Gastrostomy and Jejunostomy

8/3/2019 Gastrostomy and Jejunostomy

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Gastrostomy and Jejunostomy



Gastrostomy

• Is a surgical procedurein which an openingis created into thestomach for thepurpose of

administering foodsand liquids via afeeding tube or forgastricdecompression in the

setting of intestinalobstruction.



• A gastrostomy is preferred over NGfeedings in the patient who iscomatose, because of

gastroesophaeal sphincter remainsintact, making regurgitation andaspiration less likely than with NG

feedings.



• Gastrostomy tube maybe placed surgicallythrough an abdominal

incision with sutures tosecure the tube to theanterior gastric wall and

the creation of a tunnelbrought out through theabdomen to form apermanent stoma.



Jejunostomy

• Jejunostomy is similarly placed, but thedistal end extends beyond the pylorusinto the jejunum.

• After the procedure, an antibioticointment is applied to the tube site, anda dressing is placed over the tube. Anabdominal binder is applied to protectthe tube. Then you will be taken to your

hospital room.



• Using the J-tube for feeding Feedings through a J-tube are always done using afeeding pump. A visiting nurse or home care

company will help arrange for your feeding pumpand instructions on how to use the pump at home.They will also be available to assist you in caring foryour tube at home.



Insertion of a Percutaneous EndoscopicGastrostomy (PEG)

• Requires the service of a provider skilled endoscopyor interventional radiology.

• After local anesthetic is administered, a cannula is

inserted into the stomach through a small abdominalincision and an endoscope is inserted via thepatient's mouth and upper GIT.

• The PEG tube is guided down the esophagus, intothe stomach, and through the abdominal incision

• A mushroom catheter tip or internal fasteners secure

the tube against the stomach wall



• If an endoscope cannot be passed throughesophagus , then the gastrostomy can be attemptedunder x-ray guidance through the abdominal wall.



Removal of PEG

• The initial PEG device can be removed and replace once thetract is well established, typcally 3-6 weeks after insertion.

• Replacement of the PEG device is indicated for a clogged offractured tube.

• The PEG should be fitted securely to the stoma to prevent

leakage of gastric secretions and is maintained in place throughgentle traction between the internal and anchoring device.

• PEG tube no longer required (recovery of swallow

after stroke or surgery for laryngeal cancer)

• Persistent infection of PEG site

• Failure, breakage or deterioration of PEG tube (a new tube canbe sited along the existing track)

• "Buried bumper syndrome"

http://en.wikipedia.org/wiki/Stroke

http://en.wikipedia.org/wiki/Laryngeal_cancer

http://en.wikipedia.org/wiki/Laryngeal_cancer

http://en.wikipedia.org/wiki/Stroke



Alternative to PEG device

• An alternative to the PEG device is alow profile gastrostomy device(LPGD)

May be inserted 3-6 months afterintial gastrostomy tube placement.

• these device are inserted flush with

the skin; they eliminate the possibilityof tube migration and have antirefluxvalves to prevent gastric leakage.



• Pt. requiring lifelong enternalsupport are able to conceal thefeeding access site under their

clothing.• However, it is not possible to assess

residual volumes w/ LPGDs(ie, they

have one way valve), they also requirea special adaptor to connect the deviceto the feeding container.



The patient with a Gastrostomy orJejunostomy

• AssessmentDetermined the pt. ability both to understand and

cooperate with the procedure.

The nurse assesses the ability of both pt. and family toa change in a body image and to participate in selfcare.

the purpose of the procedure and expectedpostoperative course should be explain.

The feeding tube will bypass the mouth and esophagusso that liquid feeding can be administered directlyinto the stomach or intestines.



• If the tube is expected to be permanent, the patientshould be made aware of this.

• The procedure is being performed to relieve discomfort ,prolonged vomiting , debilitation of an ability to eat, thepatient may find it more acceptable.



• In the postopreative period, the pt. fluid andnutritional needs to assessed to ensureproper intake and GI Function.

• Inspect the tube for proper maintenance and

incision for signs of infection.• Evaluate pt. responses to the change of body

image and their understanding of the feeding

method, interventions are identified to help themcope with the tube and learn self –caremeasures.



Diagnosis

• Major diagnosis in the postoperative periodmay include the ff.

• Acute pain• Risk for infection related to presence of

wound and tube.

• Risk for impaired skin integrity at tubeinsertion site

• Disturbed body image related to thepresence of tube.



Collaborative Problems/PotentialComplication

• Would infection, cellutitis, and leakage

• GI Bleeding

• Premature dislodgement of the tube.



Planning and goals

• Minimizing pain

• Preventing infection

• Maintaining skin integrity

• Enhancing coping

• Adjusting to change in body image

• Preventing complication.



Nursing Intervention

• Meeting nutritional needs

• Providing tube care and preventinginfection

• Providing skin integrity

• Enhancing body image

• Monitoring and managing potentialcomplication

• Promoting home and community-basedcare



Evaluation

1.Maintains adequate fluid balancea. Maintains or gains wg.

b. Has normal electrolyte values

c. Is adequately hydrated

2.Is free from infection and skin breakdown

a. Is afebrile

b. Has no drainage from the incisionc. Demonstrates intact skin surrounding the exit site.



3. Adjust to change in body imagea. Is able to discuss expected change

b. Verbalizes concerns

4. Demonstrate skill in tube care

a. Handles equipment competentlyb. Demonstrate how to maintain tube patency

c. Keeps an accurate record of I and O

5. Avoids complication

a. Inhibits adequate wound healingb. Has no abnormal bleeding from puncture site

c. Tube remains intact for the duration of therapy



Parenteral Nutrition

• PN is a method of providingnutrients to the body by an IV route.

• The nutrients are complex admixture

containing proteins, carbs, fats,electrolytes, vitamins, trace mineralsand sterile water in a single container.

• The goal of PN are to improvenutritional status, establish apositive nitrogen balance, maintainmuscle mass, promote wt. maintenanceor gain, and enhance the healingprocess.



Establishing (+) nitrogen balance

• PN solution can provide enough calories andnitrogen to meet the patient daily nutritionalneeds.

• When highly concentrated Dextrose isadministered, caloric requirements are satisfiedand the body uses amino acid for proteinsynthesis rather than for energy.

• Electrolytes such as Ca,P, Mg, NaCl areadded to the solution to maintain properelectrolyte balance and to transport glucose

and amino acid across cell membranes.



Clinical Indication

• The indication for PN include an inabilityto ingest adequate oral food or fluidsw/in 7days. Enteral nutrition should be

considered before parenteral supportbecause it assist in maintaining gutmucosal integrity and is typically

associated with fewer complication.

F l



Formulas

• A total of 1-3 L of solution isadministered over a 24-hrs period.Intravenous fat emulsion (IVFEs) may

be infused site and should not befiltered. Usually 500 Ml of a 10% IVFEis administered over 6-12 hrs, 1-3 timesa week. IVFEs can provide up to 30% of

the total daily calorie intake.

INDICATION FOR PARENTERAN NUTRITION



INDICATION FOR PARENTERAN NUTRITION

CONDITION OR NEED EXAMPLESInsufficient oral or enteral intake severe burns, malnutrition,short

bowel syndrome, AIDS,sepsis, cancer

Impaired ability to ingest or absorb paralytic ileus, Crohndisease,food orally or enterally short gut, postradiation

enteritishigh-output

enteroculataneousfistula

The pt. Is unwilling or unable to ingest major psychiatric illness

Adequate nutrients orally or enterally

Preoperative and postopetative nutritional extensive bowel surgery,nutritional needs are prolonged acute pancreatitis.



Initiating therapy

• PN solution are initiated slowly andadvanced gradually each day to thedesired rate as the patient’s fluid and

dextrose tolerance permits.

• A 24 hrs urine nitrogen determinationmay be prformed for analysis of

nitrogen balance

Ad i i t ti th d



Administration methods

1. Peripheral Method(PPN)

is administered through a peripheral vein; this ispossible because the solution is less hypertonic thanfull-calorie parenteral nutrition solution

lipids are administered simultaneously to buffer thePPN and to protect the peripheral veins fromirritation.

the usual length of therapy using PPN is 5-7 days





• Central method (CPN)• CPN have 5-6 times the solute concentration of

blood (and exert an osmotic pressure of about 2000mOsm/L), they are administered in to the vascular

sysytem through a catheter inserted into a high-flow,large, large blood vessel (eg, the subclavian vein).Concentrated solution are then very rapidly diluted toisotonic levels by the blood in this vessel.

Four types of central venous



Four types of central venousaccess devices (CVADs)

1. Nontunneled Central Catheters

-used for short term (less than 6 weeks)

-subclavian vein is the most common vessel

used-the jugular vein should only be used as a last

resort and then only for 1-2 days

-single lumen, double lumen, triple lumen central

catheters are available for central lines-distal lumen can be used for administration



• Peripherally Inserted CentralCatheters

• PICC- are used for intermidiate-term (several

days to months) IV therapy in the hospital, long termcare, or home care setting.

• The basilic or cephalic vein is accessed above theantecubital space, and the catheter is threaded to the

superior vena cava.

• Taking BP and blood specimens from the extrimitywith the PICC is avoided.



• Tunneled Central Catheters• Are for long term use and may remain in place for many

years.

• These catheters are cuffed and can have single or double

lumens; examples are the Hickmans, Groshong, andPermacath.

• There catheter are inserted surgically.

• They are threaded under the skin ( reducing the risk forascending infection) to the subclavian vein and advanced

into the superior vena cava.

implanted ports



implanted ports

- Used for long term IV therepy.

- The end of the catheter is attached to a smallchamber that is placed in a subcutaneous

pocket, either on the anterior chest wall or onthe forearm.

- More expensive than the external catheters,

and access requires passing a specialnoncoring needle through the skin into thechamber to initiate IV therapy.



Discontinuing Parenteral Nutrition

• PN solution is discontinued gradully to allow the patent to adjustto decrease level of glucose.

• If PN solution is abrupt terminated, isotonic dextrose can beadministered for 1-2 hrs to prevent rebound hypoglycemia.

• Once all IV therapy is completed, the nontunneled centralvenous catheter of PICC is removed and an occlusive dressingis applied to the exit site

• Tunneled catheters and implanted ports are removed only bythe physician.



Nursing Process:Patient Recieving PN

• ASSESSMENT• Nurse assist in identifying pt. unable to tolerate oral and enteral

feeding who may be candidates for PN

• Indicators include significant wg. loss (10% or morethan ofusual wg.),

• The nurse carefully monitors the pt. hydration status, electrolytelevels, and calorie intake.



DIAGNOSIS

• The major nursing diagnosis may include the ff.• Imbalanced nutrition, less than body requirements, related to

inadequate oral intake of nutrients

• Risk for infection related to contamination of the centralcatheter site of or infusion line

• Risk for imbalanced fluid volume related to altered infusion rate

• Anxiety related to catheter care and securement

Collaborative Problems/Potential



Collaborative Problems/PotentialComplication

Most common complication are:1.Pneumothorax

2.Embolism

3.Clotted cathter line

4.Catheter displacement and contamonation

5.Sepsis

6.Hyperglycemia

7.Fluid overload8.Rebound hypoglycemia.



Planning

• Major goals for the pt.• Optimal level of nutrition

• Absence of infection

• Adequate fluid volume• Optimal level of activity

• Knowledge of and skill in self-care

• Absence of complication

Nursing intervention



Nursing intervention

• Maintaining Optimal Nutrition

• Continuous, uniform infusion of PN solution over 24 hrs periodis desired

• The time periods for infusion are sufficient to meet the ptnutritional and pharmacologic needs

• Pt is initially weighted daily at the same of the day under thesame condition for accurate comparison

• Important to keep accurate I and O records and calcutaion offluid balance

• Calorie count is kept of any oral nutrients

• Trace elements are included in PN solution and areindividualized for each pt



Preventing Infection

• High dextrose and fat content of PN solution makes them anideal culture medium for bacterial and fungal growth andCVADs provide port of entry

• Meticulous aseptic technique is essential to prevent infection

any time the IV line setup is manipulated

• The primary source of microorganism for catheter related tobloodstream infections are the skin and the catheter

• The catheter site is covered w/ an occlusive gauze dressingthat is usually changed using sterile technique every 24-72 hrs



Maintaining Fluid

• To maintain an accurate rate of PN administration, an infusionpump is necessary

• Designed rate is set in mL/hr, and the rate is checked every 3-4hrs.

• If the rate is too rapid, hyperosmolar duiresis can occur

• If the flow rate is too slow , the pt does not receive the maximalbenefit of calorie and nitrogen.

• I and O are recorded q8



• Encourage Activity• With a catheter in the subclavian vein, the pt is free to move the

extremities, and normal activity should be encourage tomaintain a good muscle tone

Evaluation



Evaluation

• Expected Pt Outcomes• Attains or maintains nutritional balance

• Is free of catheter-related infection

a. is afebrile

b. Has no purulent drainage from the catheter insertion site• Is hydrated, as evidenced by good skin turgor

• achieve an optimal level of activity, within limitations

• demonstrates skill in managing PN regimen

• prevent complication a. Maintains proper catheter and equipment function

b. Maintains metabolic balance within normal limits

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Gastrostomy and Jejunostomy