GASTROSTOMY FEEDING

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

1. Define the following 1.1 Gastrostomy 1.2 Gastrostomy tube 1.3 Gastrostomy feeding 1.4 Feeding tube 1.5 Irrigation 1.6 Total enteral nutrition 1.7 PEG 1.8 Low profile Gastrostomy 2. State the following: 2.1 Purpose 2.2 Indication and contraindication 2.3 Advantages and Disadvantages

3. Enumerate the following: 3.1 Types of Gastrostomy 3.2 types of formula feeding 3.3 Site Gastrostomy tube insertion 4. Discuss the following: 4.1 Guidelines involved in Gastrostomy 4.2 Complication of Gastrostomy Feeding 4.3 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. 1.2 Gastrostomy tube- A Tube that is inserted through the opening of the stomach 1.3 Gastrostomy feeding- It 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 Nutrition- Nutritional 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 Device- An 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 Purpose a) 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. (Source: Handbook of medical-surgical nursing By Lippincott Williams & Wilkins p.327) 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 tractPatients with dysphagia secondary to tumor are indicated for gastrostomy to allow maintenance of adequate nutrition. (Nonsurgical Therapies for the Gut and Abdominal Cavity by Steven K. Teplick p.22) 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.(Fundamentals of Nursing by Thresyamma p.305) 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. .(Fundamentals of Nursing by Thresyamma p.305)

d) Preferred for prolonged enteral nutrition support greater than 3-4 weeksFor 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. (source : Medical Surgical Nursing by Susan Smeltzer,10th edition,p.998)

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

Contraindication a) Sepsis b) Complete intestinal Obstruction ((Function of the intest) c) Malignant small bowel obstruction-(read)

d) Ascites- Ascites 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). e) When primary anastomosis is feasible-(read) f) Severe Gastroesophageal RefluxPatients with sever gastroesophageal reflux are at risk for aspiration pneumonia and therefore are not candidates of gastrostomy. (source : Medical Surgical Nursing by Susan Smeltzer,10th edition,p.999)

2.3 Advantages and Disadvantages Advantage

Provides alternative passage of food and medicine in cases of obstructionPatients with dysphagia secondary to tumor are indicated for gastrostomy to allow maintainance of adequate nutrition. (Nonsurgical Therapies for the Gut and Abdominal Cavity By Steven K. Teplick p.22)

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. (source : Medical Surgical Nursing by Susan Smeltzer,10th edition,p.998) Tube is easy to replace Tube placement is much simpler, requiring less much manipulation, almost any type of diet can be used. (Abrams' angiography: interventional radiology By Herbert L. Abrams, Stanley Baum, Michael J. Pentecost p.602)

Gastrostomy tubes and buttonsrequires less frequent changesthan nasogastric tubes. A device that is securedby a deflatable balloon than one secured by internal bumper or disc. (Clinical paediatric dietetics By Vanessa Shaw, Margaret Lawson p.38)

Disadvantage

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. (Medical Foods from Natural Sources By Meera Kaur p.10) 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. (source : Medical Surgical Nursing by Susan Smeltzer,10th edition,p.1000)

Gastric distention-There is distortion of the anatomy of the stomach and interference of the normal peristaltic movements of the stomach musculature. (Feeding Problems in Children: A Practical Guide By Angela Southall, Clarissa Martin p.44) Bleeding- Bleeding from the insertion site of the stomach may occur. . (source : Medical Surgical Nursing by Susan Smeltzer,10th edition,p.1000)

3 Enumerate the following:

3.1 Types of Gastrostomy
1. Percutaneous Endoscopic Gastrostomy is the preferred method of insertion of the gastrostomy tube and it can be as a bedside procedure and can be utilized for feeding within 24 hours of insertion. 2. Stamm Gastrostomy is 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.

3. Witzel Gastrostomy is similar to Stamm gastrostomy, the difference being that a seromuscular tunnel will be made a distance of five to eight centimmeters from the insertion site. 4. Janeway Gastrostomy is 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 MAIN 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. 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. Surgery is not necessary when removing or changing this tube. c. Skin Level button device 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.

3.2 Types of formula feeding

1. Blenderized formula - made of whole food that is blenderized into liquid consistency. 2. Lactose - containing milk based formulas that can't be given to lactose-intolerant patients. 3. Lactose free formulas that are the common type used in hospitals and at home.

4. Elemental diets - composed of amino acids or short chain peptides. These formulas have poor taste and should be given by tubes. They usually have an osmolarity of 600. Because these formulas are predigested, they are ideal for patients have short bowel or pancreatic insufficiency.

3.3 Site Gastrostomy tube insertion

4. Discuss the following:

4.1 Guidelines involved in Gastrostomy cleanse around the gastrostomy site with mild soap and water, pat dry. give tube a twist to ensure that the tube is not too tight against the abdominal wall. 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.

once the gastrostomy site has healed (usually 2 to 3 weeks after surgery) NO DRESSINGS are needed at the site watch for any signs of irritation or leakage at the gastrostomy site and report these immediately to a supervisor 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.

y 4.2 Complication of Gastrostomy Feeding

y Wound Infection, Cellulitis, Abdominal wall abscess - proper cleaning of the site and change dressings daily. Once the stoma heals and drainage ceases, a dressing is not required. - 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. y GI bleeding - Monitor the patient s vital signs and observes all drainage from the operative site, vomitus and stool for evidence of bleeding. Premature dislodgement of the tube -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.s

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