Gastrostomy Procedure Guide PDF

Gastrostomy DR. Osama Salah  Gastrostomy Outlines Objectives Definition of gastrostomy Types of gastrostomy procedures By the end of this lecture the student will be a...

Gastrostomy DR. Osama Salah  Gastrostomy Outlines Objectives Definition of gastrostomy Types of gastrostomy procedures By the end of this lecture the student will be able to Enteral nutrition Define gastrostomy Indications For gastrostomy; Describe different types of Gastrostomy techniques Contraindications For gastrostomy Sites of Tube Insertion Define enteral nutrition Delivery Systems for Feeding via gastrostomy tube; List indication for gastrostomy tube insertion Complications of gastrostomy tube feeding List contraindication for gastrostomy tube Guidelines for Immediate Post Insertion Care o Radiologically Inserted Gastrostomy (RIG) insertion o Percutaneous Endoscopic Gastrostomy: (PEG) List complications for gastrostomy tube insertion Procedure of Gastrostomy Tube Feeding Demonstrate Gastrostomy Tube Feeding o Intermittent Bolus o Intermittent Gavage Feeding Demonstrate Care of Gastrostomy Site o Continuous Gavage Care of Gastrostomy Site  Gastrostomy Definition of gastrostomy A gastrostomy is a procedure in which an opening is created into the stomach either for the purpose of administering nutrition, fluids, and medications via a feeding tube, or for gastric decompression in patients with gastroparesis, gastroesophageal reflux disease, or intestinal obstruction. A gastrostomy is preferred to deliver enteral nutrition support longer than 4 to 6 weeks  Types Of Gastrostomy Procedures percutaneous endoscopic gastrostomy (PEG) 1) Insertion of a percutaneous endoscopic gastrostomy (PEG) requires the services of a provider skilled in endoscopy, utilizes moderate sedation, and takes approximately 15 to 20 minutes. A lighted endoscope is inserted through the mouth into the stomach. Once in the stomach, the light indicates the location for hollow needle and guidewire insertion into the stomach. The wire is pulled back through the mouth, then the PEG tube itself is attached to the wire to guide the PEG tube as it moves into the mouth, down the esophagus, into the stomach, and out the incision in the abdominal wall. An internal fixation bolster, often called a bumper, is pulled snug against the stomach wall. An external retention disc/phalange sits close to the abdominal surface. The tension between the external and internal fixation bolsters keeps the tube in place.  Types Of Gastrostomy Procedures percutaneous endoscopic gastrostomy (PEG) Types Of Gastrostomy Procedures percutaneous endoscopic gastrostomy (PEG)  Guidelines for Immediate Post Insertion Care Percutaneous Endoscopic Gastrostomy: (PEG) Immediate Care Observation of vital signs and site. Water should be commenced six hours after PEG placement followed by feed. Follow the dietitian’s regimen. If patient is allowed oral intake, this should be introduced at the same time Ensure patient is in a head up elevated position of minimum 30˚ during feeding and for one hour after completion of feed if no contraindications Flush the tube before and after feeds and medication with minimum of 30ml water Inspect site daily – if any pain, swelling, redness, or leakage is experienced, obtain a bacteriological swab and apply appropriate dressing Clean daily with antiseptic for first 24 hours after insertion and apply dry dressing. After 24 hours, expose area, cleanse daily with soap and water or proprietary solution, and dry thoroughly Rotate the tube daily in a circle (360˚)  Guidelines for Immediate Post Insertion Care Percutaneous Endoscopic Gastrostomy: (PEG) Ongoing Care No baths or swimming for two weeks after insertion – shower only If tube becomes blocked, flush with 50ml soda water If tube falls out, a replacement requires to be inserted straight away If the primary tube has been in place for less than two weeks, attempt to reinsert BUT do not feed via tube without radiological confirmation of position. Types Of Gastrostomy Procedures A radiologically inserted gastrostomy tube (RIG) 2) A radiologically inserted gastrostomy tube (RIG) can be placed fluoroscopically by a skilled provider when an endoscope cannot be passed through a strictured or obstructed esophagus. The RIG is internally sutured and held in place by an internal balloon that is inflated with a small amount of water Feeding can be initiated via PEG tubes within several hours (≤4 hours) of placement. The stomal tract will take 30 to 90 days to mature, so replacement should not occur until at least 30 days after placement.  Guidelines for Immediate Post Insertion Care Radiologically Inserted Gastrostomy (RIG) Immediate Care Observation of vital signs and site. Water should be commenced four hours after RIG placement followed by feed. Follow the dietitian’s regimen. If patient is allowed oral intake, this should be introduced at the same time Ensure patient is in a head up elevated position of minimum 30˚ during feeding and for one hour after completion of feed if no contraindications Flush the tube before and after feeds and medication with minimum of 30ml water. Inspect site daily – if any pain, swelling, redness, or leakage is experienced, obtain a bacteriological swab and apply appropriate dressing. After 24 hours, cleanse with soap and water or antiseptic, dry thoroughly, and apply Tegaderm® dressing (change as required). If skin sutures are present, these should be cut to skin level after one week.  Guidelines for Immediate Post Insertion Care Radiologically Inserted Gastrostomy (RIG) Ongoing Care No baths or swimming for two weeks after insertion – shower only If tube becomes blocked, flush with 50ml soda water or warm water If tube falls out, a replacement requires to be inserted straight away If the primary tube has been in situ for less than 2 weeks, attempt to reinsert BUT do not feed via tube without radiological confirmation of position. Contact intervention radiology within 48hrs for tube replacement.  Types Of Gastrostomy Procedures A gastrostomy or jejunostomy tube 3) A gastrostomy or jejunostomy tube is usually inserted during intra-abdominal surgery. The tube may be used for feeding during the immediate postoperative period, or it may provide long-term enteral access, depending on the type of surgery. Typically, the practitioner sutures the tube in place to prevent gastric contents from leaking.  Types Of Gastrostomy Procedures A gastrostomy or jejunostomy tube Enteral Nutrition  Enteral Nutrition Enteral nutrition (Also called tube feedings and gastric gavage) is a procedure whereby nutrients directly into the stomach, duodenum, or jejunum through a tube is more physiologically beneficial and cost- effective than is parenteral feeding. enteral nutrition carries less risk of infection than does parenteral feeding and maintains a functional GI tract by preventing mucosal atrophy and biliary and hepatic dysfunction. Enteral therapy is appropriate for patients with at least a minimally functional GI tract who cannot take adequate nutrition by mouth. Enteral therapy has become utilized more frequently as more commercially available enteral formulas have been developed and long-term enteral feeding tubes have become safer and more easily inserted  Sites of Tube Insertion Short-Term Nutritional Support (30 days) 1. Gastrostomy—insertion of a tube surgically, radiologically, or by a percutaneous endoscopic procedure into the stomach. 2. Gastrostomy button—small device inserted through gastrostomy stoma to allow for long-term feeding with minimal effect on body image. 3. Jejunostomy—insertion of a tube directly into the jejunum either surgically or by a percutaneous endoscopic procedure Figure 1&2 of Gastrostomy button Figure 3&4 for Gastrostomy tube Tube feeding  Indications For Tube Feedings; Generally Clients who have a functional GI tract and will not, should not, or cannot eat. Clients who are (or may become) malnourished and in whom oral feedings are insufficient to maintain adequate nutritional status.  Indications For Tube Feedings; In details; 1) Comatose patients on mechanical ventilation or with a severe head injury 2) A neuromuscular disorder affecting swallowing reflex: Parkinson's disease, multiple sclerosis, cerebrovascular accident. 3) Severe anorexia from chemotherapy, HIV, sepsis 4) Upper GI obstruction esophageal stricture or tumor 5) Conditions associated with increased metabolic and nutritional demands include sepsis, cystic fibrosis, and burns. 6) Mental illness like dementia  Contraindications to Tube Feedings; Absolute Contraindications; Hemodynamic instability with poor end-organ perfusion. Enteral feeding in patients with bowel ischemia or necrosis can make a bad situation worse Active GI bleeding Small or large bowel obstruction Paralytic ileus secondary to electrolyte abnormalities peritonitis  Contraindications to Tube Feedings; Relative Contraindications; Moderate to severe malabsorption Diverticular disease Fistula in the small bowel Short bowel disease in the early stages.  Delivery Systems for Feeding via gastrostomy tube; 1) Intermittent Feeding; Intermittent feeding is given four to six times a day in the form of a bolus. The bolus (generally 250–400 ml of formula for adult clients) can be given using a large syringe fitted into the end of the feeding tube or using a gravity drip over 20 to 30 minutes. The intermittent method is generally practiced in the home care setting due to its ease and need for minimal equipment. It is not the preferred method, however, because the large amount of food it places in the stomach at one time often causes cramping, vomiting, aspiration, flatus, or diarrhea. This method works best with clients who have normal gastrointestinal function. Gastrostomy Tube Feeding Delivery Systems for Feeding via gastrostomy tube; 2) Continuous Feeding; Continuous feeding delivers with a infusion pump to regulate the rate. One of the advantages of continuous feeding is that it Keeps gastric volume small, Minimizing residual volume Reducing the risk of aspiration pneumonia The client is less likely to experience bloating, nausea, abdominal distention, and diarrhea. Continuous feeding is recommended for the seriously ill or comatose client. Procedure of Gastrostomy Tube Feeding  Procedure of Gastrostomy Tube Feeding Equipment Needed: 50-ml syringe for feeding Formula Emesis basin Infusion pump for feeding tube Water Clean towel Nonsterile Disposable gavage bag and gloves tubing NOT ACTION RATIONALE DONE DONE Verifies physician’s or qualified 1) Review client’s medical record for practitioner’s prescription for appropriate formula, amount, and time. formula and a 2) Gather equipment and formula Promotes efficiency during procedure 3) Check client’s armband. Verifies correct client Reduces anxiety and increases client 4) Explain procedure to client. cooperation. 5) Assemble equipment. Add color to formula per institutional policy. If Ensures efficiency when initiating feeding. using a bag, fill with prescribed Color will distinguish formula aspirate amount of formula 6) Place client on right side in high Reduces risk of pulmonary aspiration in the Fowler’s position. event client vomits or regurgitates formula  DON NOT ACTION RATIONALE E DONE. Reduces transmission of 7) Wash hands and don nonsterile pathogens from gastric gloves. content 8) Provide for privacy Places client at ease Assesses for delayed gastric 9) 10) Observe for abdominal Check feeding distention; tube. Insert syringe emptying; indicates presence auscultate for bowel sounds. into adapter port, Aspirate Stomach of peristalsis and ability Indicates whether gastric of GI Contents, and determine amount of tract to digest nutrients. emptying is delayed. gastric residual. If residual is greater Reduces risk of regurgitation than 50–100 ml (or in accordance with and pulmonary aspiration agency protocol), hold feeding until related to gastric distention. residual diminishes. Instill aspirated Prevents electrolyte contents back into feeding tube imbalance.  NOT ACTION RATIONALE DONE DONE Administer tube feeding A) Intermittent Bolus 11) Pinch the tubing. Prevents air from entering tubing. 12) Remove plunger from barrel of syringe Provides system to delivery feeding. and attach to adapter. Allows gravity to control flow rate, 13) Fill syringe with formula. reducing risk of diarrhea from bolus feeding. feeding the patient room 14) Allow the enteral formula to warm to temperature formula may reduce the room temperature before administration. risk of diarrhea 15) Allow formula to infuse slowly; continue adding formula to syringe until Prevents air from entering stomach. prescribed amount has been Decreases risk of diarrhea. administered. Ensures that remaining formula in 16) Flush tubing with 30–60 ml or tubing is administered and maintains prescribed amount of water patency of tube; prevents air from entering the stomach.  ACTION RATIONALE B) Intermittent Gavage Feeding 17) Hang bag on IV pole so that it is 18 inches Allows gravity to promote above the client’s head infusion of formula Prevents air from entering 18) Remove air from bag’s tubing stomach. Decreases risk of diarrhea 19) Attach distal end of tubing to feeding tube Allows gravity to control flow adapter and adjust drip to infuse over prescribed rate, reducing risk of time. diarrhea from bolus feeding Prevents air from entering stomach 20) When bag empties of formula, add 30– 60 ml or p and reduces risk for gas rescribed amount of water; close clamp accumulation. Maintains patency of feeding tube. 21). Wash reusable gavage bag with soap and hot Decreases risk of multiplication of water every 24 hours microorganisms in bag and tubing.  ACTION RATIONALE C) Continuous Gavage Ensures that feeding tube remains in 22) Check tube placement at least every 4 hours stomach. 23) Check residual at least every 8 hours. If residual is above 100 ml, stop Reduces risk of regurgitation and pulmonary feeding aspiration related to gastric distention 24) Add prescribed amount of formula to bag for a 4-hour period; dilute with Provides client with prescribed nutrients and prevents bacterial growth (formula is easily water if prescribed contaminated). 25) Hang gavage bag on IV pole. Prime tubing. Removes air from tubing. 26) Provides for controlled flow rate; prevents loops in tubing. Infuses formula over prescribed time. 27) Monitor infusion rate and signs of respiratory distress or diarrhea 28) Flush tube with water every 4 hours as prescribed or following Maintains patency of tube administration of medications. 29) Replace disposable feeding bag at least every 24 hours, in accord with Decreases transmission of agency’s protocol. microorganisms.  ACTION RATIONALE C) Continuous Gavage Promotes digestion and reduces skin 30) Turn client every 2 hours. breakdown. Provides comfort and maintains the integrity 31) Provide oral hygiene every 2–4 hours. of buccal cavity. 32) Administer water as prescribed with and between feeding Ensures adequate hydration. Reduces transmission of 33) Remove gloves and wash hands. microorganisms 34) Documents administration of feeding and achievement of expected outcome; e.g., client tolerates feeding and weight is maintained or increased.  Care of Gastrostomy Site Equipment; 4″ × 4″ (10-cm × 10-cm) gauze pads Soap and water or normal saline solution Water Cotton-tipped applicators Hypoallergenic tape Gloves Label Optional: external stabilization device, sterile gauze or foam dressing, skin protectant. 41  ACTION Procedure of Gastrostomy Site Care 1) Gently remove the dressing to prevent skin stripping or tearing. Don’t cut away the dressing over the catheter, because you might cut the tube or the sutures holding the tube in place. 2) Remove and discard your gloves. 3) Perform hand hygiene. 4) Put on a new pair of gloves 5) Assess the tube exit site for signs of skin breakdown, redness, edema, or the presence of purulent drainage. 6) Inspect the tube for wear and tear. A tube that has worn out needs to be replaced 7) Until healing occurs, clean the skin immediately around the gastrostomy or jejunostomy tube’s exit site daily (and as needed) using a cotton-tipped applicator moistened with normal saline solution. Next, using a 4″ × 4″ (10- cm × 10- cm) gauze pad soaked in normal saline solution, clean the adjacent skin and pat it dry using another gauze pad 8) When the exit site has healed, wash the skin around it with soap and water daily. Rinse the area with water and pat it dry 9) Secure the gastrostomy or jejunostomy tube to the skin with hypoallergenic tape 10) Coil the tube, if necessary, and tape it to the abdomen to prevent pulling and contamination of the tube. Rotate the taping site to prevent skin damage. 42  Care of PEG or PEJ site 11) Slide the tube’s outer bumper carefully away from the skin about ½″ (1.3 cm). Depress the skin surrounding the tube gently and inspect for leakage. Minimal wound drainage, which appears initially after implantation, should subside in about 1 week. 12) Assess the skin at the exit site for signs of infection, such as redness, edema, and purulent drainage. 13) Inspect the tube for wear and tear. A tube that wears out needs to be replaced. 14) Observe for a change in external tube length or the incremental marking on the tube at the exit site to assess for tube migration. 15) Clean the exit site with soap and water-moistened gauze pads, and allow it to dry 16) Rotate the outer bumper 90 degrees to avoid applying the same tension to the same skin area and to prevent pressure ulcer formation at the exit site. Ensure that the outer bumper isn’t res ting too tightly against the skin; One finger’s breadth should fit between the skin and the outer bumper. 17) If leakage appears at the PEG tube exit site, or if the patient risks dislodging the tube, Apply a sterile gauze or foam dressing and an external stabilization device around the site, as needed. 43  NOT ACTION DONE DONE 18) Label the dressing with the date, the time, and your initials. 19) Discard disposable equipment and remove the gloves. 20) Hand washing 21) Documentation