Nurse Oliver checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the appropriate action for the nurse to take?
A. Hold the feeding
B. Reinstill the amount and continue with administering the feeding
C. Elevate the client’s head at least 45 degrees and administer the feeding
D. Discard the residual amount and proceed with administering the feeding
Correct Answer: A. Hold the feeding
Unless specifically indicated, residual amounts more than 100 mL require holding the feeding. Gastric residual refers to the volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding. Nurses withdraw this fluid via the feeding tube by pulling back on the plunger of a large (usually 60 mL) syringe at intervals typically ranging from four to eight hours.
Option B: When interpreting GRV, clinicians must keep in mind that the stomach has a reservoir function and that the stomach fluid is a mixture of both the infused EN formula and normal gastric secretions.
Option C: Patients at risk for delayed gastric emptying include those with gastroparesis, poorly controlled diabetes mellitus, gastric outlet obstruction, ileus, recent surgery, trauma, or sepsis, and those using a large amount of narcotic pain medication. Efforts to prevent aspiration of gastric contents are important in these patients.
Option D: The feeding is not discarded unless its contents are abnormal in color or characteristics. In a review article, “Measurement of Gastric Residual Volume: State of the Science,” published in 2000 in MEDSURG Nursing, Edwards and Metheny reported that the literature contained a variety of recommendations for what is considered a high GRV, ranging from 100 to 500 mL.
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