Enteral Nutrition


Step 3: Implement

Interdisciplinary Team

There are many healthcare professionals involved in the interdisciplinary team. Depending on the patients medical plan and condition, there may be other team members involved. However, the list below represents a usual inpatient team. Their roles are discussed as it pertains to enteral nutrition.

  • Registered Dietitian: primarily responsible for enteral nutrition, transition to oral diet.
  • Speech Language Pathologist (SLP): assess safety of oral diet & texture recommendation.
  • Pharmacist (RPh): drug and nutrient interactions, medication dosing/ indications.
  • Registered Nurse (RN): implement nutrition care plan, provide clinical information.
  • Physiotherapist (PT): ambulation, positioning, assist with obtaining weights.
  • Occupational therapist (OT): cognitive assessment to determine if patient can provide accurate information, modified eating equipment, positioning.
  • Medical Doctor (MD) or Nurse Practitioner (NP): medical update, enter orders for IVF, labs, imaging, medications, consults.
  • Social Worker (SW): provide counselling, disposition planning and identify sources of emotional support for patients and their families.


Liaising With Carson’s Team

In Carson’s case, you will want to liaise with:

  • The SLP regarding Carson’s dysphagia. Often, the RD will wait for an SLP assessment to determine the safest diet texture before optimizing the patient’s diet for nutritional adequacy. If the SLP recommends a patient be NPO, the RD will implement enteral feeding orders.
  • The MD and/or NP regarding enteral nutrition for Carson. Provide an update on your nutrition care plan including refeeding risk, enteral regime, water flushes, and request the addition of a multivitamin and thiamine as well as daily bloodwork. The MD/NP may need to enter some or all of your orders depending on your institution’s medical directives.
  • The bedside RN, once you have finalized your nutrition care plan and the orders have been entered. The RN will be implementing Carson’s regime.
  • Other team members throughout Carson’s stay depending on what his needs are. For example:
    • The SW for discharge planning/ support/ resources for enteral feeding at home
    • The PT for an updated weight
    • The OT for modified feeding utensils

Monitoring Enteral Feeds

During implementation of the enteral feeding plan, consider monitoring:

  • GI tolerance: nausea, vomiting, bowel movements (odour, colour, frequency, consistency), abdominal cramping/distension, reflux, fistula/ostomy output.
  • Bloodwork: electrolytes, renal profile, calcium profile, liver function tests (LFTs), amylase, blood glucose, complete blood count (CBC), lactate, arterial blood gases (if applicable).
  • Weight: bi-weekly weight measurements are common for assessment of dietary strategies (or more/less frequently as indicated).
  • Daily intake and output: fluid balance, actual volume of feed received.
  • Medications: assess drug-nutrient interactions, add supplements if indicated, adjust insulin if needed.

Reassess based on changes in tolerance or medical condition.

Enteral Nutrition Complications

The tables below outline potential gastrointestinal, metabolic, and mechanical complications associated with enteral nutrition.

Possible causes and treatment for gastrointestinal complications
Adapted from the Sunnybrook Clinical Nutrition Resource Handbook
Gastrointestinal Problem Possible Causes Treatment
Nausea / Vomiting
  • Gastroparesis
  • Ileus
  • Medications (sedation, narcotics, pressors)
  • Hemodynamic instability
  • Rapid infusion of feeds
  • Use of a fibre containing formula
  • Motility agent
  • Reduce infusion rate/volume
  • Post pyloric feeding
  • Liaise with team re: meds
  • Low-fat/isotonic feed
Malabsorption (unexplained weight loss, steatorrhea, diarrhea)
  • Celiac
  • Crohn’s disease
  • Diverticular disease
  • Radiation enteritis
  • Pancreatic insufficiency
  • C. difficile
  • Test for malabsorption
  • Trial semi elemental feed first followed by an elemental feed if still not tolerated
Abdominal Distension
  • Ileus
  • Constipation
  • GI obstruction
  • Ascites
  • Initial use of fibre-feed
  • Rule out ileus or obstruction
  • Request additional bowel routine to promote bowel movements
  • Hold feeds only if necessary
  • Change to a non-fibre containing formula if distension is not resolving or is causing significant discomfort
  • Inadequate fibre/water
  • Limited mobility
  • Medications – especially narcotics/ paralytics
  • Insufficient bowel routine ordered/ administered
  • Add/increase bowel routine
  • Adequate hydration
  • Switch to fibre-containing feed
  • Mobilize as tolerated
  • Adjust medications if possible
Possible causes and treatment for metabolic complications
Adapted from the Sunnybrook Clinical Nutrition Resource Handbook
Metabolic Problem Possible Causes Treatment
Hypertonic Dehydration
  • Excessive fluid loss
  • Inadequate fluid intake
  • Concentrated feed in a patient who cannot express thirst
  • Additional fluid
  • Excess fluid intake
  • Refeeding syndrome
  • Renal, hepatic, or cardiac dysfunction
  • Fluid restricted feed, if indicated
  • Diuresis, if indicated
  • Decrease free water flushes
  • Refeeding syndrome
  • Catabolic stress
  • K-depleting medication
  • Excess losses (diarrhea, NG tube)
  • Metabolic alkalosis
  • Correct K to prevent refeeding
  • K replacement/supplementation
  • Metabolic acidosis
  • Renal failure
  • K-sparing medication
  • Excess K intake
  • Correct acidosis
  • Correct K
  • Adjust medications if possible
  • K-restricted feed
  • Dilution due to increased antidiuretic hormone (ADH)
  • Renal, hepatic, or cardiac dysfunction
  • Excess free water administration
  • Consider supplementation
  • Diuresis if indicated
  • Fluid restricted feed, if indicated
  • Decrease free water flushes
  • Inadequate fluid intake
  • Increased fluid loss
  • Increased IV Na intake
  • Additional fluid if indicated
  • Adjust IV solution
  • Refeeding syndrome
  • Excess calories
  • Binding by epinephrine
  • Meds (i.e. antacids)
  • Insulin
  • Correct Phos to prevent refeeding
  • Phos replacement/ supplementation
  • Renal failure
  • Phosphate binder
  • Phos restricted feed
  • Medical issues (diabetes, sepsis, catabolism, trauma, metabolic stress)
  • Insulin resistance
  • Refeeding syndrome
  • Excess carbohydrate (CHO) intake
  • Correct blood glucose (BG) as per protocol
  • Adjust CHO intake
  • Abruptly stopping feeds when a pt is receiving hypoglycemic agents or insulin
  • Correct BG as per protocol
  • Taper feed gradually
  • Overfeeding calories
  • Excess CHO intake in context of respiratory dysfunction
  • Metabolic cart (if applicable or available)
  • Decrease total energy/CHO administered
Possible causes and treatment for mechanical complications
Adapted from the Sunnybrook Clinical Nutrition Resource Handbook
Mechanical Problem Possible Causes Treatment
Incorrect tube placement
  • Placement in lung
  • Pneumothorax
  • Tube migration
  • Chest x-ray (CXR) or abdominal x-ray (AXR) to confirm tube placement prior to use
  • Replace/ advance/ adjust tube with desired endpoint
Tube blockage
  • Inadequate flushing
  • Small bore tube
  • Inadequately crushed/ dissolved medications or poorly dissolved “beads” from medication capsules infused to the feeding tube
  • Poorly dissolved protein powder
  • Routine water flushes
  • Replace tube
  • Pancrelipase/NaHCO3 mixture as per pharmacy
  • Change to liquid or IV meds if possible
  • Dissolve protein powder in warm water
Irritation from tube
  • Sinusitis from NGT/NDT/NJT
  • Leakage or wound infection from G-Tube/J-Tube
  • Prolonged feeding tube use with skin irritation from tape/ dressings securing it in place
  • Tube change
  • Proper tube/wound care
  • Changing placement of tape/ dressings if able
  • Lower esophageal sphincter always open with temporary tubes (i.e. NGT/OGT)
  • Supine position
  • Tube migration over time
  • Head of bed (HOB) > 45°
  • Consider small bowel feeding
  • Motility agent
  • Occasional re-imaging of tube placement if suspicions of migration

Monitoring for Refeeding Syndrome

Below is important information to know for patients who are at risk of refeeding syndrome. Having awareness of what symptoms to watch for, knowing when symptoms occur, and what to do can allow you to optimize your patient’s nutritional status as safely as possible.

  • Symptoms of refeeding syndrome most often occur within 1-3 days after initiating feeding, but may occur up to 5 days following initiation of feeding.
  • Closely monitor your patient’s heart rate and fluid intake/output for changes that happen with initiation of feeding.
  • Hypophosphatemia is a classic first sign associated with refeeding syndrome.
  • Monitor electrolytes daily (K, PO4, Mg) for a minimum of 3 days – if your patient is at high risk of refeeding syndrome or shows signs of refeeding syndrome, monitor electrolytes for up to 1 week. Correct abnormalities concurrently with feeding and prior to advancing feeds.
  • Advance feeding as soon as is safely possible to avoid hypocaloric feeding for prolonged period (advancement of 200-300 kcal every 1-3 days recommended).


Carson’s Education

Carson is asking to speak to the dietitian to understand why he is not receiving meals like his roommate. He complains of being hungry and doesn’t remember why he had a tube inserted in his stomach.

The dietitian will need to use simple language to describe the indications for EN and how EN is administered via his G-tube. The dietitian should explain possible side effects and complications, but also be able to reassure Carson with evidence that this is the best treatment plan for him at this time.

  1. Think about the possible side effects and complications with EN.
  2. List 3 benefits of EN that you could share with Carson.
  3. Create a plain-language explanation of EN to share with Carson.

Pause and answer these questions using the information provided to you so far.



PART 3: IMPLEMENT COMPLETE. Pause to reflect on the implementation strategies discussed. When you’re ready, move on to Part 4: Evaluation.




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Preparation for Dietetic Practice Copyright © by Megan Omstead, RD, MPH is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.