Chapter 3: Administer enteral nutrition

Administering enteral nutrition is a critical skill for Nutrition and Dietetics professionals working in Kenya's healthcare settings. This chapter focuses on the practical and safety considerations involved in providing nutritional support via enteral feeding. Understanding the appropriate use of personal protective equipment (PPE), the various routes for enteral nutrition, and their clinical indications ensures effective patient care while minimizing risks of infection and complications. Professionals working in hospitals, clinics, and community health services must master these components to improve outcomes for patients unable to meet their nutritional needs orally.

3.1 PPEs

Personal protective equipment (PPE) is the clothing and equipment worn to protect the person giving enteral feeds and the client from infection and contamination. Enteral feeding involves contact with feeding tubes, feed, stomach contents and, at times, vomit, saliva and stool. A feed that is contaminated while it is prepared or given can cause diarrhoea and infection in a client who is already ill, and a dietitian or nurse who is splashed can be exposed to infectious secretions. PPE is worn together with hand hygiene and clean working methods: it does not replace them.

The choice of PPE depends on the task and the risk. Preparing feeds in the feed preparation room calls for protection of the feed from the worker, while handling tubes, flushing or cleaning up spills at the bedside calls for protection of the worker from the client.

3.1.1 Types of PPEs

The PPE items used in enteral nutrition work are listed below with their purpose. Each item must fit well, be clean, be put on before the task and be taken off in the correct order.

3.1.1.1 Mask

A mask is a covering for the nose and mouth that blocks droplets from the breath, cough and speech. In the feed preparation room it stops droplets from falling into formula and onto equipment. At the bedside it protects the worker from a client with a respiratory infection and protects an immunocompromised client from the worker.

• Single use: A surgical mask is used once and discarded. It is never pulled down under the chin and put back on.
• Correct fit: The mask covers the nose, mouth and chin and is moulded to the nose bridge.
• Change when damp: A mask that is wet, torn or soiled is replaced with a fresh one.
• Hand hygiene: Hands are washed before putting on and after removing the mask, and the mask is removed by the ties or ear loops without touching the front.
• Respiratory infections: A client with a cough or suspected respiratory infection is fed with a mask in place, and the dietitian follows the facility's isolation rules.

3.1.1.2 Dust coat or gown

A dust coat or gown is a long-sleeved garment worn over uniform or clothes. It protects the skin and clothing from splashes of feed, gastric contents and body fluids and keeps contamination from spreading between clients. A dust coat is used in the feed preparation room and in routine bedside work. A disposable fluid-resistant gown is used when a heavy splash is likely, for example when a tube is flushed in a client who is vomiting, or in isolation rooms.

• Clean and fastened: The garment is fastened fully and has sleeves that cover the wrists.
• Not worn outside the work area: A dust coat is not worn in the canteen, outside the hospital or to travel.
• Changed when soiled: A soiled coat is removed and laundered, and a single-use gown is discarded.
• Laundering: Dust coats are washed hot with detergent and kept separate from home laundry.
• Removal: The coat is removed so that the outer, contaminated surface is rolled inwards and not shaken.

3.1.1.3 Closed shoes

Closed shoes cover the whole foot and are worn in every clinical and food preparation area. They protect the feet from spills of hot or contaminated liquids, from dropped objects and from sharp items on the floor. A flat, non-slip sole prevents falls on wet floors, which are common where feeds are mixed and equipment is washed.

• Closed toes and heels: Sandals and open-backed shoes are not worn.
• Non-slip sole: Soles grip wet floors and are free of worn patches.
• Easy to clean: Leather or synthetic shoes that wipe clean are preferred to canvas that soaks up spills.
• Kept for work: Work shoes are kept clean and are wiped at the end of the shift.
• Dry: Wet or soiled shoes are changed to prevent skin infection and slipping.

3.1.1.4 Gloves

Gloves are single-use barriers worn on the hands for contact with tubes, enteral feed, stomach contents, saliva and skin sites such as a gastrostomy. They are not worn instead of hand hygiene. Hands are washed or rubbed with alcohol-based hand rub before the gloves are put on and after they are removed. Disposable gloves are never washed, disinfected or reused.

• Fresh gloves for each client: Gloves are changed between clients and between tasks on the same client, for example after cleaning a stoma and before handling the feed.
• Right size: Gloves that are too tight tear and gloves that are too loose slip.
• Nitrile or latex: Nitrile gloves are used for staff or clients with latex allergy.
• Torn gloves: A torn or punctured glove is removed immediately, the hands are washed and a new pair is put on.
• Disposal: Used gloves are removed inside out and placed in the facility's waste container for contaminated items.

3.1.1.5 Head cover

A head cover is a cap or hair net that holds all the hair away from the face and the working area. In the feed preparation room, hair and scalp particles can fall into formula and onto equipment and carry bacteria, which is dangerous for clients with a weak immune system. A head cover also keeps the worker from touching the hair during the task.

• All hair covered: Long hair is tied up and tucked inside the cover. Beards are covered if the facility requires it.
• Put on first: The head cover is put on before the gown or coat so that hair does not fall onto them.
• Worn in preparation areas: The cover is worn in the feed preparation room and in sterile or intensive care areas.
• Single use or laundered: Disposable covers are discarded after each session, and cloth caps are washed after each use.
• No hair touching: The worker does not touch the hair or face during preparation, and washes the hands if they do.

3.1.1.6 Rubber boots

Rubber boots are waterproof, non-slip boots worn in wet working areas. In the feed preparation and equipment washing room, floors are often wet from cleaning and from spills, and boots protect the feet from water, detergents and sanitising solutions. They are kept for that area and are not taken into the wards.

• Waterproof and washable: The boots are rinsed and disinfected at the end of the shift.
• Non-slip sole: The sole grips wet tiles and prevents falls.
• Worn under trousers: Trouser legs go over the boots so that splashes do not run inside.
• Kept in the work area: Boots are left at the entrance of the washing room and are not worn in the wards or outside.
• Checked for cracks: Cracked or leaking boots are replaced.

Eye protection

Safety goggles or a face shield protect the eyes from splashes of feed or stomach contents. They are used when a splash is likely, such as when a blocked tube is cleared, when the client vomits during feeding or when suction is used. Goggles are cleaned and disinfected after use and are not shared without cleaning.

Putting on and removing PPE

The order matters, because the outside of used PPE is contaminated.

1. Wash the hands or rub them with hand rub.
2. Put on the head cover and closed shoes or boots first.
3. Put on the dust coat or gown and fasten it.
4. Put on the mask and mould it over the nose.
5. Put on goggles or a face shield if needed.
6. Put on the gloves last, pulling them over the cuffs of the coat or gown.
7. After the task, remove the gloves first, then goggles, then the gown, then the mask, then the head cover, and discard single-use items in the correct waste container.
8. Wash the hands again after removing all the PPE.

Chapter Summary

This chapter covered the essential personal protective equipment required for safe administration of enteral nutrition, including masks, gowns, gloves, and appropriate footwear. It then explored the various routes for delivering enteral nutrition, distinguishing between mechanical options such as nasogastric and nasojejunal tubes, and surgical routes like gastrostomy and jejunostomy tubes. The discussion on enteral nutrition feeds highlighted different formula types tailored to specific patient needs, including polymeric, renal, pulmonary, and diabetes-specific formulas. Various methods of feed administration were examined, focusing on continuous drip, intermittent, and bolus feeding techniques. The chapter emphasized the importance of monitoring and evaluating patient tolerance to enteral feeds to ensure safety and effectiveness. Finally, it addressed the critical role of accurate documentation and communication in the management of enteral nutrition to support patient care continuity.