Transcript PEG - Quia

Care of the Patient with a
Percutaneous Endoscopic Gastrostomy
(PEG) Tube
Program Description
• The purpose of this e-module is to provide the
RN with guidelines for the management of a
patient with a PEG (percutaneous endoscopic
gastrostomy) tube.
Learning Objectives
After this presentation, the learner will describe:
1. Assessment of the patient with a PEG tube
2. Hand-off communication pertaining to PEG tubes
3. Site care for a PEG tube
4. Tube care for a PEG tube
5. Administration of feedings via a PEG tube
6. Checking for PEG tube residual
7. Administration of medication via a PEG tube
8. Complications associated with PEG tubes and
nursing interventions
Assessment Guidelines
• Following PEG placement, the RN should
monitor vital signs (RR, BP, and HR) as per
prescriber’s order, then as per unit routine.
• Any sudden change in vital signs can be the
first indication of complications and should
be reported immediately to the MD/NP/PA.
• Abnormal assessment findings should be
reported to the MD/NP/PA.
Hand-Off Communication
• The accepting RN should be notified of the
presence of a PEG tube during hand-off
communication.
• The accepting RN should also be informed
as to the type of gastrostomy tube inserted.
This information can be found on the OR
sheet.
General Care
• Identify the patient with two identifiers.
• Wash hands with soap and water, foaming
antimicrobial sanitizer, or hospital-approved
hand sanitizer.
• Wear gloves when caring for tube and stoma.
• Explain the procedure to the patient.
Site Care
• Evaluate exit site for signs of breakdown, irritation, excoriation, and
the presence of drainage or gastric leakage.
• Assess site every shift, or more frequently if necessary, for any of
these signs.
• Clean site daily with gauze moistened with normal saline to remove
crust or drainage.
• Keep site clean and dry at all times.
• Apply dressing to reduce local skin irritation caused by gastric
contents.
• Change gauze when soiled.
• Avoid the use of powder.
• Avoid local administration of hydrogen peroxide or chlora-prep.
• Maintain proper tension between internal and external bolsters.
• Notify MD/PA/NP of abnormal findings and document accordingly.
Tube Care
• Apply appropriate tape with gauze over the
bumper to prevent accidental dislodgement of
the tube.
• A PEG tube may be protected by a dressing
that allows access to the tube but covers the
exit site. Typically, the tube is stabilized with
tape over the dressing.
• Prevent excessive side torsion on the PEG
tube.
Administration of Feedings
• Tube feeding, supplements, normal saline, and water are to be
administered as per order.
• The formula strength and rate of administration should meet the needs of
the individual patient and be compatible with the size of the tube, the
location of the tube, and the patient’s tolerance.
• Position patient at least 30 degrees upright during feedings.
• Keep the HOB elevated for at least one hour post feeding to facilitate
digestion and decrease the risk of aspiration.
• Hold feeds during patient care activities that require the HOB to be lower
than 30 degrees .
• Do not place patient in Trendelenburg position.
• Before starting initial feedings, verify placement by listening with
stethoscope over left upper quadrant while injecting 20 ml air into tube
(listen for sound of air going into water).
• Flush with 50 ml of water pre and post bolus feeding.
• Flush with 50 ml of water every 8 hours if on continuous feeding.
Checking for PEG Tube Residual
• Aspirate gastric contents for residual volume every 4 hours.
Return the aspirate to the stomach to prevent acid-base
and electrolyte imbalance. Unless specific prescriber’s
orders are written, the following guidelines for residual
volumes should be followed:
• If residual is greater than (>) 1.5 times the hourly rate, hold
the feeding and notify the prescriber.
• If the residual volume is greater than or equal to (>) 100 ml,
tube feeding intolerance should be considered. The tube
feeding may be continued with close monitoring of gastric
residual volumes, radiographic studies, and/or the patient’s
physical status. If excessive residual volume occurs twice,
notify the prescriber.
Medication Administration
• Use liquid form of medication whenever possible.
• If medication is crushed, ensure it is finely
crushed and dispersed well in warm water.
• Flush with 50 ml pre and post administration of
medication.
• If more than one medication is to be
administered, give separately, rinsing tube with
5ml of warm water between each medication.
• Do not mix medications with enteral feeding
formulas.
Dressing Change
Equipment
• Basin of warm soapy water
• Wash cloth
• Towel
• Bottle of Normal Saline
• Irrigation Kit
• Chux pads
• Paper bag or Chux pad (for discarded materials)
• Sterile 4 x 4 gauze compresses, or a surgical dressing such
as drainage dressing
• Surgical tape and/or surgical net
• Gloves
Dressing Change
Procedure
1. Identify patient with two identifiers.
2. Assemble equipment
3. Explain the procedure to the patient and screen the patient for privacy.
4. Assist patient into a comfortable position in bed.
5. Turn bed covers back to hip level and open gown to expose gastrostomy dressing.
6. Place chux pad at upper left side of patient.
7. Wash hands
8. While supporting tube with one hand to prevent tension, remove old dressing.
9. Inspect skin around stoma (peristomal) for irritation or breakdown, color and odor of drainage.
10. Clean peristomal area with warm soapy water or normal saline.
11. Rinse thoroughly and pat dry with a towel.
12. Note any complaints from patient of soreness or tenderness in peristomal area.
13. Rotate external bumper 90 degrees daily.
14. Apply a dry dressing. Sterile 4x4 drainage gauze may be used.
15. Ensure there is no tension on the tube.
16. Discard waste
17. Wash hands
18. Record dressing change and observations of skin.
Possible Complications and Nursing
Interventions
PEG Site Skin Breakdown
Cause:
• Excessive pressure between PEG’s external
and internal bolsters.
Intervention:
• Notify MD/NP/PA
• Set pressure between PEG’s external and
internal bolsters
PEG Site Leakage
Causes:
• Patient sitting up too high
• Fast feeding flow
• Tube balloon volume low
• Tract diameter greater than PEG tube
Interventions:
• Hold feeding
• Notify MD/NP/PA
Gastric Ulceration
Cause:
Traction on tube
Intervention:
• Notify MD/NP/PA
Inadvertent Tube Removal
Interventions:
• Clean site and apply dry sterile dressing
• Notify MD/NP/PA
Blocked Tube
(Due to formula or medication)
Interventions:
• Aspirate using 60 ml syringe
• If unsuccessful, use a smaller syringe (5 or 10 ml)
as the pressure is higher than a larger syringe
• Use warm tap water to flush tube. Press down for
at least 15 seconds before drawing back
• If unsuccessful, notify MD/NP/PA
• DO NOT attempt to eliminate blockage by
inserting a mechanical object
Dislodgement of Tube
Interventions:
• Hold feedings
• Assess patient for difficulty breathing
• Cover site with gauze
• Notify MD/NP/PA
Aspiration
Interventions:
• Stop feeding
• Notify MD/NP/PA
References
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A.S.P.E.N. Enteral Nutrition Practice Recommendations (2009). Journal of
Parenteral and Enteral Nutrition, 33,2:12-167. DOI:10.1177/0148607108330314.
American Gastroenterological Association. American gastroenterological
association medical position statement: guidelines for the use of enteral nutrition.
www.3.us.elsevierhealth.com/gastro/policy/v108n4p1280.html
Bourgault, A. M, Ipe, L., et al. (August, 2007). Development of evidence-based
guidelines and critical care nurses’ knowledge of enteral feeding. American
Association of Critical Care Nursing, 27(4).
Braun, T, Murray A. et al. (2004). Long-term placement of an enteral feeding tube –
guideline for decision making. Presented at the 15th International Congress of the
Terminally Ill, Montreal 2004.
Erdil, A., Saka, M., Ates, Y., et al. Enteral nutrition via percutaneous endoscopic
gastrostomy and nutritional status of patients: five-year prospective study.
www.medscape.com/viewarticle/506583
National Guideline Clearinghouse. Altered nutritional status. www.guideline.gov
Pennington,C. (May-June, 2002). To peg or not to peg. Clinical Medicine 2(3), 250255.