To access the stomach, duodenum, or jejunum, the physician may place a tube through the patient’s abdominal wall.This may be done surgically or percutaneously. 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 the type of surgery.Typically, the physician will suture the tube to place to prevent gastric contents from leaking.
In contrast,apercutaneous endoscopic gastrostomy (PEG) or (PEJ) jejunostomy tube can be inserted endoscopically without the need for laparotomy or general anesthesia. Typically, the insertion is done in the endoscopy suite or at the patient’s bedside.A PEG or PEJ may be used for nutrition, drainage, and decompression. Contraindications to endoscopic placement include obstruction (such as an esophageal stricture or duodenal blockage)., previous gastric surgery, morbid obesity, and ascites. These conditions would necessitate surgical placement.
Obstruction (such as an esophageal stricture or duodenal blockage)These conditions would necessitate surgical placement.
With either type of tube placement, feedings may begin after 24 hours (or peristalsis resumes).After a time, the tube may need replacement, and the physician recommended a similar tube, such as an indwelling urinary catheter or a mushroom catheter, or a gastrostomy button – a skin – level feeding tube.
This is a commonly used G-tube which advances through the abdominal wall into the stomach and is routinely used for long term enteral feedings.
The above image is of a low profile G-tube which sits flush to the skin. It is available in diameters from 14 French (4.67mm) to 24 French (8mm) with various stoma lengths. This type of G-tube comes with an extension set for gastric feeding and decompression. The low profile tube is frequently used for infants or children.
These are commonly used J-tubes which advance through the abdominal wall directly into the jejunum and would be routinely used for long term enteral feedings. The red robinson catheter needs to be sutured to the skin to maintain position. The clear silicon J-tube is held in position with a small saline filled retention balloon.
This is a commonly used GJ tube. Notice the inflated balloon which will be positioned in the stomach and will help secure the tube in the proper position.
Nursing care includes providing skin care at the tube site, maintaining the feeding tube, administering feeding, monitoring the patient’s response to feeding, adjusting the feeding schedule, and preparing the patient for self – care after discharge.
You can administer most tablets and pills through the tube by crushing them and diluting as necessary. (However, don’t crush enteric – coated or sustained – released drugs, which lose their effectiveness when crushed).
Transabdominal tube feeding and care
Transabdominal tube feeding and care<br />1<br />
Objectives<br />Discuss Transabdominal tube feeding and care procedure.<br />Demonstrate the correct procedure in performing transabdominal tube feeding and care.<br />Perform the procedures through return - demonstration correctly.<br />2<br />
In contrast…<br />A percutaneous endoscopic gastrostomy (PEG) or (PEJ) jejunostomy tube can be inserted endoscopically without the need for laparotomy or general anesthesia. <br />Used for nutrition, drainage, and decompression. <br />4<br />
Contraindications to endoscopic placement<br />Obstruction<br />Previous gastric surgery <br />Morbid obesity<br />Ascites<br />5<br />
Preparation of equipment<br />Always check the expiration date on commercially prepared feeding formulas.<br />If the formula has been prepared by the dietitian or pharmacist, check the preparation time and date.<br />Discard any opened formula that’s more than 1 day old.<br />Commercially – prepared administration sets and enteral pumps allow continuous formula administration.<br />18<br />
Preparation of equipment<br />Place the desired amount of formula into the gavage container and purge air from the tubing. <br /><ul><li>To avoid contamination, hang only a 4 – to 6 – hour supply of formula at a time.</li></ul>19<br />
implementation<br />Provide privacy, and wash your hands.<br />Confirm the patient’s identity using two patient identifiers according to facility policy.<br />Explain the procedure to the patient. Tell him, for example, that feedings usually start at a slow rate and increase as tolerated. After he tolerates continuous feedings, he may progress to intermittent feedings, as ordered. <br />21<br />
implementation<br />Assess for bowel sounds with a stethoscope before feeding, and monitor for abdominal distention.<br />Ask the patient to sit, or assist him into semi – Fowler’s position, for the entire feeding. This helps to prevent esophageal reflux and pulmonary aspiration of the formula. <br /><ul><li>For an intermittent feeding, have him maintain this position throughout the feeding and for 1 hour afterward.</li></ul>22<br />
implementation<br />Put on gloves. Before starting the feeding, measure the residual gastric contents. <br /><ul><li>Attach the syringe to the feeding tube and aspirate. If the contents measure more than twice the amount infused, hold the feeding and recheck in 1 hour.
If residual contents remain too high, notify the physician.
Chances are the formula isn’t being absorbed properly.
Keep in mind that residual contents will be minimal with PEJ tube feedings. </li></ul>23<br />
implementation<br />Allow 30 ml of water to flow into the feeding tube to establish patency.<br />Be sure to administer formula at room temperature. Cold formula may cause cramping.<br />24<br />
Intermittent feedings<br />Allow gravity to help the formula flow over 30 to 45 minutes. Faster infusions may cause bloating, cramps, or diarrhea.<br />Begin intermittent feeding with a low volume (200 ml) daily, according to the patient’s tolerance increase the volume per feeding, as needed, to reach the desired calorie intake.<br />26<br />
Intermittent feedings<br />When the feeding finishes, flush the feeding tube with 30 to 60 ml of water to maintain patency and provide hydration.<br />Cap the tube to prevent leakage.<br />Rinse the feeding administration set thoroughly with hot water to avoid contaminating subsequent feedings. Allow it to dry between feedings.<br />27<br />
Continuous feedings<br />Measure residual gastric contents every 4 hours.<br />To administer the feeding with a pump, set up the equipment according to the manufacturer’s guidelines, and fill the feeding bag. To administer the feeding by gravity, fill the container with formula and purge air from the tubing.<br />Monitor the gravity drip rate or pump infusion rate frequently to ensure accurate delivery of formula.<br />29<br />
Continuous feedings<br />Flush the feeding tube with 30 to 60 ml of water every 4 hours to maintain patency and to provide hydration.<br />Monitor intake and output to anticipate and detect fluid and electrolyte imbalances.<br />30<br />
Decompression<br />To decompress the stomach, connect the PEG port to the suction device with tubing or straight gravity drainage tubing.<br />Jejunostomy feeding may be given simultaneously via the PEJ port of the dual – lumen tube.<br />32<br />
implementation<br />Tube exit site care <br />33<br />
Tube exit site care<br />Provide daily skin care.<br />Gently remove the dressing by hight and. Never cut away the dressing over the catheter because you might cut the tube or the sutures holding the tube in place.<br />34<br />
Tube exit site care<br />At least daily and as needed, clean the skin around the tube’s exit site using 4” x 4” gauze pad soaked in the prescribed cleaning solution. <br /><ul><li>When healed, wash the skin around the exit site daily with soap.
Rinse the are with water and pat dry. Apply skin protectant if necessary.</li></ul>35<br />
Tube exit site care<br />Anchor gastrostomy or jejunostomy tube to the skin with hypoallergenic tape to prevent peristaltic migration of the tube. This also prevents tension on the suture anchoring the tube in place.<br />Coil the tube, if necessary and tape it to the abdomen to prevent pulling and contamination of the tube. PEG and PEJ tubes have toggle – bolt – like internal and external bumpers that make tape anchors unnecessary.<br />36<br />
Special considerations<br />If the patient vomits or complains of nausea, feeling too full, or regurgitation, stop the feeding immediately and assess his condition. <br />Flush the feeding tube and attempt to restart the feeding again in 1 hour (measure residual gastric contents first).<br />You may have to decrease the volume or rate of feedings. <br />38<br />
Special considerations<br />If the patient develops dumping syndrome, which includes <br />Nausea<br />Vomiting<br />Cramps<br />Pallor<br />Diarrhea<br />The feedings may have been given too quickly.<br />39<br />
Special considerations<br />Provide mouth care frequently. <br /><ul><li>Brush all surfaces of the teeth, gums, and tongue at least twice daily using mouthwash, toothpaste, or mild salt solution.</li></ul>You can administer most tablets and pills through the tube by crushing them and diluting as necessary. <br /><ul><li>Medications should be in liquid form for administration.</li></ul>40<br />
Special considerations<br />Control diarrhea resulting from dumping syndrome by using continuous pump or gravity – drip infusions, diluting the feeding formula, or adding antidiarrheal medications.<br />41<br />
References<br /><ul><li>Lippincott Williams & Wilkins, “Best Practices: Evidence – Based Nursing Procedures”, Second Edition (2007)
Website: Nasogastric tube insertion; Department of Emergency Medicine: University of Ottawa