My patient has a feeding tube

Transcription

1 My patient has a feeding tube What does that mean? Martha Kliebenstein, MSN, RN Clinical Educator (December, 2014)

2 Types of tubes Gastrostomy (G-tube) Gastrostomy jejunostomy (G-J tube) Naso gastric (NG tube) Naso jejunal (NJ tube) Jejunostomy (J tube)

3 Where does it go?

4 Naso gastric tube NG placement Initial insertion ph test X-ray verification measurement Confirmed placement Measurement Q shift, before feeds/meds

5 Stamm procedure Two incisions Gastrostomy tube: how are they placed? Percutaneous Endoscopic GT placement (PEG)

6 Percutaneous Endoscopic Gastrostomy placement PEG placement Done via endoscopy First tube change in 3 months

7 Percutaneous Endoscopic Gastrostomy placement

8 Surgical/Laparoscopic sutures will stay in place 5-7 days First G--tube change in 6 weeks Surgical: -> two incisions larger surgical incision and small GT insertion site incision Percutaneous: one incision

9 Gastromy tube VS Gastrostomy Button Placed in stomach Continuous or bolus feeds Tube or Button

10 G-tube with or without split 2x2 gauze

11 Gastro-Jejunostomy tube Used when gastric feeds not tolerated Placed in interventional radiology (after initial tube is placed) Often placed through gastrostomy tube Two options Gastric outlet vented, clamped, feeds or meds Jejunal outlet feeds, meds Clogs easily

12 Gastro-Jejunostomy tubes

13 GJ tubes Ross/Frederick Miller AMT GJ tube ORDERS TO CLARIFY Which port is for meds? For feeds? Is the g-port to gravity? To clamp? Vent? Do we replace G-tube output?

14 Jejunostomy tube Surgically placed directly into jejunum Children who cannot tolerate gastric feeds Many children also have gastrostomy tube used for venting and some meds All feeds given via DRIP, never BOLUS

15 Nursing Orders for G/J tube What type of tube Type of skin care Any dressing Bolster dressing or split 2x2 Any creams being applied Feeds given via drip - NEVER BOLUS FEEDS Flushing is critical; use water? Carbonated/selzer water?

16 Nursing Orders for G/J tube Meds via Gtube or J tube Meds in liquid form preferably Capsules/pills must be crushed well then flushed before and after meds are given FLUSHING Use 5 cc syringe or larger 2 X/day, 10 ml water (bottled or tap check w/ family) Can use selzer water

17 How to care for the site Clean with soap and water BID Assess site for redness, drainage, bleeding, granulation tissue Use hydrogen peroxide only if crusty drainage, then rinse with water Diaper creams can be used; If fungal > Nystatin cream -> Need MD order Stomadhesive powder can be sprinkled at site May use ProNet to secure tube

18 Stabilization of G tube Holds the balloon/mushroom against the stomach wall oprevents stomach contents from leaking oprevents tube from sliding into stomach or small intestine

19 Bolster Dressing Typically seen with new tube placments Used with long dwelling tube without stabilization bar 3x3 gauze Steri strips ½ x 4 inch Adhesive prep 1 tape ProNet

20 Feeding techniques Bolus Specific volume of enteral formula over shorter time period Usually minutes Can give via gravity (syringe or feeding bag) or pump If given too fast can cause stomach discomfort Bolus feeds NEVER given into jejunostomy tube

21 Feeding techniques Drip/continuous feeds At a continuous rate over a period of time Do not need to be given over 24 hours May be seen over hours Delivered by enteral feeding pump (Kangaroo pump) Required when patient has jejunal feeds Must flush well when feeds disconnected and before/after medications Always drip feeds when tube is a jejunostomy tube

22 Venting? Allows stomach to be vented or burped Can be done before, during or after feeds If stomach contents come up, typically allow contents to return into stomach

23 Residual? Routinely not done; need MD order Clinical assessment: abdominal distention, nausea/vomiting, pain, diarrhea/constipation; change in vitals, etc Done only in specified situations May be ordered if assessment indicates intolerance

24 Cecostomy tube CHRONIC CONSTIPATION Antegrade VERSUS Retrograde Less invasive Independent management easier for children

25

26 Problems Granulation tissue Leaking at insertion site Site redness Yeast (tiny red bumps, moist) Irritation/redness Tube clogged Tube comes out

27 Trouble shooting Granulation tissue Pink, moist tissue May have yellow, green drainage Keep site clean and dry Triamcinolone 0.5% cream or silver nitrate treatment Leaking at site Gently pull back on tube to ensure snug against stomach wall May need to change button if size incorrect May need stabilization tube Check balloon for appropriate water volume

28 Trouble shooting Yeast Tiny, red bumps Tends to look moist May use nystatin cream or powder (MD order) Site red, irritated Dampness, gastric leakage Dry dressing when moist need to keep site dry Barrier shield wipes may be used Stomadhesive powder Kaltostat Moisture barriers (desitin, triple paste, etc)

29 Trouble shooting Tube clogged Check for kinks Flush with water, may need carbonated water IF GJ tube will need to go to IR for re-insertion if unable to unclog IMPORTANT flush before and after

30 Trouble shooting Tube out Not an emergency Place gauze over site and contact MD/GT nurse on call Have about 1 hour before stoma will start to close If primary tube do not replace If established tract trained RN or GT nurse on call can replace IF GJ tube or Jtube needs to go to Interventional Radiology to be replaced

31 What s the problem?

32 What s the problem?

33 Where do I find info? Policy and Procedures Enteral Feeding G/J tube site care and maintenance On line Resource Care of the Child with a gastrostomy tube: ename=/groups/clinicalresources/jits/gtubeonlineresource. pdf

34 QUESTIONS?????