PNCM1189-CCN-Skill-Lab-Caring-for-a-Gastrostomy-Tube.docx

I. **GASTROSTOMY** A gastrostomy is a surgical procedure in which an opening is created into the stomach for the purpose of administering foods and fluids. In some instances, a gastrostomy is preferred for prolonged nutrition (greater then 3 to 4 weeks)---for example, in the elderly or debilitat...

I. **GASTROSTOMY** A gastrostomy is a surgical procedure in which an opening is created into the stomach for the purpose of administering foods and fluids. In some instances, a gastrostomy is preferred for prolonged nutrition (greater then 3 to 4 weeks)---for example, in the elderly or debilitated patient. Gastrostomy is also preferred over NG feedings in the comatose patient because the gastroesophageal sphincter remains intact. Regurgitation and aspiration are less likely to occur with a gastrostomy than with NG feedings. Different types of feeding gastrostomies may be used, including the Stamm (temporary and permanent), Janeway (permanent), and percutaneous endoscopic gastrostomy (temporary) systems. The Stamm and Janeway gastrostomies require either an upper abdominal midline incision or a left upper quadrant transverse incision. The Stamm procedure requires the use of concentric purse-string sutures to secure the tube to the anterior gastric wall. To create the gastrostomy, an exit wound is created in the left upper abdomen. The Janeway procedure necessitates the creation of a tunnel (called a gastric tube) that is brought out through the abdomen to form a permanent stoma. ***STAMM Gastrostomy***   ***JANEWAY Gastrostomy***   A percutaneous endoscopic gastrostomy (PEG) is a procedure that requires the services of two physicians (or a physician and a nurse with specialty skills). After administering a local anesthetic, one physician inserts a cannula into the stomach through an abdominal incision and then threads a nonabsorbable suture through the cannula; the second physician looks through an endoscope that has been passed into the upper GI tract and uses the endoscopic snare to grasp the end of the suture and guide it up through the patient's mouth. The suture is knotted to the dilator tip at the end of the PEG tube. The endoscopist then advances the dilator tip through the patient's mouth while the first physician pulls the suture through the cannula site. The attached PEG tube is guided down the esophagus, into the stomach, and out through the abdominal incision. The mushroom catheter tip and internal crossbar secure the tube against the stomach wall. An external crossbar or bumper keeps the catheter in place. A tubing adaptor is in place between feedings, and a clamp or plug is used to close or open the tubing. If an endoscope is unable to pass through the esophagus, then the gastrostomy can be performed under x-ray guidance through the abdominal wall. This procedure is known as fluoroscopically guided percutaneous gastrostomy, or FGPG ( Johnson, 1997).  The initial PEG device can be removed and replaced once the tract is well established (10 to 14 days after insertion). Replacement of the PEG device is indicated to provide long-term nutritional support, to replace a clotted or migrated tube, or to enhance patient comfort. The PEG replacement device should be fitted securely to the stoma to prevent leakage of gastric acid and is maintained in place through traction between the internal and anchoring devices. An alternative to the PEG device is a low-profile gastrostomy device (LPGD). The LPGD may be inserted 3 to 6 months after initial gastrostomy tube placement. These devices are inserted flush with the skin; they eliminate the possibility of tube migration and obstruction and have antireflux valves to prevent gastric reflux. Two types of devices may be used--- obturated or nonobturated. The obturated devices (G-button) have a dome tip that acts as an internal stabilizer. A major drawback is the need for a physician to obturate (insert a tube that is larger than the actual stoma). The nonobturated device (MIC-KEY) has an external skin disk and is inserted into the stoma without force; a balloon is inflated to secure placement. A nurse in the home setting can insert these devices easily. The drawbacks of both types of LPGDs are the inability to check residual volumes (one-way valve) and the need for a special adaptor to connect the device to the feeding container.  Patients with severe gastroesophageal reflux are at risk for aspiration pneumonia and therefore are not candidates for a gastrostomy. A jejunostomy is preferred, or jejunal feeding through a nasojejunal tube may be recommended. ***THE PATIENT WITH A GASTROSTOMY*** The focus of the preoperative assessment is to determine the patient's ability both to understand and to cope with the impending surgical experience. The nurse evaluates the patient's ability to adjust to a change in body image and to participate in self-care, along with the patient's and the family's psychological status. The purpose of the operative procedure is explained so that the patient will have a better understanding of the expected postoperative course. The patient needs to know that the result of this surgery is to bypass the mouth and esophagus so that liquid feedings can be administered directly into the stomach by means of a rubber or plastic tube or a prosthesis. If the prosthesis is to be permanent, the patient should be made aware of this. Psychologically, this is often difficult for the patient to accept. If the procedure is being performed to relieve discomfort, prolonged vomiting, debilitation, or an inability to eat, the patient may find it more acceptable. The nurse evaluates the patient's skin condition and determines whether a delay in healing may be anticipated because of a systemic disorder (eg, diabetes mellitus, cancer). In the postoperative period, the patient's fluid and nutritional needs are assessed to ensure proper intake of food and fluids. The nurse inspects the tube for proper maintenance and the incision for signs of infection. At the same time, the nurse evaluates the patient's response to the change in body image and the patient's understanding of the feeding methods. Interventions are identified to help the patient cope with the tube and learn self-care measures. Potential complications that may develop include the following: * Wound infection, cellulitis, and abdominal wall abscess* * GI bleeding* * Premature removal of the tube* The major goals for the patient may include: - attaining an optimal level of nutrition - preventing infection - maintaining skin integrity - enhancing coping - adjusting to changes in body image - acquiring knowledge of and skill in self-care - preventing complications **Nursing Interventions** ***MEETING NUTRITIONAL NEEDS*** The first fluid nourishment is administered soon after surgery and usually consists of tap water and 10% glucose. At first, only 30 to 60 mL (1 to 2 oz) is given at one time, but the amount is increased gradually. By the second day, 180 to 240 mL (6 to 8 oz) may be given at one time, provided it is tolerated and no leakage of fluid occurs around the tube. Water and milk can be instilled after 24 hours for a permanent gastrostomy. High-calorie liquids are added gradually. In some settings, during the early postoperative period the nurse aspirates gastric secretions and reinstills them after adding enough feeding solution to bring the volume to the desired total. By this method, gastric dilation is avoided. Blenderized foods are added gradually to clear liquids until a full diet is achieved. Powdered feedings that are easily liquefied are commercially available. The patient who receives blenderized tube feedings typically is not forced to give up usual dietary patterns, which may prove to be psychologically more acceptable. In addition, near-normal bowel function is promoted because the fiber and residue are similar to that of a normal diet. Intake of milk is avoided in patients with lactase deficiency. ***PROVIDING TUBE CARE AND PREVENTING INFECTION*** A small dressing can be applied over the tube outlet, and the gastrostomy tube can be held in place by a thin strip of adhesive tape that is first placed around the tube and then firmly attached to the abdomen. The dressing protects the skin around the incision from seepage of gastric acid and spillage of feedings. The nurse verifies the tube's placement, assesses residuals, and rotates the tube or stabilizing disk once daily to prevent skin breakdown. Some gastrostomy tubes have balloons that are inflated with water to anchor the tube in the stomach. The adequacy of balloon inflation is checked weekly by deflating the balloon using a Luer-tip syringe. ***PROVIDING SKIN CARE*** The skin surrounding a gastrostomy requires special care because it may become irritated from the enzymatic action of gastric juices that leak around the tube. Left untreated, the skin becomes macerated, red, raw, and painful. The nurse washes the area around the tube with soap and water daily, removes any encrustation with saline solution, rinses the area well with water, and pats it dry. Once the stoma heals and drainage ceases, a dressing is not required. A long-term gastrostomy may require a special dressing or stabilization device to protect the skin around the tube from gastric secretions and to help secure the tube in place. Skin at the exit site is evaluated daily for signs of breakdown, irritation, excoriation, and the presence of drainage or gastric leakage. The nurse encourages the patient and family members to participate in this inspection and in hygiene activities. If skin problems do occur, an enterostomal therapist or wound care specialist can be of assistance. ***ENHANCING BODY IMAGE*** The patient with a gastrostomy has experienced a major assault to body image. Eating, a physiologic and social function, can no longer be taken for granted. The patient is also aware that gastrostomy as a therapeutic intervention is performed only in the presence of a major, chronic, or perhaps terminal illness. Calm discussion of the purposes and routines of gastrostomy feeding can help keep the patient from feeling overwhelmed. Talking with a person who has had a gastrostomy can also help the patient to accept the expected changes. Adjusting to a change in body image takes time and requires family support and acceptance. Evaluating the existing family support system is necessary. One family member may emerge as the primary support person. ***MONITORING AND MANAGING POTENTIAL COMPLICATIONS*** During the postoperative course, the nurse monitors the patient for potential complications. The most common complications are wound infection and other wound problems, including cellulitis at the wound site and abscesses in the abdominal wall. Because many patients who receive tube feedings are debilitated and have compromised nutritional status, any signs of infections are promptly reported to the physician so that appropriate antibiotic therapy can be instituted. Bleeding from the insertion site in the stomach may also occur. The nurse closely monitors the patient's vital signs and observes all drainage from the operative site, vomitus, and stool for evidence of bleeding. Any signs of bleeding are reported promptly. Premature removal of the tube, whether it is done inadvertently by the patient or by the caregiver, is another complication. If the tube is removed prematurely, the skin is cleansed and a sterile dressing is applied; the nurse immediately notifies the physician. The tract will close within 4 to 6 hours if the tube is not replaced promptly. **CARING FOR A GASTROSTOMY TUBE** +-----------------------------------------------------------------------+ | **PROCEDURE** | +=======================================================================+ | **1. Gather materials needed for the procedure.** | | | | - **clean gloves** | | | | - **gastrostomy tube** | | | | - **cotton applicator** | | | | - **sterile solution** | | | | - **wash cloth** | | | | - **soap** | | | | - **disposable bag** | | | | - **small basin with water** | +-----------------------------------------------------------------------+ | **2. Introduce yourself and verify patient's identity. Explain to the | | patient what you are going to do, why it is necessary, and how the | | client can cooperate.** | +-----------------------------------------------------------------------+ | **3. Perform hand hygiene and observe other appropriate infection | | control procedures.** | +-----------------------------------------------------------------------+ | **4. Provide for patient privacy.** | +-----------------------------------------------------------------------+ | **5. Place the patient in the appropriate position and drape all | | areas except the gastric area.** | +-----------------------------------------------------------------------+ | 6\. Don disposable gloves. | +-----------------------------------------------------------------------+ | a. If the gastrostomy tube is new and still has sutures holding it | | in place: dip cotton tip applicator into sterile solution and | | gently cleansed around the insertion site removing any crust or | | drainage. | +-----------------------------------------------------------------------+ | b. If the gastric tube insertion site has healed and the sutures are | | removed: wet a washcloth and apply a small amount of soap onto | | washcloth. Gently cleanse around the insertion removing any crust | | or drainage. Rinse site removing all soap. | +-----------------------------------------------------------------------+ | 7\. Pat skin around insertion site dry. | +-----------------------------------------------------------------------+ | 8\. If the sutures have been removed, rotate the guard or external | | bumper 90 degrees at least once a day. | +-----------------------------------------------------------------------+ | 9\. Remove gloves and perform hand hygiene. | +-----------------------------------------------------------------------+ | 10\. Record care given, including appearance of site, any drainage | | present, and patient's response. | +-----------------------------------------------------------------------+ +-----------------------------------+-----------------------------------+ | **References** | **Textbook:** | | | | | | Brunner & Suddarth's Textbook of | | | Medical-Surgical Nursing (Single | | | Volume), 15th Edition  | | | | | | Skills Checklists to Accompany | | | Taylor's Clinical Nursing Skills: | | | A Nursing Process Approach by | | | Pamela Evans-Smith and Marilee | | | LeBon | | | | | | **Online References:** | | | | | | | +-----------------------------------+-----------------------------------+