Caring for Enteral Tubes

Up to 40% of hospitalised patients in Australia are affected by malnutrition (Baird et al. 2026).

Without nutritional support, these patients may deteriorate, leading to poor outcomes such as prolonged hospital stays, impaired wound healing, greater risk of infection and higher mortality rates (Baird et al. 2026).

What is Enteral Feeding?

Enteral feeding, or tube feeding, is the delivery of liquid nutritional support through a tube inserted into the gastrointestinal (GI) tract. It is used for patients who are unable to meet or maintain their nutritional requirements through oral intake.

This may be because:

• Their oral intake is inadequate (e.g. poor appetite)
• They are physically unable to intake orally in a safe way (e.g. dysphagia, reduced level of consciousness).

(DA 2023)

Different types of enteral tubes are available, and the choice of tube, including its intended duration of use, is determined by the patient's individual clinical needs (SCHN 2025).

Indications for Enteral Feeding

Enteral feeding is considered for patients who:

• Are unable to meet their nutritional requirements through oral intake, and
• Have a functional and accessible GI tract.

(Adeyinka et al. 2022)

Patients with the following conditions may require enteral feeding:

• Stroke or another neurological condition causing dysphagia
• Serious illness or injury that reduces energy or the ability to eat
• Failure to thrive or inability to eat in young children
• Neuromuscular disorders affecting swallowing, such as Parkinson's disease or multiple sclerosis
• GI dysfunction, disease or obstruction
• Conditions causing increased metabolic and nutritional demands, such as sepsis, cystic fibrosis or burns
• Head and neck cancers
• Reduced appetite due to conditions such as chemotherapy, HIV and sepsis.

(Adeyinka et al. 2022; Dietitians Australia 2023; Doley 2022)

Contraindications for Enteral Feeding

If the patient's gastrointestinal tract is compromised (e.g. gut failure or intestinal obstruction) or inaccessible via an enteral tube, they may require parenteral nutrition instead. This involves the direct infusion of nutrients into the bloodstream via a central venous catheter (Adeyinka et al. 2022; Dietitians Australia 2023).

Older adults or patients receiving palliative or end-of-life care may not be suitable for enteral or parenteral feeding interventions. When making this decision, consider quality of life, possible complications and expected outcomes (DAA 2018).

Routes of Enteral Feeding

There are three sites on the body where an enteral feeding tube can be inserted, and several types of tubes that can be used, each taking a different route. This will depend on:

• The intended duration of the nutritional support
• The patient's condition, and
• Whether there is any trauma or obstruction that would impede access to a certain site.

(DAA 2018)

Delivery Sites

(Table adapted from WACHS 2025)

Enteral Feed Planning

Before enteral feeding begins, a structured planning process is required to ensure the patient receives safe, appropriate and individualised nutritional support.

The dietitian plays a central role in this process. They conduct a formal nutrition assessment to determine the patient's nutritional requirements, set treatment goals and develop a nutrition care plan (WACHS 2025).

In collaboration with the dietitian, the medical team must determine the:

• Route and site of feeding: The choice depends on the intended duration of nutritional support, the patient's condition, and any limitations, such as trauma or obstruction.
• Formula and regimen: Selected to meet the individual patient's nutritional and clinical needs, with quality of life taken into consideration.
• Blended tube feeding: A type of tube feeding where blended foods or a liquidised diet are administered via the enteral feeding device.
• Mode of delivery:
  • Continuous feeding (24-hour infusion via gravity drip or pump): preferred for critically ill patients or those with rapid gut motility
  • Intermittent feeding (feeding stopped for 4–16 hours, day or night): allows greater patient mobility and is useful when transitioning toward oral intake
  • Bolus feeding (prescribed volume administered over 15–60 minutes at regular intervals): physiologically similar to normal eating patterns, but carries the highest risk of reflux, aspiration and abdominal distension.

(WACHS 2025; TG 2022)

Prior to commencing enteral feeding, the patient or substitute decision-maker must be informed about the intended procedure and appropriate consent obtained. Substitute decision-maker legislation varies by state and territory (WACHS 2025).

Enteral Tube Positioning

Prior to administering any enteral feeds, water flushes or medications via an enteral tube, the tube position must be verified and documented (RCH 2024).

Placement must be confirmed by X-ray, external tube length and/or pH measurement of gastric aspirate. A pH below 5.5 generally indicates that the tube is correctly positioned in the stomach; acceptable pH thresholds and confirmation requirements may vary between organisations. Always refer to your facility's policies and procedures (WACHS 2025).

Tube placement should be assessed:

• After the initial insertion
• At least once per shift
• Before administering feed, fluid or medication
• After a break in continuous feeding
• Following oro-pharyngeal suction
• If the patient complains of discomfort or feed reflux
• After the patient vomits, retches or coughs
• If the external tube length has changed
• If respiratory difficulties arise
• Following patient transfer
• When there is any doubt about its positioning.

(WACHS 2025)

Preventing Aspiration

In addition to ensuring the tube is correctly positioned, you can also minimise the risk of aspiration by:

• Ensuring the patient is positioned at greater than 30 degrees during feeding and for at least 30 minutes afterwards, where safely possible
• Pausing feeding at least 30 minutes before any physical movement, transfers, or vigorous activity
• Regularly checking that the feeding tube remains correctly positioned
• Reviewing medications that may contribute to feeding difficulties
• Assessing and documenting individual risk factors for aspiration, including neurological conditions or a reduced level of consciousness.

(WACHS 2025)

Caring for Enteral Tubes

Caring for enteral tubes may include:

• Monitoring and documenting the patient's weight, fluid balance, biochemistry, blood glucose levels, aspirates and bowel function/stoma output
• Ensuring the tube is positioned correctly
• Introducing food and medications via the enteral tube according to the patient's care plan
• Assessing the patient's tolerance to the feeding regimen
• Performing mouth care
• Performing oro-pharyngeal suctioning
• Flushing and aspirating the tube
• Keeping the stoma area clean
• Identifying and reporting any signs of infection, leakage, inflammation or infection around the stoma
• Identifying and addressing symptoms that may require intervention (e.g. reflux, unexpected weight changes, dehydration, allergic reactions, poor chest health).

(WACHS 2025; TG 2022)

Monitoring Enteral Tubes

When caring for a patient with an enteral tube, it is important to regularly monitor the following:

• Nutritional intake, including a food chart if applicable
• Weight and height measurements
• Fluid balance chart
• Bowels and urine output
• Vital signs, including blood sugar levels
• Enteral device documentation (positioning, external length, flushes, aspirate, etc.)
• Oedema and ascites
• Wound staging
• Biochemistry, including electrolyte monitoring.

(SCHN 2025; WACHS 2025)

Note: Refer to your organisation's policies and procedures for the required frequency of monitoring.

Complications

Possible complications of enteral feeding include:

• Tube-related complications: E.g. migration, blockage, leakage, accidental dislodgement/removal
• Infection: E.g. aspiration pneumonia
• Gastrointestinal complications: E.g. nausea, vomiting, diarrhoea, constipation, abdominal pain or distension
• Metabolic complications: E.g. refeeding syndrome
• Stoma-related complications: E.g. wound infection, bleeding, leakage.

(Adeyinka et al. 2022)

Refeeding Syndrome

Refeeding syndrome (RFS) is a group of clinical complications that can develop when a malnourished or starved patient starts eating again through any method of feeding, and can cause serious health complications.

During starvation, the body breaks down fat and protein, depleting intracellular electrolytes. When feeding resumes, insulin drives glucose and electrolytes into cells, which can cause:

• Low levels of key electrolytes (phosphate, magnesium, potassium)
• Vitamin deficiencies (thiamine, B12, folate)
• Fluid and sodium retention.

These changes can be life-threatening, leading to serious complications such as heart failure, delirium and sudden death.

It is important to assess a patient's risk of refeeding syndrome before starting feeds and to continue monitoring throughout the process (WACHS 2025; AuSPen 2025; InsideOut Institute 2022).

Scope of Practice

Always work within your scope of practice and your role's responsibilities. Refer to your manager and/or local policies and procedures for more clarity on your specific role and responsibilities if you are unsure.

Conclusion

Enteral feeding plays a vital role in supporting the nutritional needs of patients who are unable to eat adequately on their own. However, it carries significant risks if not managed carefully, making thorough and ongoing monitoring essential. Nurses and healthcare workers must remain vigilant for potential complications, including refeeding syndrome, tube displacement, and aspiration. Always work within your scope of practice and refer to your facility's policies and procedures to ensure safe, individualised patient care.

To build on this knowledge, complete Ausmed's Course on Enteral Feeding and Nutrition.