Running head: Best Practices for Nurses and Enteral Nutrition

Best Practices for Nurses and Enteral Nutrition

Do we Really Need to Monitor Gastric Residuals?
Jennifer Williams
Nurs 211: Evidence Based Paper

Best Practices for Nurses and Enteral Nutrition

Best Practices for Nurses and Enteral Nutrition

There are many evolving issues regarding enteral nutrition, or tube feeding, and nursing.
In regards to changing a practice, success relies heavily on teaching, training good Registered
Nurses (RNs). The history of checking gastric residual volume (GRV) was conceived with the
rationale of increased residuals may be related to gastric intolerance, and may lead to
regurgitation, and subsequent aspiration. Aspiration is defined as the inhalation of foreign matter
into the lungs, and is one of the leading causes of infection, or pneumonia. There is great debate
within the various health profession communities, including physicians, nurses, and dietitians as
to what is the best prevention of aspiration, and if measuring GRV, and if even a specific measure
is indicative of a reason for action (Ridley & Davies, 2011). A recent article in the Journal of
American Medical Association (JAMA) raises the question of the effects not monitoring GRV, in
critically ill populations, and came to the conclusion that when compared to those patients whose
residuals were checked, it was not an inferior practice, that is to say, it may not even be
necessary to do so, and can interfere with nutrition therapy that is essential for recovery! The
authors state that consistent checking of GRV leads to unnecessary interruptions of nutrition
delivery, and should be removed from the standard of care of critically ill patients receiving
invasive mechanical ventilation and early enteral nutrition (Reignier, Mercier, & Le Gouge,
2013). This is a specific population, however RNs should pay attention to what changes are
happening in critical care, so to anticipate what may work in other patient populations.
This brings up the question of what the literature is saying regarding best practices for
RNs in regards to enteral nutrition. There are many topics that could be addressed, however in
regards to GRV checking best practices includes proper technique, good clinical skills, stopped
old or anecdotal practices, creating clogs through excessive (or improper) checking, disturbing

Best Practices for Nurses and Enteral Nutrition

patient with GRV check in the middle of the night, or not considering physiology of patient such
as diabetic gastroparesis, or post-operation, and any other considerations that may delay gastric
emptying or create any other GI dysfunction (Pamela Charney & Malone, MS, RD, CNSC,
2013). Waking a patient brings up another entire best practice conversation, not appropriate for
this paper, however the point is that making one small change is in the benefit of the patient, can
cascade and actually benefit in other capacities, leading to overall better patient/client care.
Being able to set a definitive amount that quantitatively measures an individuals ability
to tolerate enteral nutrition, or tube feeding, safely has be a debate since the advent of enteral
nutrition. Of the risks of tube feeding, aspiration is the largest concern. The progressions of
recommendations by governing bodies as well as the most current recommendation will be
discussed. Ee-Yuee Chan et al. in a cross-sectional, self administered survey using clinical
scenarios, chose to address this in their facility by surveying over 1200 RNs working in general
wards in a tertiary hospital regarding their knowledge and practices related to tube feeding. They
were able to take the RNs responses and implement changes such as eliminating blue dye
practices, safely checking for tube placement, and consistent measures for holding with GRV.
The authors continue to recommend further research for a consistent threshold of GRV in
relations to tolerance. They also bring up the consideration that a low GRV may not necessarily
indicate gastric tolerance, which raises the question of even wasting time to check said GRV.
They encourage utilization of nursing clinical skills to monitor the patient for signs of distress,
such as nausea/vomiting or difficulty breathing, as well as identifying those patients who may be
at higher risk for intolerance (Ee-Yuee Chan, et al. 2012). Kenny and Goodman in an evidenced
based implementation project with pre and posttest measures. They wanted to measure and
improve overall staff knowledge and practices regarding prevention of clogs, proper flushing,

Best Practices for Nurses and Enteral Nutrition

medication administration, proper HOB practices, and accurate documentation and education.
They were able to show some improvement in all these areas, but most impressive was 100%
with HOB elevation (Kenny, LTC, AN, USA, PhD, RN & Goodman COL, AN, USA, PhD, RN,
2010). Finally, Kanouff et al. after a literature review, initiated their own protocol to decrease the
occurrence of ventilator-associated pneumonia (VAP) and demonstrated after this, they decreased
their own VAP rate occurrence from 159 cases to 68 cases yearly. Their practices included
consistent HOB elevation, good oral care, and sedation weaning protocols. They identified the
practice of maintaining HOB >30-45 degrees is beneficial twofold: first, decreasing the risk of
aspiration of gastrointestinal contents, as well as oropharyngeal and nasopharyngeal secretions.
Second, this also helps improve patient ventilation (Kanouff, MD, DeHaven, MSN, RN, CRNP,
& Kaplan, MD, FCCP, 2008). Again, this is a specific population set, those who are
mechanically ventilated, however the best practices of maintaining HOB >30-45 degrees and
maintaining good oral care can be extrapolated to all patient populations, and perhaps decrease
the practice of checking residuals.
The development of a threshold of GRV has been difficult since every patient is different,
with different anatomy, level of consciousness (LOC), histories, environments, genetics, even
taking into different types of formulas or nursing styles. It is also difficult to develop a
consistent threshold since there is lacking evidence linking elevated GRVs to increased
aspiration pneumonia risk. Holding the enteral nutrition due to elevated GRVs interferes with
nutrition delivery, which with patients needing enteral nutrition, they are likely nutritionally
compromised, and cannot afford the lack of nutrition (Shleton RD, CD, 2013)! Kenny and
Goodman noted research that found there was no difference in aspiration risk if cessation of
feeding was based on 400ml rather than 200ml, further evidence that the GRV and aspiration are

Best Practices for Nurses and Enteral Nutrition

not linked (2010). Another concern with checking GRV is the documented increased tube
clogging due to constant pulling of residuals. The clog then leads to another interruption of
nutrition delivery, and may interfere with the patients healing process. The American Society for
Parenteral and Enteral Nutrition (ASPEN) is the authoritative voice on policies and guidelines
for nutrition support. Their last released clinical guidelines, in line with the Society of Critical
Care Medicine (SCCM) gave A grades to guidelines including: assuring proper tube placement
prior to feeding, implementing HOB >30-45 degrees during feeding times, and if a GRV >250ml
after a second check, a promotility agent should be considered (Bankhead, et al., 2009). The
American Dietetic Association (now called the Academy of Nutrition and Dietetics) follows
ASPEN recommendations in recommending proper HOB positioning, and also encourages good
clinical nursing skills including promoting good oral health, addressing opioid reduction, and
checking for proper tube placement (Mary Krystofiak Russell, 2013). They continue to
encourage RNs to be aware of who may be at risk for aspiration, such as documented previous
aspiration occurrence, decreased LOC, need for a prolonged supine position, or emesis to name a
few. Another concern is inadequate nursing staffing, which can and should be addressed based on
the acuity level of the patient population (Gail Cresci, 2013) .
Nurses should have strong clinical skills to monitor when their patients are at risk for
intolerance whether it be related to the gastrointestinal or respiratory systems. Using evidence
from critical care populations, and the subsequent guidelines and recommendations given, the
safe practices and techniques should be followed for the more stable patient; even if just to
prevent them from becoming critically ill. Nurses are the forefront of patient care and often
forget that nutrition is considered a therapy used towards healing. When nurses put nutrition,
particularly nutrition that can be controlled at the forefront of their care, they can expect better

Best Practices for Nurses and Enteral Nutrition

patient outcome, satisfaction, and overall general well being for the client, staff, and healthcare
systems. It is suggested that eliminating the practice of GRV checks can lead to better patient
outcome and satisfaction on many different levels.

Best Practices for Nurses and Enteral Nutrition

References
Ee-Yuee Chan, ,. I.-L.-H.-N.-C. (2012). Nasogastric feeding practices: A survey using clinical
scenarios. International Journal of Nursing Studies , 49 (3), 310-319.
Gail Cresci, P. R. (2013). Enteral Access. In P. R. Pamela Charney, & M. R. Malone. Chicago,
IL, USA: Academy of Nutriiton and Dietetics.
Kanouff, MD, A. J., DeHaven, MSN, RN, CRNP, K. D., & Kaplan, MD, FCCP, P. D. (2008).
Prevention of Nosocomial Infections in the Intensive Care Unit. Critical Care Nurse Quarterly ,
31 (4), 302-308.
Kenny, LTC, AN, USA, PhD, RN, D. J., & Goodman COL, AN, USA, PhD, RN, P. (2010). Care
of the Patient With Enteral Tube Feeding An Evidence-Based Practice Protocol. Nursing
Research , 59 (1S).
Mary Krystofiak Russell, M. R. (2013). Complications of Enteral Feedings. In P. R. Pamela
Charney, & M. R. Malone, Pocket Guide to Enteral Nutrition (2nd Edition ed., pp. 170-197).
Chicago, IL, USA: Academy of Nutrition and Dietetics.
Pamela Charney, P. R., & Malone, MS, RD, CNSC, A. (2013). Pcket Guide to Enteral Nutrition
(2nd ed.). Chicago, IL, USA: Academy of Nutrition and Dietetics.
Reignier, J., Mercier, E., & Le Gouge, A. (2013). Effect of Not Monitoring Residual Gastric
Volume on Risk of Ventilator-Associated Pneumonia in Adults Receiving Mechanical Ventilation
and Early Enteral Feeding: A Randomized Controlled Trial. . JAMA , 309 (3), 249-256.
Ridley, E., & Davies, A. (2011). Practicalities of nutrition support in the intensive care unit: The
usefulness of gastric residual volume and prokinetic agents with enteral nutrition. Nutrition , 27
(5), 509-512.
Shleton RD, CD, M. (2013). Monitoring and Evaluating of Enteral Feedings. In P. R. Pamela
Charney, & M. R. Malone, Pocket Guide to Enteral Nutrition (2nd Edition ed., pp. 153-169).
Chicago, IL, USA: Academy of Nutrition and Dietetics.