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GUIDELINES FOR GASTROSTOMY

FEEDING CAREPLAN

GASTROSTOMY TUBE

What is a PEG (Percutaneous Endoscopic Gastrostomy)

PEG describes a method (Percutaneous Endoscopic) in which the feeding

tube is placed in the stomach. An endoscope (a fibre optic tube with a

camera and light) is passed down through the child’s mouth and throat into

the stomach. The light shines through the skin of the stomach onto the

surface of the abdomen and shows the surgeon the best position for the

stoma to be formed. The stoma is made via a small incision and a tube

placed through it by the use of guide wires. It is then secured by a flange (or

bumper) from the inner stomach wall. Outside there is a fixation clip which

sits on the outer abdomen wall, and usually a clamp and feeding adaptor.

Care of the gastrostomy site

  1. Carers should wear gloves and aprons when using gastrostomy.
  1. The site must be cleaned and dried daily with mild soap and warm water. Clean right under the external base, one of the main complications affecting gastrostomy tubes is infection, therefore, good hand washing and gastrostomy care is essential to minimise infection rates.
  1. Rotate the tube in a full circle daily. This prevents adhesions to the tract and soreness under the external base.
  1. Check stoma site daily for leakage, signs of infection, sore skin or granulation. Refer to guidelines for over-granulation and contact your community nurse if you have any concerns.
  1. The external fixator may need to be loosened as the child gains weight and grows.
  1. Bathing is possible with a PEG.
  1. Ensure that syringes used are 10ml and larger to reduce the pressure on the tube.
  1. All giving sets are for single use only and-may be re-used over a 24 hour period.

Checking the position of the tube

It is essential that the tube position is checked before fluid/feed is administered via the gastrostomy.

  1. Wash your hands.
  2. Carers should wear gloves and aprons when using the gastrostomy tube
  3. Assemble correct equipment. This will include syringe (size 10ml or over),

PH stix and extension set.

  1. Explain procedure to Child
  2. Attach syringe to the gastrostomy tube.
  3. Unclamp extension set and draw back 1-2mls of gastric contents.
  4. Clamp off extension set. Disconnect syringe and close tube port.
  5. Place small drop of gastric contents on to the PH stix and allow 10 seconds for any colour change. If the fluid is from the stomach it will be acidic and change colour of PH paper. Using the colour chart provided with the paper, identify colour match and read off PH. The reading should be 5.5 or below. This tells you that the tube is sited correctly. If the reading is PH 5.5 or above, DO NOT FEED.

NB: This method is not completely fool proof, but is considered to be the best indicator available.

If you are unable to obtain any gastric contents, you can try changing the position of the Child.

Never put fluid/milk/medicines down the tube unless you are sure it is in the correct position.

What affects pH?

The pH of gastric contents can be affected by medications and by the frequency of feeding (see Section 4 – Administration of Medication).

Flushing the tube

This is to prevent the tube from becoming blocked. The gastrostomy needs to be flushed before and after use. If it is not used regularly it should be flushed at least once per day. Ideally it is best to use only sterile or cool, boiled water.

  1. Wash your hands.
  2. Carers should wear gloves and aprons.
  3. Assemble correct equipment. This will include a syringe and water
  4. Explain procedure to Child.
  5. If unsure of tube position then follow guidelines for checking tube position.
  6. Attach 30ml or 50ml syringe to feeding port
  7. Pour in prescribed amount of water.
  8. Open clamp and allow the water to run through. If there is a blockage the water will not run through with gravity and it may be necessary to gently flush in the water with the syringe. If this is not possible the gastrostomy tube may be blocked so refer to guide about blocked PEG.
  9. Refasten clamp when water reaches bottom of the syringe. This is to prevent air from being introduced into the stomach. Continue with feed or medication.
  10. Flush tube after each feed, in between and after medications. Disconnect syringe and close port at the end of the feed.

Administering a continuous feed via a pump

This is done via a feeding pump

  1. Wash your hands.
  2. Carers should wear gloves and aprons.
  3. Assemble the equipment required. This will include the feed, cooled, boiled water, syringes, feeding set and pump.
  4. Run the feed through the feeding set and position it in the pump ready to commence feeding. Set correct rate and volume limit.
  5. Explain to Child and ensure he is comfortable and preferably in a semi-upright position to minimise reflux and vomiting.
  6. Check tube position.
  7. Attach 50ml syringe and give prescribed flush of water.
  8. Disconnect syringe and connect end of feeding set to the feeding port.
  9. Ensure both clamps are open and commence feed.
  10. At end of feed close both clamps, disconnect feeding set from the feeding port.
  11. Connect syringe to gastrostomy tube and administer final flush of water.
  12. Close clamp, disconnect the syringe from the tube and ensure feeding port is closed and secure.
  13. If the child vomits during continuous feeding, you may have to stop feeding for a short while and recommence once child has settled.

ADMINISTRATION OF MEDICATION

Medications that can raise the pH of stomach contents are:

Antacids, such as-

Aluminium Hydroxide (Alu-cap, Maalox and Mucogel.)

Magnesium Carbonate

Magnesium Trisilicate

Altacite plus

Asilone

Dentinox

Infacol

Gaviscon

Woodward’s colic drops

H2 Antagonists

Cimetidine

Famotidine

Nizatidine

Ranitidine

Proton-pump inhibitors Omeprazole

Esomeprazole

Pantoprazole

Rabeprazole

Lansoprazole

Liquid medicine or soluble tablets are preferred to ensure easy administration through a gastrostomy tube or button. If possible, they should be sugar-free.

Some tablets may be finely crushed using a tablet crusher and then dispersed in a little water directly before administration. There are, however, some medicines that must not be given this way. These include:

All modified release (MR, CA, Retard, SR, CR) preparations

All enteric (EC) preparations

Any medication which is unstable in solution form

Any capsule containing granules rather than powder as these may block the tube

Medication should ideally be given in a non-feeding period to preventinterference between the feed nutrients and medications. If it is necessary to administer medication during feed, the feed must be stopped and the tube flushed with water before and after medication is given. The feed is then recommenced.

All medicines must be given separately and the tube flushed with water between each medicine. Some drugs are known to be incompatible with enteral feeding solutions and advice should be sought from the pharmacist regarding their use. The following drugs are known to be incompatible with enteral feeding solutions:

Chlorpromazine Ciprofloxacin Iron preparations Metoclopramide Oxytetracycline Phenytoin

Potassium Chloride

BLOCKED PEG OR GASTROSTOMY BUTTON

Possible causes:

  1. Medications mixed with feed
  2. Fat globules in feed
  3. Inadequate flushing
  4. Crushed medication not fully disposed in water
  5. Multiple medications not given one at a time and flushed in between
  6. Action (if one method is unsuccessful, try the next):
  7. Ensure all clamps are open and tubing is not kinked. Try moving retention plate to a different position on tube.
  8. Connect 50ml syringe to end of tube and try to aspirate to remove any excess fluid.
  9. Massage tube around area of blockage.
  10. Flush with normal amount of warm water (sterile or cooled, boiled). Leavein clamped tube for 30 minutes. Reflush.
  11. When trying to flush use gentle pumping action with the plunger on syringe.
  12. Wrap tube in warm flannel for 10 minutes.
  13. Massage along tube and around entry site. Reflush.
  14. When tube is clear reflush and resume feed.
  15. DO NOT ATTEMPT TO PROBE OR FORCE FLUIDS DOWN TUBE.

INFECTED GASTROSTOMY SITE

Possible causes:

  1. Contamination of tube or insertion site
  2. Poor hand hygiene when handling tube or gastrostomy site

Action:

  1. Ensure all those involved with care of tube are carrying out effective hand hygiene.
  2. Clean regularly with saline and if it continues to be troublesome apply a non-adherent dressing.
  3. Ensure correct position of gastrostomy, i.e. not migrating as infection may carry internally.
  4. If symptoms do not improve with increased care or child has a temperature, then follow what if policy
  5. Take a swab from gastrostomy site for culture and sensitivity and treat according to result.
  6. If swab for culture and sensitivity is inconclusive and site remains inflamed, query a fungal infection. Therefore, swab to request fungal spores and, if positive, treat with anti-fungal medication/ointment.

GASTRIC LEAKAGE AT STOMA SITE

Possible causes:

  1. Migration of tube into stomach
  2. Increased abdominal pressure possibly due to constipation or coughing
  3. Stoma site is too large
  4. Poor position while feed is in progress

Action:

  1. If it is a gastrostomy tube, release external fixation plate to check internal retention disk is in correct position; give gentle pull on tube to feel resistance; push back in very slightly to prevent pressure necrosis.
  2. If Child is constipated or has chest infection, treat accordingly.
  3. If site is too large and exudate cannot be managed, seek advice from your community nurse. To manage actual leakage:
  4. Use non-woven absorbent dressing for heavy exudate
  5. Use Cavilon spray to protect skin
  6. Use hydrogel to treat excoriated area of skin

TUBE DISPLACEMENT/FALLS OUT

If this happens the stoma/tract will close within 2 hours.

  1. Explain what is taking place to the Child.
  2. Wash hands.
  3. Put on gloves and apron.
  4. If the tube is still part way into the stoma/tract, remove and replace with spare button or G tube then go through the test procedure prior to feeds being administered. Any concerns follow the ‘What if’ policy after 5pm and at weekends
  5. If tube is completely out follow the same advice as 4.

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