Effective monitoring is vital to reduce the incidence of complications, reduce electrolyte and metabolic abnormalities and ensure adequate nutrition is delivered. The frequency of monitoring and parameters measured will be dependent on the diagnosis and underlying clinical condition of the patient; duration and tolerance of enteral feeding; and rationale for feeding. Monitoring will also vary according to the clinical setting and availability of appropriate expertise.
Monitoring should be done by suitably trained health care professionals, however patients on long term enteral feeding and their carers should be educated to monitor parameters such as bowels, weight and nutritional intake; identify potential problems; and report concerns to the relevant health care professional as needed. The goals of nutritional support should also be regularly reviewed.
Table 1. Monitoring patients on enteral feeding
| Parameter | Frequency | Rationale |
|---|---|---|
| Food chart (if appropriate) | Daily | To compare intake with requirements and aid transition between nutrition support and oral intake. |
| Fluid balance charts | Daily in acute setting including fluid delivered by other routes e.g. medications/ IV fluids/ feed flushes and oral fluids. Urine frequency and colour should be monitored in community patients. | Help assess hydration status. To compare feed given with feed prescribed To assess fluid volume prescribed with volume given To assess if feed rest periods are adhered to. |
| Weight/BMI | Twice weekly, or more frequently if hydration concerns. Monthly for established home enteral feeding If weight difficult to obtain use mid-arm circumference and tricep skinfold thickness | To assess changes on hydration and body composition over time. |
| Temperature/pulse/ respiration | Daily when in acute unit | To monitor overall condition and monitor for signs of infection/dehydration. |
| Bowels | Daily | To monitor bowel function and tolerance of enteral feed. |
| Capillary blood glucose | Random daily initially until stable, four hourly if unstable or has diabetes. | To detect hyper/hypo glycaemia To ensure timing of feed and medication optimal for blood glucose control. |
| Medication | Daily | To ensure potential side effects and drug-nutrient interactions are identified and prevented. Ensure drugs are in an appropriate presentation for tube administration and absorption. |
| Nausea and vomiting | Daily | Monitor tolerance of feed. |
| Gastric residual volumes | 4 hourly where clinically indicated in acute setting. | In some units used to assess gastric emptying and ascertain appropriateness of increasing feed rate. |
| Feeding tube position | NG tubes before each feed, fluid or medication administration. Long term feeding tubes (gastrostomy/ jejunostomy) before each feed begins noting external bumper markings. | To confirm gastric position and prevent feed aspiration. To ensure feeding tube has not migrated from/into stomach. |
| Feeding tube insertion site | Daily | To check for infection/ soreness/ leakage. Check for nasal erosion with nasal placed tubes To ensure tube appropriately secured |
| Tube integrity | Daily | To ensure tube is safe to use and prevent leakage. |
| Gastrostomy rotation Gastrostomy progression Balloon water volume checked in balloon retained tubes | Daily Weekly Weekly | To prevent buried bumper syndrome. To prevent tube displacement. |
| General clinical condition of patient | Daily | To ensure feed is tolerated and that feeding and feeding route remain appropriate. |
| Oral health | Daily | To optimise oral hygiene and reduce risk of aspiration pneumonia. |
| Aims and objectives of feeding/route/risk/benefit. | As appropriate for aim and duration of nutrition support. | To ensure progression towards agreed objectives of nutrition support. To ensure feeding remains appropriate. |
Biochemistry monitoring
Biochemical monitoring should be interpreted in a timely manner by health professionals with relevant expertise. Patients at risk of refeeding syndrome should be monitored daily with correction of electrolytes as needed.
| Sodium Urea Creatinine | Daily until stable then as clinically indicated | Assess fluid status Detect electrolyte or metabolic abnormalities Assess renal function |
| Potassium Phosphate Magnesium Corrected calcium | Daily if refeeding risk; then three times a week until stable; then as clinically indicated. | To detect electrolyte/ metabolic abnormalities Monitor for refeeding syndrome |
| Glucose | Baseline then twice daily if indicated | To ensure optimum glycaemic control |
| Liver function tests | Baseline then weekly until stable then as needed | To detect overfeeding |
| C-reactive protein | Twice weekly until stable | To assess acute phase response and assist interpretation of protein and micronutrient results |
| Albumin | Weekly until stable then as clinical concern | Aids interpretation of minerals. Low albumin reflects disease not protein status |
| Full blood count | Twice weekly until stable then as clinically indicated | To monitor for infection and anaemia |
| Zinc Copper Selenium | When clinically indicated. | Deficiency common with increased losses but results can be difficult to interpret as altered by disease, infection and trauma |
| Folate B12 | Baseline if indicated and if clinical concern | Deficiency common in certain disease states |
| Vitamin D | 6 monthly on long term nutrition or if deficiency suspected | Often low in housebound patients |
Further reading:
Stroud et al (2003) Guidelines for Enteral Feeding in Adult Hospital Patients; Gut, 52 (Suppl Viii):vii1-vii12
Maher N (2012) Monitoring adults on Long Term Enteral Nutrition; Nutrilibrary, Best Practice Summer 2012
NNNG guidelines on care of balloon gastrostomy
