Week 12- Gastronomy

Question 1

What is a gastronomy? different types?

Answer 1

The feeding tube is PLACED DIRECTLY INTO THE GASTRO-INTESTINAL TRACT (GI) THROUGH THE ABDOMINAL WALL
patients who can’t tolerate oral or nasal enteric feeds
Types of tubes:
GASTROSTOMY tube (G tube or a PEG )
JEJUNOSTOMY TUBE
Low-profile gastrostomy device (LPGD)

Question 2

What is the jejunostomy tube used for?

Answer 2

Long term feeding

Used in clients who:
High risk for aspiration
Impaired function above jejunum

Question 3

What is the Percutaneous Endoscopic Jejunostomy ?

Answer 3

Same as peg but inserted into the jejunum

Question 4

What do the orders and careplan include for a gastronomy?

Answer 4

Feeding tube type
Enteral formula
Feeding schedule 
	intermittent
continuous
cyclic	
Rate (use enteral pump to control rate)

Residual checks and holding of feeds
Client positioning
Additional free water
Medication flushes
When to change bag
Formula expiry

Question 5

What is the site care for gastronomy/ jejunostomy?

Answer 5

Assess for: Signs of infection (surgical asepsis until incision heals),Inflammation, Swelling, Skin breakdown, Leakage, Yeast)
Site care: Proper use of dressing, Skin care around the tube, Manipulation of the stabilizing disk to prevent skin breakdown
Patient knowledge and ability to learn/Self-care ability and support
Nutrition& fluid status
Assess for Potential complications
Wound infection
GI bleeding
Premature removal of tube
Aspiration
Constipation
Diarrhea

Question 6

nursing diagnosis?

Answer 6

Imbalanced nutrition
Risk of infection
Risk for impaired skin integrity
Ineffective coping
Disturbed body image
Risk for ineffective therapeutic regimen management

Question 7

What are you assessing the site for?

Answer 7

Signs of infection 
(surgical asepsis until incision heals)
Inflammation
Swelling
Skin breakdown
Leakage
Yeast

Question 8

what are the ongoing assessments (besides of the site)?

Answer 8

Ensure tube securely anchored
Complete GI assessment
Respiratory assessment
Hydration status
Weight
Lab values
Urine sample

Question 9

What are the different types of feeding gastronomies (hint: S, J, P)? (readings)

Answer 9

Different types of feeding gastrostomies:  
the Stamm (temporary and permanent),  
Janeway (permanent) 
percutaneous endoscopic gastrostomy (PEG; temporary) systems.  
The Stamm and Janeway gastrostomies require either an upper abdominal midline incision or a left upper quadrant transverse incision.  
The Stamm procedure requires the use of concentric pursestring sutures to secure the tube to the anterior gastric wall. 
To create the gastrostomy, an exit wound is created in the left upper abdomen.  
The Janeway procedure necessitates the creation of a tunnel (called a gastric tube) that is brought out through the abdomen to form a permanent stoma.

Question 10

What is a low profile feeding device?

Answer 10

An alternative to the PEG device is a low-profile gastrostomy device LPGD may be inserted 3 to 6 months after initial gastrostomy tube placement.
These devices are inserted flush with the skin; they eliminate the possibility of tube migration and obstruction and have antireflux valves to prevent gastric reflux. Two types of devices may be used—obturated or nonobturated.
The obturated devices (G-button) have a dome tip that acts as an internal stabilizer. Only a physician may obturate
(insert a tube that is larger than the actual stoma). The nonobturated device (MIC-KEY) has an external skin disk
and is inserted into the stoma without force; a balloon is inflated to secure placement. A nurse in the home setting
may insert these nonobturated devices. The drawbacks of both types of LPGDs are the inability to assess residual volumes (one-way valve) and the need for a special adaptor to connect the device to the feeding container.
Reflux from stomach feedings can result in aspiration pneumonia. Therefore, patients at risk for aspiration pneumonia are not ideal candidates for a gastrostomy.
jejunostomy is preferred, or jejunal feeding through a nasojejunal tube may be recommended. (one of my patients had this, who had no gag reflex)

Question 11

Nursing Diagnoses?

Answer 11

Imbalanced nutrition (less than body requirements) related to enteral feeding problems
• Risk for infection related to presence of wound and tube
• Risk for impaired skin integrity at tube insertion site
• Ineffective coping related to inability to eat normally
• Disturbed body image related to presence of tube
• Risk for ineffective therapeutic regimen management related to knowledge deficit about home care and the feeding procedure

Question 12

collaborative problems/ potential complications?

Answer 12

Potential complications that may develop include:
• Wound infection, cellulitis, leakage, and abdominal wall abscess
• GI bleeding
• Premature removal of the tube
• Aspiration
• Constipation or diarrhea

Question 13

What are the goals of this treatment?

Answer 13

The major goals for the patient may include attaining an optimal level of nutrition, preventing infection, maintaining skin integrity, enhancing coping, adjusting to changes in body image, acquiring knowledge of and skill in self-care, and preventing complications.

Question 14

How does the nurse meet nutritional needs, soon after surgery?

Answer 14

The first fluid nourishment is administered soon after surgery and usually consists of tap water and 10% dextrose.
Only 30 to 60 mL is given at one time
amount administered is increased gradually.
By the second day, 180 to 240 mL may be given at one time, provided no leakage of fluid occurs around the tube. ]=
Water and enteral feeding can be infused after 24 hours for a permanent gastrostomy.
Blenderized foods can be added gradually to clear liquids until a full diet is achieved.

Question 15

How does the nurse Provide Tube Care and Prevent Infection ?

Answer 15

A small dressing can be applied over the tube insertion site, and the gastrostomy tube can 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.
The dressing protects the skin around the incision from seepage of gastric acid and spillage of feedings
The nurse verifies the tube’s placement, assesses residuals, and gently manipulates the tube or stabilizing disk once daily to prevent skin breakdown.
Some gastrostomy tubes have balloons that are inflated with water to anchor the tube in the stomach.
Balloon integrity is checked weekly by deflating and reinflating the balloon using a Luer-tip syringe.

Question 16

What is the skin care?

Answer 16

The skin surrounding a gastrostomy requires special care because it may become irritated from the enzymatic action of gastric juices that leak around the tube.
The nurse washes the area around the tube with soap and water daily, removes any encrustation with saline solution, rinses the area well with water, and pats it dry.
Skin at the exit site is evaluated daily for signs of breakdown, irritation, excoriation, and the presence of drainage or gastric leakage.

Question 17

What is the monitoring and management of complications?

Answer 17

During the postoperative course, the nurse monitors the patient for potential complications.
including cellulitis at the exit site and abscesses in the abdominal wall.
Bleeding from the insertion site in the stomach may also occur.
Any signs of bleeding are reported promptly.
If the tube is removed prematurely, the skin is cleansed and a sterile dressing is applied; the nurse immediately notifies the physician.
The tract will close within 4 to 6 hours if the tube is not replaced promptly.

Question 18

What patient teaching is done?

Answer 18

The nurse assesses the patient’s level of knowledge, interest in learning about the tube feeding, and ability to understand and apply the information before providing detailed instructions about how to prepare the formula and manage the tube feeding.
Demonstration of the tube feeding begins by showing the patient how to check for residual gastric contents before the feeding.
The patient then learns how to check and maintain the patency of the tube by administering room-temperature water before and after the feeding.
This establishes patency before the feeding and then clears the tube of food particles, which could decompose if allowed to remain in the tube.
All feedings are given at room temperature or near body temperature.
For a bolus feeding, the nurse shows the patient how to introduce the liquid into the catheter by using a funnel or the barrel of a syringe.
The receptacle is tilted to allow air to escape while the liquid is being instilled initially.
As the funnel or syringe fills with liquid, the feeding is allowed to flow into the stomach by gravity by holding the barrel or syringe perpendicular to the abdomen
Raising or lowering the receptacle to no higher than 45 cm above the abdominal wall regulates the rate of flow.
A bolus feeding of 300 to 500 mL usually is given for each meal and requires 10 to 15 minutes to complete.
The patient and caregiver must understand that keeping the head of the bed elevated a minimum of 45 degrees for at least 1 hour after feeding facilitates digestion and decreases the risk of aspiration.
The patient or caregiver is instructed to flush the tube with 30 to 50 mL of water after each bolus or medication administration and to also flush the tube daily to keep it patent.

Question 19

What assessment is done before administering medications?

Answer 19

Assessment:
Assess for any contraindications to receiving medications enterally, including presence of bowel inflammation, reduced peristalsis, recent gastrointestinal (GI) surgery, and gastric suction that cannot be turned off
For postoperative patient, review postoperative orders for type of enteral tube care.
Check with pharmacy for availability of liquid preparation for patient’s medications

NOTE: Whenever possible, use liquid medications instead of crushed tablets; but, if you have to crush tablets, the tubing must be flushed before and after the medication to prevent the drug from adhering to the inside of the tube. In addition, make sure that concentrated medications are thoroughly diluted. Never add crushed medications directly to a tube feeding

Question 20

How do you administer medications (caution.. very, VERY, long answer from readings)

Answer 20

Determine if medication interacts with enteral feeding. If interaction occurs, hold feeding for 30 minutes before medication administration
Prepare medications for instillation into feeding tube
Fill graduated container with 50 to 100mL of tepid water.
Tepid water prevents abdominal cramping, which can occur with cold water.
Use sterile water for immunocompromised or critically ill patients
Tablets: Crush each tablet into a fine powder, using pillcrushing device or two medication cups
Dissolve each tablet in separate cup of 30mL of warm water.
Fine powder dissolves more easily, reducing chance of occluding feeding tube.
b Capsules: Ensure that contents of capsule (granules or gelatin) can be expressed from covering. Open capsule or pierce gel cap with sterile needle and empty contents into 30mL of warm water (or solution designated by drug company). Gel caps dissolve in warm water, but this may take 15 to 20 minutes.
Elevate head of bed to minimum of 30 degrees and preferably 45 degrees (unless contraindicated) or sit patient up in a chair
If continuous enteral tube feeding is infusing, adjust infusion pump to hold tube feeding.
Apply clean gloves. Check placement of feeding tube by observing gastric contents and checking pH of aspirate contents.
Gastric pH for a patient who has fasted for 4 hours is usually 1.0 to 4.0. Ensures proper tube placement and reduces risk of introducing fluids into respiratory tract.
Check for gastric residual volume (GRV). Draw up 10 to 30mL of air into a 60-mL syringe and connect syringe to feeding tube. Flush tube with air and pull back slowly to aspirate gastric contents. Determine GRV using either scale on syringe or a graduate container. Return aspirated contents to stomach unless a single GRV exceeds 500mL or if two measurements taken 1 hour apart each exceed 250mL.
When GRV is excessive, hold medication and contact health care provider. GRV categories have been identified in studies as significant when patients have two or more GRVs of at least 250mL or one or more GRVs exceeding 500mL. Large residuals indicate delayed gastric emptying and put patient at increased risk for aspiration
Irrigate the tubing.
Pinch or clamp enteral tube and remove syringe. Draw up 30mL of water into syringe. Reinsert tip of syringe into tube, release clamp, and flush tubing. Clamp tube again and remove syringe.
Some enteral tubes are connected to continuous-feeding tubing with stopcock apparatus such as a Lopez valve that contains a medication port. Attach tip of syringe to medication port on stopcock; turn “off’” setting of stopcock away from patient and toward infusion tubing. Flush tube and set stopcock “off ” again to medication port. Remove syringe.
Remove bulb or plunger of syringe and reinsert syringe into tip of feeding tube.
Administer first dose of liquid or dissolved medication by pouring into syringe. Allow to flow by gravity If giving only one dose of medication, flush with 30mL of water after administration.

To administer more than one medication, give each separately and flush between medications with 15 to 30mL of water.
Follow last dose of medication with 30 to 60╯mL of water. Maintains patency of enteral tube and ensures passage of medication into stomach
Clamp proximal end of feeding tube if tube feeding is not being administered and cap end of tube.
Help patient to comfortable position and keep head of bed elevated for 1 hour
Dispose of soiled supplies, rinse graduated container and syringe with tap water, remove and dispose of gloves, and perform hand hygiene

When continuous tube feeding is being administered by infusion pump, follow medication administration Steps 1 to 13.
If medications are not compatible with 9pfeeding solution, hold feeding for additional 30 to 60 minutes.

Feed good for 12hrs after hanging 
Hi-fowlers 30-45 degrees 
Give meds individually  
Flush with 15ml before and after 
 Please see powerpoint as well