GASTROSTOMY FEEDING

After 5 hours of varied classroom discussion the level IV students will be able to:

1. Define the following1.1 Gastrostomy1.2 Gastrostomy tube1.3 Gastrostomy feeding1.4 Feeding tube1.5 Irrigation1.6 Total enteral nutrition1.7 PEG1.8 Low profile Gastrostomy

2. State the following:

2.1 Purpose2.2 Indication and contraindication2.3 Advantages and Disadvantages

3. Enumerate the following:

3.1 Types of Gastrostomy3.2 Types of formula feeding3.3 Site Gastrostomy tube insertion

4. Discuss the following:4.1 Guidelines involved in Gastrostomy4.2 Complication of Gastrostomy Feeding4.3 Nursing responsibilities before, during and after

5 Demonstrate beginning skills in Gastrostomy

1. Definition of terms

1.1 Gastrostomy

an artificial opening through the abdomen into the abdomen into the stomach can be performed surgically, laparoscopically or endoscopically.

an operation performed to create an opening into the stomach for the purpose of administering food and fluids.

1.2 Gastrostomy tube

a Tube that is inserted through the opening of the stomach

1.3 Gastrostomy feeding

is the introduction of liquid food through a tube or catheter which the surgeons has introduced it into the stomach through the abdominal wall

1.4 Feeding tube

a medical device used to provide nutrition to the patient who cannot obtain nutrition by swallowing.

1.5 Irrigation

the washing of a cavity or wound with a stream of water.

1.6 Total Enteral Nutritionnutritional formula feedings introduced through a tube directly into the gastrointestinal tract.

1.7 PEG- Percutaneous Endoscopic Gastrostomy a flexible polyurethane tube that is passed down through the throat and into the stomach using an endoscope while the patient is under general anesthesia.

1.8 Low profile Gastrostomy Devicean alternative to the PEG device is the low profile gastrostomy device or LPGD. It may be inserted 3 to 6 months after after initial gastrostomy tube placement.

2. State the following:

2.1 Purposea) To feed a person who is unable to swallow to provide proper

nutrition-

Provides a route for tube feeding when it is needed for weeks of longer since the incidence of regurgitation is lower.

b) Act as drainage tube to bypass obstruction from tumors and scarring

c) Provide drainage for the stomach when it is necessary to bypass a long standing obstruction of the stomach outlet into the intestine

d) Provides fluid and nutrition directly into the stomach.

Gastrostomy feeding is the introduction of liquid food through a tube or catheter which the surgeons has introduced it into the stomach through the abdominal wall

2.2 Indication and contraindication

Indication:a) Tumors in the upper alimentary tract-

Patients with dysphagia secondary to tumor are indicated for gastrostomy to allow maintainance of adequate nutrition.

b) Cancer of the esophagus- the most common symptoms of esophageal cancer are dysphagia (difficulty swallowing) and odynophagia (painful swallowing) gastrostomy feeding provides patients with esophageal cancer maintenance of adequate nutrition.

c) Stricture of the esophagus caused by poison- During swallowing food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach. When esophagus becomes constricted because of poison food cannot pass to the stomach.

d) Preferred for prolonged enteral nutrition support greater than 3-4 weeks- For example elderly of debilitated patients. Gastrostomy feeding is preferred over NGT feeding in patients who is comatose because the gastroesphageal sphincters are still intact. Regurgitation and aspiration are less likely to occur with NG feeding.

e) Comatose patients – Gastrostomy feeding is preferred over NGT feeding in patients who is comatose because the gastroesphageal sphincters are still intact. Regurgitation and aspiration are less likely to occur with NG feeding.

Contraindication

a) Complete intestinal Obstruction and Malignant small bowel obstruction

Digestion is the process whereby nutrients are reduced to appropriate form for intestinal absorption. Intestinal absorption transports nutrients across the mucousa to the portal blood when there is complete intestinal obstruction there is inability of nutrients to be readily catabolized and transported.

b) Ascites

In Ascites there is extra fluid in the peritoneal cavity, which is the space between the layers of tissue that line the belly's wall and the abdominal organs (such as the liver, spleen, gall bladder and stomach).

c) Severe Gastroesophageal Reflux

Patients with sever gastroesophageal reflux are at risk for aspiration pneumonia and therefore are not candidates of gastrostomy.

2.3 Advantages and Disadvantages

Advantage

1. Provides alternative passage of food and medicine in cases of obstruction- Patients with dysphagia secondary to tumor are indicated for gastrostomy to allow maintenance of adequate nutrition.

2. Decrease the risk of pulmonary aspiration-. Gastrostomy feeding is preferred over NGT feeding in patients who is comatose because the gastroesphageal sphincters are still intact. Regurgitation and aspiration are less likely to occur with NG feeding.

3. Tube is easy to replace

Tube placement is much simpler, requiring less much manipulation, almost any type of diet can be used.

Gastrostomy tubes and buttons requires less frequent changes than nasogastric tubes. A device that is secured by a deflatable balloon than one secured by internal bumper or disc.

Disadvantage

A. Infection- Infection of the stoma site since there is a break in the continuity of the skin, there are opportunistic bacteria that when given a chance enters into the tissues and causes infection.

B. Leakage and Skin Irritation- The skin surrounding the a gastrostomy requires special care because it may become irritated from enzymatic action of the gastric juices that leak around the tube. Left untreated the skin may become macerated, red, raw and painful.

C. Gastric distention-There is distortion of the anatomy of the stomach and interference of the normal peristaltic movements of the stomach musculature.

D. Bleeding- Bleeding from the insertion site of the stomach may occur.

3 .Enumerate the following:

3.1 Types of Gastrostomy Tube

a. Percutaneous Endoscopic Gastrostomy (PEG) tube

a flexible polyurethane tube that is passed down through the throat and into the stomach using an endoscopic while the patient is under general anesthesia. The end of the PEG tube is then brought to a small incision into the abdomen to allow smell access for feeding and is secured in place inside the stomach and held against the skin by a fixation device.

Advantage:

can be utilized for feeding within 24 hours of insertion.

These tubes are more suited to long term usage and can stay in place for many months.

Disadvantage:

Invasive Need minor surgical Procedure to insert them. Subsequent proximal displacement

Picture:

b. Balloon Gastrostomy Tube

Is a flexible surgically placed catheter that is inserted through an incision in the abdomen; it is similar to the PEG tube in that it has a long external extension tube, but it has a wider diameter. The main difference is that the section of the tube or catheter that is in the stomach is held place by an inflatable silicone balloon and may need to be temporarily secured with sutures to the skin. The tube may be temporarily for the first 6-8 weeks and can be then replaced by a balloon device.

Advantage:

Surgery is not necessary when removing or changing this tube Low risk of migration and dislodgement

Disadvantage:

More difficult and painful to replace Malfunctions more often

Picture:

c. Low Profile Gastrostomy Tube

Also known as balloon retention low profile gastrotomy tube is a much shorter tube; the exterior of this device sits flush with the skin, the device is a silicone shaped end that sits inside the stomach and is cosmetically pleasing.

Advantage:

Simplified care Decrease skin irritation Low risk of migration and dislodgement Comfortable wear-no bulk under clothing Cosmetically pleasing

Disadvantage:

Limited sizes The requirement of a mature stoma tract Expense greater to traditional tubes Possible of pressure necrosis due to inappropriate sizing

Picture:

SURGICAL GASTROSTOMY INSERTIONS

Stamm Gastrostomyis the insertion of the gastrostomy tube through a small incision in the midline or subcostal area. The tube is inserted in the stomach through a purse-string suture, and the site of insertion will be sutured to the abdominal wall with three or four interrupted sutures.

Witzel Gastrostomyis similar to Stamm gastrostomy, the difference being that a seromuscular tunnel will be made a distance of five to eight centimeters from the insertion site.

Janeway Gastrostomyis similar to Stamm gastrotomy with a difference that a gastric flap will be created to cover the tract to the skin. This type of gastrostomy is permanent, and removal of tube does not cause spontaneous closure of the gastrostomy site.

3.2 Types of formula feeding

1. Polymeric (1.0 to 2.0 Kcal/ml)

-include milk based blenderized foods prepared by hospital dietary staff or in the client’s home.-includes commercially prepared whole nutritional formulas-For this formula to be effective, the clients G.I tract must be able to absorb whole nutrients.

2. Lactose free formulas

3. Elemental diets (1.0 to 3.0 Kcal/ml)

-contains predigested nutrients that are easier for a partially dysfunctional G.I tract to absorb

4. Modular diets (3.8 to 4.0 Kcal/ml)

-are single macronutrient (e.g protein, glucose, polymer or lipids) preparation but are not nutritionally complete.

-Formula added to another food for meeting the client’s individual nutritional needs.

5. Special formulas (1.0 to 2.0 Kcal/ml)

-commercially prepared for specific indications or situations (e.g liver failure, pulmonary disease, HIV infection)

TUBE FEEDING ADMINISTRATION METHODS

1. Intermittent gravity drip-administering tube feeding into the stomach, Given by bottle or bag, Hooked to a feeding tube set and is administer at specific times of the day

2. Continuous Pump Infusion-is the preferred method of delivering enteral nutrition in the critically ill patients. A peristaltic pump can be used to provide continues infusion of the formula at a precisely controlled flow rate, which decreases problems with infection and diarrhea.

3. Syringe bolus – The bolus is usually delivered with the aid of a catheter tipped , large-volume (60ml) syringe.

3.3 Site Gastrostomy tube insertion

PARTS OF A GASTROSTOMY TUBE AND ITS USES

4. Discuss the following:

4.1 Guidelines involved in Gastrostomya. cleanse around the gastrostomy site with mild soap and water, pat dry.b. give tube a twist to ensure that the tube is not too tight against the abdominal wall.c. if the tube does not twist easily, loosen the tube retainer device so that there is

1/8-inch distance between the skin and the reatainer disc or triangle.d. once the gastrostomy site has healed (usually 2 to 3 weeks after surgery) NO

DRESSINGS are needed at the sitee. watch for any signs of irritation or leakage at the gastrostomy site and report these

immediately to a supervisorf. when a patient puts tension on a G-tube, the tube should be stabilized with a

mesh netting or wrap to prevent discoloration of the tube or tissue breakdown.

4.2 Complication of Gastrostomy Feeding

Wound Infection, Cellulitis, Abdominal wall abscess

- Excessive handling and manipulation of tube-can increase risk for ulceration and subsequent infection.- Patients are at increased risk for infection if they are: diabetic, obese, on chronic corticosteroids or immunosupressed- this could also lead to peritonitis

Intervention:

- wash the area around the tube with soap and water daily, remove any encrustation with saline solution, rinse the area well with water, and pat it dry.

- keep the dressing dry and protect the skin from moisture with alcohol-free skinsealants or ointments- proper cleaning of the site and change dressings daily. Once the stoma heals and drainage ceases, a dressing is not required.

GI bleeding

- internal part of the tube is too tight against the abdominal wall- the common cause of GI bleeding is gastric ulceration beneath the internal bolster- can also occur as a result of frictional abrasion which can lead to pressure necrosis.

Intervention:-monitor the patient’s vital signs and observes all drainage from the operative site, vomitus and stool for evidence of bleeding-avoid dark color foods

-avoid caffeinated drinks -check the characteristics of stools

Premature dislodgement of the tube

-tube displacement-inadequate tube stabilization

Intervention:

-allow sufficient length of tubing to prevent tension or pulling on the tube. Routinely check the position of markings on the tube to determine if slippage has occurred.

-gastrostomy tube must 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.

Leakage around gastrostomy tube

-Tube displacement-Improper balloon inflation-Inadequate tube stabilization-Increased abdominal pressure related to:

o Cough, constipation, hypertonicity/spasticityo Inability to decompress gastric content (i.e. burp)

Intervention:Use proper hand washing technique before and after all nursing interventions.• If balloon catheter, check tube for proper inflation of balloon

o Verify tube type and proper amount of fluid in the balloon as recommended by manufacturero Using a syringe attached to the port, pull back the fluid in the balloon. A slip-tip syringe may be necessary for certain low-profile tubeso If insufficient fluid is present in the balloon, re-inflate with the correct amount of sterile watero Balloon volume should be checked weekly.

• Stabilize the tubeo Gently pull up on the tube until the internal anchoring device or balloon is against the wall of the stomacho If unable to stabilize in this manner or there is no anchoring device, consider the use of an external stabilizing device

• Verify leakage has ceased

Skin Irritation

- leakage of gastric secretions around the tube- pressure at the PEG’s external and internal bolsters

Interventions:

- skin must be kept clean with frequent use of soap and water and should be kept dry; a protective ointment such as Zinc oxide or Petrolatum gauze may be applied around the tube.-Cover with dry gauze under stabilizer to wick minor drainage until the skin irritation is resolved. Ensure there is adequate space for the foam dressing below the bumper/stabilizer so the tube is not under excessive tension. Avoid tape if possible.

Dumping syndrome

Dumping is the effect of alteration in the motor functions of the stomach, including disturbances in the gastric reservoir and transporting function. Gastrointestinal hormones play an important role in dumping by mediating responses to surgical resection.

Intervention :-patient should be positioned in a semi-recumbent position during mealtime. -Following the meal, the patient should lie down for 20-30 minutes to delay stomach emptying-Fluids are discouraged with meals but may given up to an hour before mealtime or one hour following mealtime-Fat may be given to tolerance, but Carbohydrate intake should be kept in low-Antispasmodics, as prescribed, may aid in delaying the emptying of the stomach.

4.3 Nursing responsibilities before, during and after

Before:• explain the procedure to the patient and to the significant others• perform medical handwashing• gather all the materials needed and bring to the patinet's bedside• position patient in sem-fowler's position• inspect the site for any unsual reaction• check the placement of the tubing• auscultate the bowel sound• assess for bowel distention• open the sterile materials asepticallys• rink the distal end of the tube to present air from coming in, attach the syringe• do lavage (if content is more than or equal to 100cc withhold the feeding)• hold the tube upright above the level of the stomach

During:• fill the aseptosyringe with the feeding solution• release the kink tubing to allow the solution to flow• allow the syringe to empty gradually by gravity• refill the syringe until the prescribed amount is introduce to the client• flush 30mL of water• kink the proximal end of the tube before disconnecting the syringe• cover the end of the tube with a cap• allow patient to remain in semi-fowler's position for 30 minutes

After:

• do after care• rinse all reusable materials with water and let it dry• Documentation comes next

5. Demonstrate beginning skills in Gastrostomy

INFORMATION SOURCES:

Thresyamma , Fundamentals of Nursing ,p.305

Medical Surgical Nursing by Susan Smeltzer,10th edition,p.998)

Steven K. Teplick ,Nonsurgical Therapies for the Gut and Abdominal Cavity , p.22

Herbert L. Abrams ,Abrams' angiography: interventional radiology  p.602

Vanessa Shaw and Lawson,Margaret, Clinical pediatric dietetics ,p.38

Meera Kaur ,Medical Foods from Natural Sources, p.10

Angela Southal and Martin,Clarissa ,Feeding Problems in Children: A Practical Guide , p.44

Susan Smeltzer ,Medical Surgical Nursing,Lippincott William and wilkins:Singapore,10th

edition,p.1000

Janice Colwell et.al ,Fecal & urinary diversions: management principles ,p. 357-359

Ruth A. Bryant and Nix, Denise, Acute and chronic wounds: current management concepts , Missouri: Elsevier,p.522

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edition,1314

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