Unit VIII Nutrition

PROCEDURE Percutaneous Endoscopic 138 Gastrostomy (PEG), Gastrostomy, and Jejunostomy Tube Care

Margaret M. Ecklund PURPOSE: Gastrostomy, percutaneous endoscopic gastrostomy, and jejunostomy tubes provide long-term access to the gastrointestinal tract for nutrition.

PREREQUISITE NURSING ❖ Ascites KNOWLEDGE ❖ Morbid obesity ❖ Esophageal or gastric varices • Knowledge of the anatomy and physiology of the upper ❖ Esophageal stricture or narrowing and lower gastrointestinal (GI) system is necessary. • Replacement gastrostomy tubes usually have a balloon in • Patients who cannot have enteral tubes passed orally or the intestinal lumen that is infl ated with sterile water. This nasally because of anatomy or surgery and those who need balloon prevents inadvertent dislocation. The distal end of supplemental enteral nutrition support for longer than 4 the tube has an infusion port and a port for the balloon weeks should be considered as candidates for long-term instillation ( Fig. 138-2 ). enteral access. • A jejunostomy tube, which does not have a balloon, is • The most commonly used long-term enteral access is the indicated in those patients at risk for aspiration or who are percutaneous endoscopic gastrostomy (PEG) tube. The unable to tolerate enteral feedings into the stomach. These PEG tube is inserted without general anesthesia. A local tubes are routinely sutured in place for stability (Fig. 138- anesthetic (i.e., 1% lidocaine injection) is used at the 3). They are usually smaller bore, less than 14 Fr, and abdominal puncture site. A guidewire is threaded via therefore are more susceptible to occlusion. endoscope through the oropharynx, esophagus, and • If the tubes are inadvertently removed, reinsertion of the stomach and brought out through the abdominal wall. The tubes is a routine procedure after the tunnel and stoma are tube is then threaded over the guidewire and passed into healed (approximately 2 to 6 weeks after insertion). the stomach. The tapered end of the tube is brought • Because these tubes all enter through the abdominal wall, through a stab wound in the abdominal wall until the skin care at the site of insertion is important for skin mushroomed end of the tube is placed against the stomach integrity and prevention of infection. wall. An adapter for infusion is attached to the end of the • Consult with the multidisciplinary team to individualize tube, and a disk on the tube is moved up to the abdominal nutrition goals. The nutrition plan is developed on the wall to stabilize the tube in place. basis of the collaborative assessment of the nurse, dieti- • PEG tubes are large-bore catheters that range from 18 to tian, and physician or advanced practice nurse. 22 Fr and have a mushroom-shaped, curved end in the stomach and a two-port distal end to instill enteral nutri- EQUIPMENT tion, medications, and fl uid. Commercial PEG tubes have disks, perpendicular to the tube, to hold the device close • Nonsterile gloves to the skin and lessen the shift of the tube in and out of • 4 × 4 gauze pads the skin ( Fig. 138-1 ). • Cotton-tipped swabs • Relative contraindications for PEG placement include the • Mild soap following: • 4 × 4 gauze pads, drain cut ❖ Previous gastric resection • Protective skin barrier (e.g., vitamins A and D ointment ❖ Tumors that block the passage of the endoscope or other commercial topical moisture barrier products)

1216 138 Percutaneous Endoscopic Gastrostomy (PEG), Gastrostomy, and Jejunostomy Tube Care 1217

Figure 138-1 Percutaneous endoscopic gastrostomy.

Figure 138-3 Jejunostomy tube placement.

• Explain that long-term enteral access catheters can be removed when oral intake meets the needs of the indi- vidual. Rationale This information may serve as a goal for the patient to consume more via the oral route. • Aspiration is a continued risk when the patient is posi- tioned fl at. Rationale: Gastric residual volume can refl ux and create a risk for pulmonary aspiration.

Figure 138-2 Gastrostomy tube. PATIENT ASSESSMENT AND PREPARATION Patient Assessment • Silk tape (or paper tape if patient has a sensitivity to silk • Perform a GI assessment. Note the presence of abdominal tape) distension, bowel sounds, fl atus, and bowel movements. Additional equipment, to have available as needed, includes Determine whether the patient has had diarrhea, constipa- the following: tion, or signs of GI dysfunction. Rationale: A patient • Abdominal binder needs a functional gut to receive enteral nutrition. • Assess skin condition at the exit site of the feeding tube PATIENT AND FAMILY EDUCATION at the stoma; signs and symptoms of infection include the following: • Explain the purpose for the tube to the patient and family. Rationale: Intact skin integrity is a defense against infec- Rationale: This information may decrease patient and tion. Early assessment of signs of infection promotes family anxiety. early, appropriate intervention. • Explain the reason for skin care assessment and tube ❖ Site redness or edema maintenance. Rationale: This informs the patient and ❖ Warmth family of what to expect. ❖ Purulent drainage • Stress the importance of not pulling on the tube. Ratio- ❖ Pain or tenderness nale: Unnecessary pain and skin irritation may be avoided. ❖ Fever • Explain that oral nutrition may be possible even if the patient has a long-term enteral access catheter. Rationale: Patient Preparation This explanation provides the patient and family with • Perform a time out and verify that the patient is the correct important information. patient using two identifi ers. Rationale: Before perform- 1218 Unit VIII Nutrition

ing a procedure, the nurse should ensure the correct iden- information as needed. Rationale: Understanding of pre- tifi cation of the patient for the intended intervention. viously taught information is evaluated and reinforced. • Ensure that the patient understands preprocedural infor- • Assist the patient to a position of comfort. Rationale: mation. Answer questions as they arise, and reinforce Stoma of tube is easily accessible. Procedure for Percutaneous Endoscopic Gastrostomy (PEG), Gastrostomy, or Jejunostomy Tube Care Steps Rationale Special Considerations 1 . HH 2 . PE 3. Use soap and warm water to Soap and water clean the skin surface moisten gauze pads and two at the stoma. 1–3 cotton-tipped applicators. (Level E * ) 4. Clean the tube (stoma) Moisture under the bumper can erode A. Wipe the area closest to the skin at the tract. 1–3 tube (stoma) with the cotton- tipped applicators and proximal skin with the moistened gauze. B. Rinse with water. C. Displace the bumper to ensure cleaning and drying next to the skin at the stoma. D. Verify that the bumper is not too tight against the skin. One fi nger ’ s breadth should fi t between the bumper and the skin. (Level E * ) 5. Dry the skin and stoma Prevents chafi ng and skin maceration. thoroughly with a dry gauze pad. 6. If signifi cant moisture is found on Protective barrier ointment provides a Increased moisture can cause a fungal the skin around the stoma, use moisture barrier for skin and assists infection that can be treated cotton-tipped applicators to apply wound healing. topically.1,3 a protective skin barrier (e.g., If purulent drainage is persistent, vitamin A and D ointment or collaborate with the physician or other commercial topical advanced practice nurse to obtain moisture barrier products) in a an order for an antimicrobial circular motion around stoma. ointment and apply it after skin (Level E * ) cleansing.1–3 7. Apply a 4 × 4 split gauze sponge Gauze absorbs moisture from the around the tube and secure it with stoma. If no drainage is present, the tape along the edges. Change the gauze may be left off. 1–3 gauze every 12 hours or when soiled or moist. (Level E * ) 8. Anchor the tube to the skin at an Reduces tension on the tube and adjacent area on the abdomen. avoids stoma erosion.1–3 The bumper (fl ange) should be rotated to avoid skin damage from repeated taping. (Level E * ) 9. Adjust the head of the bed to 30 Minimizes the risk of aspiration.4 degrees or higher when feedings are infusing. (Level C * ) 10. Remove PE and discard used supplies.

* Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results. * Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations. 138 Percutaneous Endoscopic Gastrostomy (PEG), Gastrostomy, and Jejunostomy Tube Care 1219

Expected Outcomes Unexpected Outcomes • Intact skin at stoma of long-term enteral access device • Infection or ulceration at the stoma • Long-term enteral access for enteral feeding and fl uid • Tube removal by patient or accidental dislodgment administration remains patent with patient movement • Migration of the tube into the intestinal lumen • Peritonitis • Aspiration • Bleeding • Gastric outlet obstruction • Clogged tube • Degradation of tube

Patient Monitoring and Care Steps Rationale Reportable Conditions These conditions should be reported if they persist despite nursing interventions. 1. Assess the integrity of the skin and Intact skin is the fi rst line of • Erosion of the stoma quality of drainage from the stoma prevention against infection. • Signs and symptoms of infection every 4 hours, with any changes or as needed. 2. Ensure that the PEG tube has a The disk helps prevent excess • Pressure injury adjacent to the disk aligned next to the skin movement of the tube in and out of stoma without pressure into the skin. the skin. If the disk exerts excess • Removal of the tube by the patient pressure, tissue injury may occur.1–3 • Clogging of the device • Buried bumper 3. Ensure that the patient does not A tube removed before the tract is • Removal of the enteral access remove long-term enteral access established is a potential surgical device device. A loosely applied emergency and may necessitate abdominal binder may help deter a immediate return to the operating confused patient from pulling on room or endoscopy suite for repair the tube. (Level E * ) and replacement. Inform the physician or advanced practice nurse so he or she can determine the urgency of replacement. The immediate response may be to place a replacement commercial tube or Foley catheter in the tract. Follow institutional standards. Tubes with established tracts can be replaced by the nurse at the bedside with a tube of comparable size and length. 5 Fistula disruption and hemorrhage are the most common complications of device replacement.6

* Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations.

Procedure continues on following page 1220 Unit VIII Nutrition

Patient Monitoring and Care —Continued Steps Rationale Reportable Conditions 4. Note the distance of the tube from Facilitates future assessment for tube • Length that has deviated the infusion adapter to the entrance migration either inward or outward. signifi cantly into the skin. Label the tube with the insertion date and the measurement at the entrance to the skin. 5. Assess for nausea and vomiting. Nausea and vomiting may indicate • Nausea pyloric obstruction from a tube • Vomiting migrating inward. 1–3 6. Evaluate excess wear on the tube No routine tube change is indicated. • Tube wear caused by ongoing use. The tube is changed when the device fails.3

Documentation Documentation should include the following: • Patient and family education • Type of tube and distance of the tube from the • Condition of the stoma adapter to the entrance into the skin • Any treatment rendered related to site complications • Unexpected outcomes • Tube patency • Nursing interventions • Pain assessment, interventions, and effectiveness

References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .