lose any of the contained medications.
4. Premixed liquid oral medications will require the gentle shaking of the medication for a few seconds to ensure the equal distribution of the medication within the liquid.
   1. Place the medication cup on a level surface and crouch until you are at eye-level with the volume measurement. Pour the premixed liquid medication into the medication cup until it reaches the correct volume. Liquid poured while standing and looking down at the medication cup will cause an insufficient volume to be dispensed, constituting a medication error.
   2. Return a multi-dose container to the medication dispensing device. If a single-dose liquid medication container is used, dispose of the remaining volume according to institutional policy.
5. Write the medication name and dosage on tape or a pre-printed medication label. Some institutions may require additional information, depending upon their medication labeling policy.
6. Dispose of all medication packaging in the proper disposal receptacle.

4. In the medication preparation, area complete the second safety check using the five "rights" of medication administration. Refer to the "Safety Checks for Acquiring Medications from a Medication Dispensing Device" video.

5. Gather the necessary supplies, including two 60-mL catheter-tip syringes, a graduated cylinder, a bottle of sterile water or normal saline, plastic medication cups, 2 washcloths or small towels, a pH indicator strip bottle/package, a roll of silk or cloth tape, and an indelible marker. Take the supplies into the patient's room.

Administration

6. Upon first entering the patient's room, set the medications and supplies down on the counter and wash hands, as described in step 1.1.

1. Prepare the patient and supplies.
   1. Place a washcloth or a small towel at the base of the neck and over the chest of the patient. This will protect the patient's skin and gown if the fluid inadvertently leaks from the tube or syringe during the assessment and administration processes.
   2. Elevate the head of the bed to 30-45°.
   3. Pull the bedside table to within reach.
   4. Open the bottle of sterile water/normal saline and pour 30-60 mL of fluid into the graduated cylinder.
   5. Open both packages of 60-mL catheter-tip syringes and place the syringes on a clean washcloth or towel.
2. Confirm the enteric tube termination location.
   1. Don clean gloves.
   2. Remove one 60-mL catheter-tip syringe from package and remove the protective cover from the catheter tip.
   3. With your non-dominant hand, grasp the end of the enteric tube between your thumb and forefinger; with your dominant hand, grasp the enteric tube plug and gently remove it. To avoid gastric content overflow, folding and pinching the tube prior to plug removal may be necessary. Continue to pinch the tubing to form a manual clamp whenever withdrawing a plug or syringe.
   4. Hold the 60-mL catheter-tip syringe in your dominant hand and gently place the end of the catheter into the enteric tube opening until it is secure.
   5. With your dominant hand, gently pull back on the plunger of the syringe until gastric fluid appears in the syringe.
   6. While continuing to hold the end of the enteric tube between your non-dominant thumb and forefinger, gently twist the syringe while pulling outward to detach it from the end of the enteric tube. Place the syringe on the bedside table.
   7. Grasp the enteric tube plug between the dominant thumb and forefinger and insert the plug into the end of the enteric tube.
   8. Open the pH indicator strip bottle or packaging and remove one pH strip. Hold it between your non-dominant thumb and forefinger.
   9. Hold the syringe with your dominant hand, place the pH test strip at the end of the catheter tip, and gently depress the plunger until a drop of fluid forms and saturates the end of the pH test strip.
   10. After 3-5 s, or when the test strip color-stabilizes, compare the test strip to the pH chart on the pH bottle or packaging. A pH below 6 is consistent with the pH associated with gastric fluids and indicates that the end of the enteric tube is in the gastrointestinal tract. If the pH is above 6, this suggests that the tube may not be within the gastrointestinal tract. Contact the medical provider and obtain radiographic confirmation of enteric tube termination prior to instilling any medications or fluid into the tube.
   11. Hold the syringe with your non-dominant hand, place the catheter tip into the sterile water/saline in the graduated cylinder, and withdraw 15 mL of fluid.
   12. With your non-dominant hand, grasp the end of the enteric tube between your thumb and forefinger and then gently remove the enteric tube plug.
   13. Hold the 60-mL catheter-tip syringe in your dominant hand and gently place the end of the catheter into the enteric tube opening until it is secure. Hold the syringe upright.
   14. With the thumb of your dominant hand, gently depress the plunger, pushing the fluid into the tube and "flushing" the fluid line.
   15. Remove the syringe tip from the end of the enteric tube and place the syringe on the bedside table.

7. Perform the third and final medication safety check, adhering to the five "rights" of medication administration. Refer to the "Preparing and Administering Oral and Liquid Medications" video.

8. Prepare the medications and remaining supplies.

1. For powdered medications, gently pour 10-15 mL of sterile water or normal saline into each medication cup and gently stir with the catheter tip of the syringe. Allow time for the powder to dissolve into the liquid.
2. For liquid medications that are not in a medication cup, gently squirt or pour the medication into a medication cup.
3. Prepare sterile water or saline to flush the enteric tube between medications. From the bottle of the sterile water or saline, withdraw 15 mL of the water or saline for every medication to be delivered into the 60-mL syringe. Each medication must have a 10- to 15-mL flush between medications. Some enteric medications may precipitate and clog the tube if allowed to mix within the nasogastric tubing; therefore, generous flushing between medications is necessary.

9. Administer the enteric tube medications.

1. Hold the syringe in your dominant hand and take the medication cup with your non-dominant thumb and forefinger.
2. Place the syringe into the medication cup and gently stir the medication with the fluid while simultaneously pulling upward on the syringe plunger. Some medications do not dissolve in liquid and easily precipitate, falling to the bottom of the medication cup. Stirring the medication while withdrawing will allow the medication to remain suspended in the liquid and ensure that all the medication is withdrawn. Place the cup and syringe onto the bedside table.
3. With your non-dominant hand, grasp the end of the enteric tube between your thumb and forefinger and remove the enteric tube plug with your other hand.
4. Gently place the end of the catheter tip syringe containing the suspended medication or liquid medication into the enteric tube opening until it is secure.
5. With your dominant thumb, gently depress the plunger, pushing the medication into the tube.
6. Remove the empty syringe and place it on the bedside table. Pinch the tube to avoid content overflow and loss of medication.
7. Pick up the syringe, containing only sterile water or normal saline, with your dominant hand and gently place the end of the catheter into the enteric tube opening until it is secure.
8. Gently depress the plunger, pushing 10-15 mL of fluid into the enteric tube, flushing the enteric tube.
9. Repeat steps 9.1 through 9.8 until all medications have been administered.
10. After the last medication has been administered, the post-flush volume should be at least 30 mL of sterile water or normal saline to ensure that all medications have been cleared from the enteric tube.
11. Clean the supplies and dispose of the waste in the appropriate receptacles.
    1. Take the syringes and graduated cylinder to the sink.
    2. Add 100 mL of sterile water or saline to the graduated cylinder. To clean the syringe that was used to administer medications, pull 30-60 mL of clean water into the syringe and then push the fluid out into the sink. Repeat the process until medication residue is cleared from the syringe.
    3. Pour the remaining fluid from the graduated cylinder.
    4. Using the tape and marker, label each syringe, cylinder, and bottle of sterile water or saline with the current date and time. These supplies are to be replaced every 24 h to prevent the growth of pathogens. If unlabeled supplies are present in the room, these should be discarded and new supplies should be acquired.
    5. Dispose of the medication cups and packaging in the appropriate trash receptacles.
    6. Remove the cloths from the patient and the bedside table and place them in the dirty linen receptacle.

10. Document the enteric tube medication administration in the patient's electronic health record.

1. In the patient's electronic health record, record the date, time, location/site of the enteric tube medication administration, and the findings of the enteric tube termination assessment.
2. Record the total volume of fluid administered (including the medication fluid administration and the post-administration flushes) in the fluid intake section of the electronic health record.

11. Leave the patient room. Upon exiting the room, wash hands as describe in step 1.1.

This video details the process of administering medications into an enteric tube. Prior to instilling any fluid or medication into the enteric tube, it is important to confirm that the enteric tube terminates in the intended location in the gastrointestinal tract using the pH strip confirmation method. Flushing the enteric tube prior to, in between, and after medication administration helps to prevent medications from remaining in the line and the occlusion of the line. A common error associated with administering enteric tube medications is drawing all medications into the 60-mL catheter-tip syringe at the same time, thus administering all medications in one syringe. Doing so may result in the inadvertent clogging of the enteric tube or the exposure of the medications to each other in a non-acidic environment. This could potentially result in alterations of medication action and an adverse reaction in the patient. Another common error is failing to flush the enteric tube between and following medication administration, which could result in interactions between the medications or enteric tube occlusion, requiring the replacement of the tube.