Gastrostomy, Gastric-Jejunal and Jejunostomy Tube ... · Web viewOne of the cardinal signs of a leaking/misplaced tube is abdominal pain. If after insertion of a gastrostomy, gastric-jejunal

Gastrostomy, Gastric-Jejunal and Jejunostomy Tube – Nursing Management – Adults, Adolescents and Children (not Neonates).docx

Canberra Hospital and Health Services

Clinical Procedure

Gastrostomy, Gastric-Jejunal and Jejunostomy Tube – Nursing Management – Adults, Adolescents and Children (not Neonates)

Contents

Contents1

Purpose3

Alerts3

Scope4

Section 1 – General Information4

Section 2 – Gastrostomy, Gastric-Jejunal and Jejunostomy Tube and Stoma Care and Monitoring5

Section 3 - Decompression or Venting13

Section 4 - Measuring the Length of a Stoma Tract14

Section 5 – Flushing a Gastrostomy, Gastric-Jejunal and Jejunostomy Tube15

Section 6 – Feeding via a Gastrostomy, Gastric-Jejunal and Jejunostomy Tube in the Hospital19

Section 7 – Medication Administration in the Hospital22

Section 8 - Management of an Occluded Tube23

Section 9 – Planned Replacement of a Gastrostomy Tube25

9.1 General Information25

Section 10 – Gastrostomy Tube Replacement with an Indwelling Urinary Foley Catheter (IDC) - PEG or Balloon Gastrostomy Tubes Only28

Section 11 – Permanent Removal of a Gastrostomy, Gastric-Jejunostomy or Jejunostomy Tube31

Section 12 – Care in the Community and Discharge Planning32

Section 13 – Contacts for Further Information34

Implementation35

Related Policies, Procedures, Guidelines and Legislation35

References36

Definition of Terms37

Search Terms38

Attachments38

Attachment 1: Types of Gastrostomy Tubes, Initial Insertion, Planned and Unplanned Replacement39

Attachment 2: Types of Gastric-Jejunal, Jejunostomy Tubes, Initial Insertion, Planned and Unplanned Replacement41

Purpose

The purpose of this procedure is to outline the best practice for the nursing management of a patient with a gastrostomy, gastric-jejunal or jejunostomy tube.

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Alerts

ENFit

Only ENFit syringes should be used for water flushing or administering medication or feeds through a gastrostomy, gastric-jejunal or jejunostomy tube. ENFit connections have been introduced to reduce the risk of misconnections of enteral feeding tubing and syringes to non-enteral tubing. This a safety precaution to prevent medication and enteral feed administration errors which can result in poor outcomes (such as administration to catheters). If the patient’s gastrostomy/gastric-jejunal/jejunostomy tube requires an adaptor for ENFit use they can be sourced from the Acute Support Nutrition Department for in-patients and for community patients from the healthcare supplier listed in their nutrition and feeding tube plan prepared by the dietitian.

New, Sustained or Severe Abdominal Pain

One of the cardinal signs of a leaking/misplaced tube is abdominal pain. If after insertion of a gastrostomy, gastric-jejunal or jejunostomy tube the patient experiences new, sustained or severe abdominal pain, a surgical review is mandatory. A community patient must attend the Emergency Department (ED), an inpatient is reviewed in the hospital. If a patient complains of abdominal pain when feeding or flushing is commenced – the feed or flush must stop and a surgical review is mandatory. A computed tomography (CT) scan, may be needed to confirm correct tube position.

Concerns Post-Procedurally for CHHS Angiography Patients

If staff have concerns post-procedurally for CHHS Angiography patients, they can contact

Angiography Suite T: 6244 2804 business hours. After hours staff can contact the Radiology registrar via switchboard T: 6244 2222 and the registrar can escalate to the Radiologist on call if required. If staff are concerned with an urgent issue it is always appropriate to organise for the community patient to present to ED, an inpatient is reviewed in the hospital.

Inadvertent Removal of a Gastrostomy, Gastric-Jejunal or Jejunostomy Tube

If the tube is inadvertently removed a replacement tube should be inserted, ideally within 2 hours, otherwise the stoma will constrict, making replacement more difficult.

Gastrostomy Tube

If the initial gastrostomy tube has been in place for less than or equal to 12 weeks a Medical Officer (MO) should replace the tube. If the initial gastrostomy tube has been in place for greater than 12 weeks a MO, competent RN or trained family carer can replace the gastrostomy tube.

If the time between the original gastrostomy tube insertion and inadvertent removal is greater than 6 weeks but less than 12 weeks consider radiological intervention.

Community patients with a gastrostomy stoma less than or equal to 12 weeks from the original procedure should present to the Emergency Department for assessment promptly.

Gastric-Jejunal or Jejunostomy Tube

The patient should have a prompt medical review, the tube is usually replaced in the Radiology Department. Community patients should present to the Emergency Department for assessment promptly.

Bolus Feeding

Bolus feeding is unsuitable for a patient with a gastric-jejunal or a jejunostomy tube due to lack of reservoir capacity in the small bowel.


Scope

This clinical procedure applies to the following Canberra Hospital and Health Service staff working within their scope of practice:

· Nurses and midwives

· Students under direct supervision.


Section 1 – General Information

Gastrostomy, gastric-jejunal and jejunostomy tubes are inserted by a medical officer (MO).

Methods of insertion:

Endoscopic: using endoscope (e.g. Percutaneous Endoscopic Gastrostomy [PEG]and Percutaneous Endoscopic Gastrostomy Jejunostomy [PEG-J] tubes)

Radiological: radiologically/fluoroscopically/ultrasound/CT guided placement (e.g. Radiologically inserted gastrostomy (RIG) and radiologically inserted jejunostomy (RIJ) tubes

Surgical: via laparotomy or under laparoscopic guidance.

In most cases a RIG tube is replaced with a balloon gastrostomy tube in the Radiology Department. Ongoing balloon gastrostomy tube changes can be done by Registered Nurse (RN), MO or trained family carer at the bedside, in a clinic or home setting.


Section 2 – Gastrostomy, Gastric-Jejunal and Jejunostomy Tube and Stoma Care and Monitoring

· For the first 48 hours after initial tube insertion, the dressing should be kept dry and intact. If the site requires a dressing change during the first 48 hours use an aseptic technique to attend to the procedure. The patient can shower with the site uncovered 48 hours after initial insertion of the tube. No dressing is required after 48 hours, except for a Fresenius Kabi Freka jejunostomy tube. Refer to Section 2 Freka jejunostomy tube.

· Gastrostomy tubes are rotated 360 on a daily basis when pain free after initial insertion (unless secured by a statlock or similar device, sutures or specifically contraindicated).

· RIG Wills-Oglesby Gastrostomy (WOG), Gastric-Jejunal and Jejunostomy tubes are not rotated.

· The external flange is maintained ½ cm off the abdomen to prevent excessive tension between the internal retention device and the external flange. Ensure no pressure points develop on the abdomen under the external flange. If the patient’s weight changes, ensure the external flange is maintained ½ cm from the abdomen.

· Carefully handle the caps on the ports of the tube by gently squeezing the tube with pads of fingers below where the caps sits within the port of the tube and easing the cap off with pads of fingers with a gentle side to side movement.

· Move the clamp along a PEG tube to prevent compression of tubing through repeated use.

· Don’t bend a ‘long’ balloon gastrostomy tube to prevent leakage of gastric contents when the cap is removed for access, this may lead to tube breakage. Instead have all equipment on hand including a towel to protect the patient’s clothing, hold the tube upright, remove the cap, place a clean gloved thumb over the end of the tube or gently squeeze the tube closed with pads of fingers and access the tube as required.

· Keep the stoma and tube clean and dry. Clean the stoma and tube daily and more often if required.

· Even when a patient is ‘nil by mouth’ and receiving all of their nutrition and hydration via a feeding tube it is important that oral hygiene continues.

· Establish a system for monitoring bowel actions, urine output, hydration and weight in consultation with the dietitian.

2.1 Tube and Stoma Care

Equipment

Soft pre-moistened cloths (community only) and Alcohol Based Hand Rub (ABHR)

Personal protective equipment (PPE) including safety goggles or face shield, clean gloves and gown

Dressing pack

Normal saline 30 mL (at body temperature warmth)

Disposable sheet / bluey

Non transparent rubbish bag.

Procedure

1. Explain the procedure to the patient and obtain consent as per Consent and Treatment Policy on the policy register.

2. Attend to hand hygiene using soft pre-moistened cloths and ABHR.

3. Don safety eyewear and gown.

4. Set up equipment.

5. Place blue sheet to protect patient’s clothes.

6. Attend to hand hygiene and don gloves.

7. Inspect the surrounding skin for redness, tenderness, swelling, irritation, purulent drainage or gastric leakage.

8. Check that the tube is round, clean, not flattened, perished or dirty.

9. Use gauze soaked in normal saline in a spiral pattern beginning at the stoma site and moving outward. Clean any debris on the tube, external flange, adapter or caps. Gently pat dry with gauze or leave open to air dry. Alternatively the peristomal area can be cleaned with warm soapy water and a clean cloth, rinsed with clean water and dried with a clean cloth, this can be done in the shower.

10. Gently rotate the tube (PEG and balloon gastrostomy tubes only) 360 in the gastrostomy tract by rolling between thumb and index finger and rotating the tube.

11. Ensure the external flange is resting off the abdomen leaving ½ cm between the external flange and the abdomen. Maintain the flange at this position.

12. Discard equipment.

13. Remove PPE.

14. Attend to hand hygiene.

15. Document in the patient’s clinical record.

2.2 Gastrostomy Tube Position Check for ‘Long’ Gastrostomy Tubes Only, Excludes Self-Retaining Loop ‘Pigtail Catheters’

1. Move the external flange off the abdomen toward the y-port adapter.

2. Withdraw the tube gently until tension is felt as the internal bumper or balloon rests against the stomach wall.

3. Note ‘cm’ measurement closest to the skin and compare with the documentation in the patient’s clinical record.

4. Record the cm measurement in the patient’s clinical record on admission and on subsequent patient contacts.

5. If ‘cm’ markings are not visible, mark the tube with a permanent pen, (the mark may need to be reinforced regularly) and record the marking in the patient’s clinical record.

6. Alternatively the external portion of the tube can be measured. Withdraw the tube gently until tension is felt as the dome or balloon rests against the stomach wall. Measure the length of the tube from exit site to the top of the cap in the longest y-port of the adapter.

7. Record the length in the patient’s clinical record.

2.3 How to Move the External Flange

1. If the external flange is difficult to move away from the abdomen apply normal saline or water to tube where the external flange meets the tube.

2. Withdraw the tube gently until tension is felt as the internal retention dome or balloon rests against the stomach wall.

3. Note the cm marking on the tube at skin level.

4. Hold the flange in the non-dominant hand and the tube in the dominant hand.

5. Squeeze the sides of the tube together and push the tube through the centre of the flange allowing the tube to move into the stomach 2 to 3 cms via the stoma tract.

6. Withdraw the tube gently until tension is felt as the internal retention dome or balloon rests against the stomach wall.

7. If the external flange needs to be moved back further, there should be room between the abdomen and the skin flange to grasp the tube with the non-dominant hand and move the flange further away from the skin with the dominant hand.

8. Withdraw the gastrostomy tube gently until tension is felt as the internal retention dome or balloon rests against the stomach wall.

9. Position the external flange ½ cm from the abdomen. Maintain the external flange at this position.

2.4 Catheter Securement Device - Statlock Universal Plus Change

The statlock should be monitored daily and replaced every 7 days or sooner if it is lifting. The butterfly wings of the statlock can be trimmed to enhance patient comfort if required.

E.g. 8 cm

Base of Hub

Insertion

Site

At the first dressing/ statlock change and subsequent changes measure the length of exposed tube from the insertion site to the base of the ‘hub’ and compare with the original measurement recorded in the patient’s clinical record.

Picture 1 Measurement of the External Length of the Tube – Insertion site to base of the hub

Equipment

Soft pre-moistened cloths (community only) and ABHR

PPE including safety eyewear or shield and clean gloves

Alcohol swabs

Tape measure

Statlock - Universal Plus in the appropriate size


Non transparent rubbish bag

Scissors (to trim statlock if required)

Dressing pack (if required)

Normal saline (if required).

Procedure



3. Don safety eyewear.





8. Check that the tube is round and clean, not flattened or split.

9. Assess the position of the tube.

10. Statlock Removal:

a. Open the retainer by pressing the tab and lifting the lid.

b. Carefully lift the tube from the retainer.

c. Ensure the tube is secured to the patient with tape when the Statlock is removed

d. Use alcohol swabs to loosen edge of the pad. To dissolve the adhesive pad - hold the edge of the pad, while gently stroking the under surface of the pad with wipes or swabs. Slowly lift the pad away from the skin. Do not force the pad for removal.

11. Ensure the tube is secure by supporting the tube in place with the non-dominant hand to prevent tube dislodgement.

12. Measure the length of exposed catheter (see picture 1) and compare with the original measurement recorded in the patient’s clinical record. If the tube measures < 2 cm longer clean the tube at the insertion point with saline and gauze or mild soap and water and re-insert the tube to the recorded original measurement. If the tube measures > 2 cm contact the MO for advice.

13. Use gauze soaked in normal saline in a spiral pattern beginning at the stoma site and moving outward. Clean any debris on the tube or adapter with normal saline and allow to air dry. Alternatively the peristomal area can be cleaned with warm soapy water and a clean cloth, rinsed with clean water and dried with a clean cloth.

14. Statlock Application:

a. Trim the ‘butterfly wings’ of the Statlock if required.

b. Prepare the targeted securement site with alcohol swabs to degrease the skin. Allow to dry for 10-15 seconds. Then, apply skin prep swab for enhanced adherence and skin protection. Allow to dry for 10-15 seconds.

c. Wipe the tube with normal saline, water or an alcohol swab (to wet it for easier insertion into the StatLock retainer).

d. Always secure tube to Statlock before placing pad on the skin. Bring the Statlock anchor pad into position. Stabilise the tube between fingers and stretch the tube to fit into the retainer.

e. Close the lid.

f. Peel away the StatLock paper backing and place on skin.


16. Remove PPE.



2.4 Balloon Volume Checking

General Information

· In addition to anchoring the tube inside the stomach, the balloon helps keep the stoma from leaking.

· Check balloon volume every 7 days as small amounts of fluid are lost over time.

· An assistant may be necessary to reassure and stabilise the patient during the procedure.

· Check the tube manufacturer’s instructions for use for recommended balloon volume and capacity.

Equipment

· Soft pre-moistened cloths (community only) and ABHR

· PPE including safety eyewear or shield and clean gloves

· Syringe luer slip 10 mL x 2 (e.g. PICS Product ID: 10341)

· Sterile water ampoule

· Non transparent rubbish bag.

Procedure




4. Set up equipment. Draw up sterile water into the 10 mL syringe.

5. Attend to hand hygiene and don clean gloves.

6. Verify correct tube placement.


8. Check that the tube is round, clean, not flattened, perished or dirty.

9. Stabilise the tube with the non-dominant hand during the entire procedure.

10. Insert the first syringe gently with a ¼ twist to the balloon port, allow the syringe to fill, and then gently draw back on the syringe to ensure all the water has been removed from the balloon.

11. Disconnect the syringe and compare the amount of water in the syringe with the documented volume of water in the balloon.

12. If there is difficulty deflating the balloon:

a. Rotate the tube in the gastrostomy tract then try to empty the balloon again.

b. If this fails, using a luer slip syringe inject an additional 1-2 mL of water into the balloon access port to open the valve. Remove the piston from the syringe barrel. Insert the syringe tip into the balloon valve. Lay the syringe barrel in a clean container below the level of the balloon in the stomach for 5 minutes, to allow the water to drain from the balloon, while ensuring the gastrostomy tube is secure in place with the non-dominant hand. Measure the amount of water drained from the balloon and compare to amount of water instilled into the balloon, taking into account the addition of 1-2 mL of water.

13. Connect the second syringe to the balloon port and refill the balloon to stated amount.

14. Gently apply traction to the tube so that the balloon is snug but not tight against the stomach wall.

15. Ensure the external flange is resting off the skin leaving ½ cm between the flange and skin.


17. Remove PPE.


19. Document date and time the balloon was checked, amount of water removed and amount instilled in the balloon, in the patient’s clinical record.

2.6 Fresenius Kabi Freka Jejunostomy Tube

· The Freka jejunostomy tube is a 9 Fr jejunostomy feeding tube which is secured with a fixation plate and sutures. Most stitches become loose over time and need to be replaced. If this occurs secure the tube with heavy duty tape, don’t use the tube. The patient should have a medical review for replacement of the sutures promptly.

· The tube has a smaller Fr size smaller than other feeding tubes and needs to be carefully looked after so it does not block.

· Do not rotate the tube or advance the tube to avoid displacement.

· When a Freka jejunostomy tube is changed in the Radiology Department potentially the tube could be secured with a statlock rather than a fixation plate and sutures. If this is the case a dressing is not required and the site can be left open. Refer to Section 2 Statlock Universal Change.

Dressing and Tube Care

Equipment

Soft pre-moistened cloths (community only) and ABHR

PPE includes, safety goggles or face shield, clean gloves and gown

Dressing pack

Normal saline packaged 30 mL (at body temperature warmth)

Gauze (extra if required)

Occlusive dressings 10 cm by 12 cm (e.g. Tegaderm)

Tape measure

Securing tape



Procedure







7. Carefully remove the old dressing.


9. Check that the tube position and it is secured by sutures. Measure external length insertion site to the base of the hub on the tube and document in the patient’s clinical record. This measurement will be the initial measurement to be used as a baseline for checking against for ongoing external length measurements.

10. Remove gloves.


12. Use gauze soaked in normal saline in a spiral pattern beginning at the stoma site and moving outward. Clean any debris on the tube, fixation plate, adapter or caps. Gently pat dry with gauze or leave open to air dry. Cleaning under the fixation plate is usually not possible related to difficult access due to sutures.

13. Apply gauze over the tube insertion site and fixation plate and sutures to prevent the occlusive dressing adhering to the tube. Gauze may need to be placed under the coiled tube if required. Place the occlusive dressings over the gauze and insertion site. Ensure the tube is secured by the occlusive dressings and the dressing is waterproof.

14. Coil the tube and secure to the patient’s skin with tape.


16. Remove PPE.



Ongoing Care after 48 hours from Initial Insertion

The dressing is changed and the external length is measured and checked against the baseline measurement once per week and more often if the integrity of the dressing or seal is breached. More frequent dressing changes may be indicated if signs of infection are present.

2.7 Replacement of PEG Tube Y-Port Adapter

The PEG tube Y-port adapter can be replaced when broken. Patients should have a spare adapter on hand at all times in case the adapter needs to be replaced.

For adapter information:

· In-patients refer to the dietitian.

· Community patients, refer to the Nutrition and Tube Feeding Plan.

Equipment


· PPE including safety eyewear or shield and clean gloves

· Y-port adapter

· Scissors (optional)

· Disposable sheet / bluey


Procedure



3. Set up equipment. Ensure caps are closed on the new adapter.




7. Ensure clamp on PEG tube and caps on adapter are closed.

8. Remove broken adapter.

9. Trim 1 cm off the distal end of the PEG tube with scissors if worn or stretched.

10. Connect new adapter.


12. Remove PPE.


14. The PEG tube is ready for use immediately after adapter replacement.


2.8 Removal of a Gastropexy Suture Device

A patient may have a gastropexy suture “t-fastener” / “harpoon” or similar device which is a step in percutaneous radiologic gastrostomy in which the stomach is fastened to the abdominal wall with a gastropexy suture device.

Equipment

· Medical order documented in the progress notes or treatment order (community nursing only)


· PPE including safety eyewear or shield, clean gloves and gown

· Dressing pack

· Normal saline 30 mL (at body temperature warmth)

· Scissors – recommend to use scissors from a suture removal set



Procedure

1. Check medical order to remove the gastropexy suture device.







8. Inspect surrounding skin for redness, tenderness, swelling, irritation, purulent drainage or gastric leakage.

9. Carefully lift up the gastropexy suture device and cut the suture under the device/ foam piece / disc flush with the skin. Repeat this step if the more than one gastropexy suture device is in place. It may assist to ask the patient or an assistant to gently press down on the abdomen to make some room to access the suture.

10. Use gauze soaked in normal saline in a spiral pattern beginning at the stoma site and moving outward. Dry thoroughly with gauze.


12. Remove PPE.


14. Document in patient’s clinical record.


Section 3 - Decompression or Venting

Abdominal discomfort and bloating may be caused by excessive air/gas in the stomach. Decompression or venting will allow the air to escape. The decompression or venting process can be carried out as per the MO order before formula administration or as required.

Equipment




· Low Profile Devices:

· Bard Button – decompression tube extension set

· Halyard MIC-KEY Low Profile Balloon Gastrostomy Tube – bolus extension set

· Medtronic Kangaroo Low Profile Balloon – bolus extension set

· Medtronic Skin Level Cage - bolus feeding set

· Syringe 60 mL ENFit x 2

· Clean container of tap water (or sterile water if appropriate)

Process

1. Check medical order for decompression or venting.


3. Perform hand hygiene using soft pre-moistened cloths and ABHR.



6. Place blue sheets to protect patient’s clothes.



9. Ensure head of bed remains elevated both during and for 30 – 60 minutes post accessing the tube.

10. Draw up water flush into the 60 mL syringe. Remove the piston from the barrel of the 2nd 60 mL syringe.

11. Insert extension set into the low profile device (if applicable).

12. Remove the cap from the feeding port and attach the 2nd 60 mL syringe (barrel only) to the feeding port. 13. Lower the syringe below the stomach. Allow the stomach contents (froth may be present) to fill the syringe. Drain stomach contents back into the stomach by raising the syringe above the stomach. Disconnect the syringe barrel. 14. Flush the tube with 20 to 30 mL of water.15. Remove the extension set (if applicable).

16. Clean equipment. Wash and dry syringe(s) and store in clean container with a lid.

17. Remove PPE.




Section 4 - Measuring the Length of a Stoma Tract

The length of the gastrostomy tract can be measured using a stoma measuring device that is inserted into the stomach via the stoma. The length of the gastrostomy tract is the distance from the internal retention device to skin level as measured by the centimetre makings on the stoma measuring device. The stoma length measurement assists with fitting of a low profile/skin level gastrostomy tube.

See Section 9 - Planned Replacement of a Gastrostomy Tube for process for removing and replacing a gastrostomy tube.

Equipment


· PPE includes, safety goggles or face shield, clean gloves and gown

· Dressing pack


· Stoma measuring device (e.g. PICS 71353 Halyard MIC-KEY Stoma Measuring Device)

· Syringe luer slip 5 mL

· Water soluble lubricant



· Non transparent rubbish bag

Procedure



3. Set up equipment. Moisten the stoma measuring device with lubricant or water.



6. Position patient supine and flat.



9. Insert the measuring device through the stoma into the stomach.

10. Inflate the balloon with 5 mL of sterile water.

11. Gently pull the device away from the patient until you feel resistance against the abdominal wall.

12. Slide the plastic disc down to the stoma.

13. Read the measurement at the top of the disk. Adding 1 to 2 mm to the stoma length allows some movement for proper fit of the gastrostomy or gastric-jejunal tube.

14. Slide the disk up away from the stoma and raise the patient to an upright position. Slide the disk down to the stoma.

15. Read the measurement at the top of the disk.

16. Record the average of the two centimetre readings, this is the stoma length.

17. Deflate the balloon and remove the device.


19. Remove PPE.




Section 5 – Flushing a Gastrostomy, Gastric-Jejunal and Jejunostomy Tube

Alert

· If a patient complains of abdominal pain when flushing is commenced – the flush must stop and a surgical review is mandatory. A CT may be needed to confirm correct tube position.

· To reduce the risk of aspiration the patient must remain semi-upright (minimum 30°) during flushing and for 30 – 60 minutes after flushing.

· For adults with uncomplicated gastrostomy, gastric-jejunal or jejunostomy tube placement, water flushing can commence within 2 to 4 hours of the procedure as per the medical order or unless stated otherwise.

· For paediatrics patients a minimum of 4 to 6 hours is recommended post gastrostomy, gastric-jejunal or jejunostomy tube insertion before commencing the administration of water flushes as per the medical order or unless stated otherwise.

· Prior to administration of anything via a gastrostomy, gastric-jejunal or jejunostomy tube the external length of tubing (markings at skin level or measurement from insertion site to base of hub) is checked to ensure it has not changed since initial insertion (for non-skin level devices). For skin level devices check that the external base t-piece is sitting flush with the abdomen. If there is significant change the position of the device must be confirmed prior to use by consulting with a MO.

· The gastrostomy, gastric-jejunal or jejunostomy tube should be flushed with 50 mL of water (room temperature is recommended) at least once per day even if it is not being accessed for feeds or medications. The volume may need to be reduced for paediatric patients or patients on fluid restrictions or patients with a gastric-jejunal or jejunostomy tube, refer to the medical orders or nutrition plan.

Sterile water is recommended for water flushes for patients:

1. Who are immune compromised

2. In critical care

3. Under 12 months of age in hospital

4. Where the position of the tube or device is compromised (e.g. suspected buried bumper).

· Cooled boiled water can be used for flushing the tubes of children under 12 months of age who are being cared for at home, unless stated otherwise in the Nutrition Plan

· Tap water is acceptable for use in all other patient groups, including before and after formula and medication administration, unless stated otherwise in the nutrition plan

· Low profile tubes (Halyard MIC-KEY gastrostomy, gastric-jejunal and jejunostomy; Medtronic Kangaroo and Entristar; and Bard Button) all have compatible extension sets to access the tube. Refer to the manufacturer’s instructions for use for detailed information.

· Halyard MIC-KEY Low Profile Balloon Gastric-Jejunal feeding tube has two ports labelled ‘JEJUNAL’ and ‘GASTRIC’. The jejunal port is used for feeding into the small intestine and the gastric port is used to drain the stomach if ordered by the MO and to administer medications.

· Halyard Gastric-Jejunal ‘long balloon’ Feeding Tube has two ports labelled ‘JEJUNAL and ‘GASTRIC’. The jejunal port is used for feeding into the small intestine and the gastric port is used to drain the stomach if ordered by the MO and to administer medications.

Equipment


· PPE includes, safety goggles or face shield and clean gloves

· Container of water (or sterile water if appropriate)

· Syringe 60 mL ENFit

· Extension set (low profile tubes only)


Procedure





5. Draw up water into the syringe.




9. Assess the position of the tube.

10. PEG tube:

a. Close clamp on the tube.

b. Open cap on the adapter of the tube.

c. Connect the syringe with a ¼ turn and flush the tube with 50 mL of water.

d. Close clamp on the tube.

e. Disconnect the syringe.

f. Apply the cap to the adapter.

11. Long balloon, RIG and RIJ tube:

a. Open cap on the adapter of the tube.

b. Hold the tube upright and place gloved thumb over opening of adaptor to prevent gastric leakage.

c. Connect the syringe with a ¼ turn and flush the tube with 50 mL of water

d. Disconnect the syringe.

e. Place gloved thumb over opening of adapter to prevent gastric leakage.

f. Apply the cap to the adapter.

12. Low profile tube:

a. Prime extension set if required, close the clamp.

b. Open cap on the tube.

c. Connect extension set as per manufacturer’s instructions for use.

d. Connect the syringe with a ¼ turn, open the clamp and flush the tube with 50 mL of water.

e. Close the clamp.

f. Disconnect the syringe.

g. Disconnect the extension set as per manufacturer’s instructions for use.

h. Close the cap on the tube.


14. Remove PPE.




Section 6 – Feeding via a Gastrostomy, Gastric-Jejunal and Jejunostomy Tube in the Hospital

Alerts

· If a patient complains of abdominal pain when feeding is commenced – the feed must stop and a surgical review is mandatory. A CT may be needed to confirm correct tube position.

· To reduce the risk of aspiration the patient must remain semi-upright (minimum 30°) during feeding and for 30 – 60 minutes after feeding.

· Bolus feeding is unsuitable for a patient with a gastric-jejunal or a jejunostomy tube due to lack of reservoir capacity in the small bowel.

· For adults with uncomplicated gastrostomy, gastric-jejunal or jejunostomy tube placement, enteral feeding can commence within 2 to 4 hours of the procedure as per the medical order or unless stated otherwise.

· For paediatrics patients a minimum of 4 to 6 hours is recommended post gastrostomy, gastric-jejunal or jejunostomy tube insertion before commencing the administration of enteral tube feeds as per the medical order or unless stated otherwise.

6.1 Storage and Management of Feeds and Feeding Sets

Store opened (seal broken) bags/containers of feed in the refrigerator when not being used.

Discard after 24 hours once opened or according to manufacturer’s instructions.

Recommended hang times:

Ready to hang closed system packs or bottles can hang for 24 hours at room temperature.

Ready to hang systems used for bolus feeding can be stored in the refrigerator between uses with line remaining connected.

Decanted systems or feeds prepared from powder- 4 hrs at room temperature.

Replace plastic containers and enteral feeding giving sets every 24 hours. Feeding containers, giving sets and syringes are for single patient use only.

Equipment

Syringe 60 mL ENFit

Measuring jug

Enteral feed giving set and pump

Prescribe feed formula


PPE includes, safety goggles or face shield and clean gloves.

Procedure

1. Undertake positive patient identification as per the Patient Identification and Procedure Matching Procedure on the policy register.

2. Immediately prior to administration check formula matches the dietitian feed order and check the formula expiry date.

3. Prior to bolus feed or on transfer from another clinical area, check the position of the feeding tube according to when it was originally inserted.

4. Patient Preparation

· Inform patient of the purpose and method of the feeding regime

· Place patient in 30 – 45 degree position during the administration of entire feed and for 30 – 60 minutes once feed completed

· Attend to hand hygiene and don gloves.

5. Follow the administration of the feed as ordered.

6.2 Administration of a Feed via Enteral Feed Connection Set and Pump (if ordered by Dietitian)

Refer to manufacturer’s instructions for feed pump operation.

Attend to hand hygiene, don safety eyewear and gloves.

Using a non-touch technique, connect the enteral feed giving set to the formula and the tube.

Ensure connections are secure. Refer to Dietitian order and administer amount according to orders.

On completion of feed flush tube with ordered volume of water.

Re-check position of the feeding tube.

Following administration, replace cover to the end of giving set and hang end over intravenous pole.

Enteral feeding giving sets should be changed every 24 hours.

Remove PPE and attend to hand hygiene.

6.3 Administration of a Feed via Bolus Gravity Method and ENFit Syringe (if ordered by Dietitian)


Using a non-touch technique, remove plunger from the barrel of the syringe connect the barrel of the syringe to the feeding tube.

Ensure connections are secure.

Refer to dietitian order and administer amount according to orders.

Ensure fluid is administered by gravity – DO NOT PUSH FLUID into feeding tube.

On completion of feed flush feeding tube with ordered volume of water (minimum 30 mL).


6.4 Administration of a Feed via Bolus Push Method and ENFit Syringe (if ordered by Dietitian)


Using a non-touch technique, connect the ENFit syringe to the feeding tube.


Refer to dietitian order and administer amount according to orders.

Ensure fluid is administered by a slow push into feeding tube.

On completion of feed flush feeding tube with ordered volume of water (minimum 30 mL).


6.5 Administration of Continuous Feeding via Enteral Feed Connection Set (if ordered by Dietitian)


Using a non-touch technique, connect the enteral feed giving set to the formula, enteral pump and feeding tube.


Refer to Dietitian order and administer amount according to orders.

On completion of feed flush the feeding tube with ordered volume of water.


Discard equipment after 24 hours.

6.6 Monitoring for Signs of Aspiration

Observe patient for signs of respiratory distress, including dyspnoea; tachypnoea; wheezing; agitation & cyanosis.

If above present, stop feed and inform MO.

Ensure head of bed remains elevated both during and for 30 – 60 minutes post administration of feed.

6.7 Feed Intolerance

Review/assess/observe patient for:

Nausea and vomiting

Diarrhoea and constipation

Complaints of bloating/fullness

Abdominal distension

Absent bowel sounds (not always reliable)

Document all instances of the above in the patient’s clinical record. Refer all instances of above to MO and Dietitian as feeds may need to be reduced or altered.

6.8 Documentation

Record observations (external tube measurement, aspirate amount and degree patient positioned) in the patient’s clinical record.

Record input and aspirate amounts (if discarded) on appropriate documentation.

Document an evaluation of the patient’s tolerance to the feeding regime and other management issues in the patient’s clinical record.


Section 7 – Medication Administration in the Hospital

DO NOT add medications to the feed formula container.

Use a liquid form or dispersible form of medications where available.

Crush appropriate medications finely and dissolve in warm water.

Empty contents of appropriate capsules into water and dissolve.

Flush the tube with water prior to medication administration.

Flush the tube between each medication and after the last medication then recommence feed.

If the patient has a gastric-jejunal tube insitu confirm with the MO and Pharmacist which port (gastric or jejunal) each medication needs to be administered through.

Equipment

ABHR

PPE includes, safety goggles or face shield and clean gloves

Syringe x 2 either 60 mL or 20 mL for flush

Syringe 20 mL ENFit for medication

Tap water (or sterile water if appropriate) - room temperature for flush

Cup

Prescribed medication.

Alert

Some medications cannot be crushed, including slow release and enteric coated medications. Check the Australian Don’t Rush to Crush Handbook or check with the pharmacist if unsure. If crushed and given down the tube there is a high risk of tube blockage as well as interference with medication dispersion, uptake and correct dosage.

Procedure

1. Check medication order.

2. Attend to hand hygiene by either hand washing or using ABHR.

3. Ensure privacy and undertake positive patient identification as per the Patient Identification and Procedure Matching Procedure on the policy register.

4. Explain the administration process and purpose of the medication.

5. Obtain verbal consent as per Consent and Treatment Policy on the policy register.

6. Attend hand hygiene by hand washing or using ABHR.

7. Gather equipment and medication.

8. Attend hand hygiene by hand washing or using ABHR.


10. Draw up water into syringe (x 2 flushes).

11. Ensure the 5 rights of medication administration are followed as per the Medication Handling Policy on the policy register.

12. Check the expiry date of the medication.

13. Dissolve the medication in water (or as per product advice/pharmacy advice).

14. Draw up the medication in 20 mL syringe.

15. Confirm patient identity by asking their name and checking the identification band.

16. Confirm allergies.

17. Attend hand hygiene by either washing hands or using ABHR.

18. Don gloves.

19. If attached to a continuous feeding, pause pump for medication administration.

20. Disconnect enteral feeding line or drainage bag.

21. Perform flush procedure.

22. Connect the syringe with medication to tube.

23. Slowly inject the medication down the tube.

24. Perform flush procedure.

Alert:

A patient with a drainage bag attached must have the drainage bag removed and the tube capped for 30 minutes post medication administration.

25. Discard equipment into clinical waste receptacle.

26. Remove PPE.


28. Document the administration on the patient's medication chart.

29. Report any abnormal findings to the MO.


Section 8 - Management of an Occluded Tube

Alert

It is not recommended to attempt to clear blocked tubes using carbonated beverages such as coke, as they are acidic and can cause precipitation/coagulation of the feed.

Equipment



· Syringe 60 mL ENFit

· Water (or sterile water if appropriate) room temperature

· Syringe 2, 5 or 10 mL luer lock (Cook RIG/RIJ only)


· Activated Pancreatic enzyme solution if required

· Sodium bicarbonate if required


· Clean container to expel flush solution

· Non transparent rubbish bag

Procedure




4. To reduce the risk of aspiration the patient should sit up at a 30ᴼ angle or more during and for 30 to 60 minutes after the procedure.

5. Place disposable sheet to protect patient’s clothes.



8. Check for any ‘kinks’ or a closed clamp on the tube.

9. If able to stabilise the tube at the insertion site with one hand, squeeze and rub the tube between the index finger and thumb of the other hand, starting at the insertion site and working all the way back towards the open end of the tube. It may be necessary to repeat this several times to express all the occluding material.

10. Connect extension set (low profile tubes only).

11. Aspirate the tube with a 60 mL syringe to remove as much liquid as possible from within the tube.

12. Attempt tube irrigation with warm water in a 60 mL syringe by injecting and aspirating sequentially (using a back and forth motion) to remove particles of coagulated feeding formula or medication from the tube. Repeat the irrigation attempts with water at room temperature in a 60 mL syringe, and then reattempt flushing of the tube with water at room temperature in a 60 mL syringe.

13. If the tube remains blocked, leave the warm water in the tube for 5-15 minutes. Then try to flush the tube again.

14. If this method fails, put the patient in a different position and try again.

15. Cook RIG/RIJ only remove red adapter and connect 2, 5 or 10 mL luer lock syringe directly onto the tube and follow steps from 11.

16. Remove and dispose of gloves.


18. If there is little or no movement within the tube on flushing attempts following the previous tube manipulation and irrigation procedure, the likelihood of restoring patency is limited. Activated Pancreatic Enzyme Solution instillation may be ordered. At least 5 mL solution instillation in the tube (without leakage) is required. A medical order is required. If not using Activated Pancreatic Enzyme Solution go to step 25.

19. Activated Pancreatic Enzyme Solution Instillation

· Obtain script for Pancrease (“Creon”) capsules (Lipase 5600 BPU, protease 350 BPU amylase 3200 BPU) x 2, and Sodium Bicarbonate 840mg.

· Check for contraindications to Pancreatic Extract e.g.: allergies to drug constituents, allergies to pork products. Check for lifestyle choices that may influence patient consent to use of substance e.g. Vegetarian/ Vegan or Muslim/Jewish.

20. Prepare Solution

a. Attend to hand hygiene.

b. Open and empty out the contents of two Pancrease capsules and finely crush the granular contents in a pestle and mortar.

c. Open and empty the powder contents of one 840 mg Sodium Bicarbonate capsule into the mortar.

d. Combine the powdered drug constituents in a mortar and add 5 mL of tap or sterile water as required. Vigorously mix and stir with the hub of a 60 mL syringe to break up any clumps.

e. When the solution is mixed, and no clumps or sediment remain, draw up in the 60 mL syringe.

21. Solution Instillation

a. Attend to hand hygiene

b. Don PPE – safety eyewear, gown and gloves.

c. Attach the 60 mL syringe containing the solution to the tube and holding the connection point firmly together to prevent leakage, instil 5 mL solution (or as much as possible) into the tube.

d. Close the cap on the tube to hold the solution within the tube.

e. Leave the tube capped for 45 – 60 minutes.

22. Replace adapter to the end of the tube (Cook RIG /RIJ only).

23. Disconnect extension set (low profile tubes only).

24. If the tube has been unblocked flush the tube with water and go to step 26.

25. If the tube remains blocked:

· Balloon gastrostomy tube with a mature gastrostomy tract (12 weeks or longer since initial gastrostomy insertion) can be changed by a MO, competent RN or trained family carer. Refer to Section 9 Planned Replacement of a Gastrostomy Tube.

· If the gastrostomy tract is immature (less than 12 weeks since initial gastrostomy tube insertion), other types of gastrostomy tubes and Gastric-Jejunal and Jejunostomy Tubes will all require a medical review.

· In-patients - organise for the patient to have a medical review in hospital.

· Community patients – advise the patient to proceed to the ED promptly for assessment.


27. Remove PPE.




Section 9 – Planned Replacement of a Gastrostomy Tube

9.1 General Information

· Usually the initial RIG is replaced with a ‘long’ balloon gastrostomy tube 14 Fr in the Radiology Department, ongoing tube changes can be done at the bedside, in the clinic or home setting.

· The method of removing and replacing a gastrostomy tube depends on its type:

· PEG tubes are removed in the Endoscopy Unit and replaced with a balloon gastrostomy tube.

· Balloon gastrostomy tubes can be changed at the bedside, in the clinic or in the home setting.

9.2 Replacement of a Balloon Gastrostomy Tube

· If the initial gastrostomy tube has been in place for less than or equal to 12 weeks a MO should replace the tube. If the initial gastrostomy tube has been in place for more than 12 weeks a MO, competent RN or trained family carer can replace the gastrostomy tube.

· A medical order is not required to replace a balloon gastrostomy tube in the community.

· The patient should fast for 2 hours prior to the procedure.

· Patients in the community are to provide their replacement balloon gastrostomy tube. Refer to Nutrition and Tube Feeding Plan for tube information. It is recommended the patient has 2 spare balloon gastrostomy tubes on hand at all times.

Equipment



· Dressing pack




· pH graded paper (PICS Product ID: 58034)

· Syringe 10 mL luer slip x 2 [e.g. PICS Product ID: 10341]

· Syringe 60 mL ENFit x 2

· Water flush or (sterile water if appropriate) room temperature

· Balloon gastrostomy tube the same Fr size as the tube in place


· Water-soluble lubricant


Procedure



3. Place patient semi-upright (minimum 30ᴼ) during the procedure.





8. Draw up sterile water into the 10 mL syringe for balloon inflation.

9. Draw up water flush into the 60 mL syringe.

10. Prepare balloon gastrostomy tube:

a. Confirm the correct size of the replacement tube.

b. Close the caps on the tube.

c. Check the amount of water required for balloon inflation on the balloon access port. Using the 10 mL syringe inflate the balloon with the prescribed amount of sterile water. If the balloon is asymmetrical, roll it gently between your fingers until the balloon frees itself, check for leakage. Deflate the balloon.

d. Establish the depth to which the new long balloon gastrostomy tube requires insertion:

i. Gently apply traction to the tube in place so that the balloon is snug but not tight against the stomach wall, next examine and note the cm mark at skin level on the tube

ii. Add 3 cm to the cm mark at skin level, this is the depth the new long tube is inserted before inflating the balloon. Move the external flange on the new tube to this mark

e. Lubricate the tube tip only with water-soluble lubricant.



13. Slide the external flange (long balloon gastrostomy tubes only) away from the stoma.

14. Clean the stoma with gauze soaked in normal saline.

15. Apply water-soluble lubricant to the base of the gastrostomy tube insitu. The lubricant can then be worked into the stoma by moving the tube in-and-out of the gastrostomy tract and rotating the tube 360.

16. Deflate the balloon of the tube insitu with the syringe.

17. Apply counter pressure by placing the non-dominant hand on the patient’s abdomen at the base of the gastrostomy tube to support the abdomen.

18. Grasp the gastrostomy tube close to the stoma with the dominant hand. Apply slow, deliberate traction in a twisting motion when removing the gastrostomy tube until the tip with the deflated balloon emerges through the stoma. Avoid sudden pulls.

19. Check the gastrostomy tube is intact.

20. Clean the area with gauze soaked in normal saline in a spiral pattern beginning next to the stoma site and moving outward. Dry thoroughly with gauze.

21. Lubricate the stoma with water-soluble lubricant.

22. Gently insert the new gastrostomy tube with a slight twisting motion into the stoma at a 90 angle through the tract into the stomach to the external flange (the established depth for balloon inflation) or to the external base T-piece low profile tube. If any resistance is felt ask the patient to relax by taking a deep breath (this may assist in relaxing the stoma) and continue the insertion using a slight twisting motion, next try to dilate the stoma by gently probing it with the tip of the lubricated new gastrostomy tube. If further resistance is felt stop the procedure and advise the patient to proceed to ED immediately for assessment and gastrostomy tube insertion (community patients only). For in-patients, seek MO advice.

23. Inflate the balloon with sterile water to the stated amount.

24. Check placement by a pH strip test:

a. Using the 60 mL syringe, aspirate the tube. Low profile gastrostomy tube will require the application of a compatible extension set. Positioning the patient on their left side usually aides obtaining an aspirate.

b. Place aspirate in a clean container.

c. Observe the aspirate colour.

d. Place the pH-graded paper in the aspirate.

e. Observe the pH-graded paper for a pH of 5 or less to indicate correct position in the stomach. Note the pH could be above 5 if the patient is on acid suppression medication or continuous enteral feeding.

f. If there are any concerns regarding correct position of tube organise for a medical review before the tube is accessed for feeds, flushes or medications.

25. Clean the area with gauze soaked in normal saline in a spiral pattern beginning next to the stoma site and moving outward. Dry thoroughly with gauze.

26. Gently apply traction to the tube so that the balloon is snug but not tight against the stomach wall.

27. Rotate the tube 360 and move in/out ½ cm of the gastrostomy stoma tract.

28. Slide the external flange toward the abdomen allowing ½ cm space between the abdomen and the skin flange and check cm marking at skin level on the tube (long balloon gastrostomy tubes only).

29. Flush the gastrostomy tube with 50 mL of water. Low profile gastrostomy tubes will require the insert of the extension set into the tube to do this.


31. Patient must remain semi-upright (minimum 30o) for 30 - 60 minutes after the procedure.

32. Remove PPE.


34. Document the change procedure noting the manufacturer, type and Fr size, length of stoma low profile gastrostomy tubes only, Lot number of the replacement tube, pH of gastric aspirate, skin condition, cm marking at skin level (long balloon gastrostomy tubes only), amount of water in the balloon, recommended date for next tube change (usually every 6 months) and patient tolerance of the procedure in the patient’s clinical record. Some manufacturers supply peel away labels on the tube packaging which can be placed in the paper based patient’s clinical record.

35. Feeding and medications can be commenced immediately after the tube is replaced and correct position confirmed.


Section 10 – Gastrostomy Tube Replacement with an Indwelling Urinary Foley Catheter (IDC) - PEG or Balloon Gastrostomy Tubes Only

General Information

If the gastrostomy tube has been accidentally removed, it should be replaced with the same Fr size as the gastrostomy tube previously in place within 2 hours to preserve the gastrostomy tract.

If the initial gastrostomy tube has been in place for less than 12 weeks a MO should replace the tube. If the initial gastrostomy tube has been in place for more than 12 weeks a MO, competent RN or trained family carer can replace the IDC gastrostomy tube.

If a PEG or balloon gastrostomy tube has accidently been removed, and the patient does not have a spare tube on hand, an IDC can be used as a temporary gastrostomy tube. The practice is not recommended for RIG, the patient should attend ED promptly.

A few community patients use an IDC as a permanent gastrostomy tube, as prescribed by the hospital treating team. The tube is usually changed every 3 to 6 months. The patient provides their replacement IDC. It is recommended the patient has 2 spare IDCs on hand at all times.

Educate the patient and/or carer to apply gentle traction to the gastrostomy tube IDC so that the balloon is snug but not tight against the stomach wall before accessing the tube each time for flushes, formula and medication administration.

Check IDC packaging for volume of water required to fill the balloon.

Check the balloon volume every 7 days.

Equipment

Soft pre-moistened cloths and ABHR

PPE including safety eyewear or shield, clean gloves and gown

Dressing pack

Normal saline 30 mL (at body temperature warmth)

Sterile water ampoule

IDC the same Fr size as the prescribed gastrostomy tube

Catheter spigot (e.g. PICS ID: 10434)

Tape measure

Marking pen

Heavy duty tape

Scissors

Syringe luer slip x 2 [e.g. PICS ID: 10341]

Syringe 60 mL ENFit x 2

Water flush (room temperature)

Water soluble lubricant

pH graded paper (e.g. PICS Product ID: 58034)



Procedure



3. Place patient semi-upright (minimum 30ᴼ) during the procedure.





8. Draw up sterile water into the 10 mL syringe for balloon inflation.

9. Draw up water flush into the 60 mL syringe.

10. Prepare the IDC – confirm the correct size of the replacement IDC. Check the amount of water required for balloon inflation on the IDC packaging. Insert the spigot into the IDC.

11. To develop a ‘stopper’ to prevent the catheter moving into the stomach, mark the IDC with a pen at 8cm (patient less than 8 years) and 10cm (patient 8 years and older) from the tip. Wrap a piece of heavy duty tape 40cm long around the catheter just above the mark forming a ‘stopper’.

12. Apply water-soluble lubricant to the tip of the IDC.

13. Attend to hand hygiene and don clean gloves.


15. Clean the stoma with gauze soaked in normal saline if necessary.

16. Lubricate the stoma with water-soluble lubricant.

17. Gently insert the IDC into the stoma with a slight twisting motion at a 90 angle through the gastrostomy tract into the stomach. Advance the IDC further into the gastrostomy tract stopping 2cm below the ‘stopper’.

18. Inflate the balloon with sterile water to the stated amount.

19. Check placement by a pH strip test:

a. Using the 60 mL syringe, aspirate the tube. Positioning the patient on their left side usually aides obtaining an aspirate.

b. Place aspirate in a clean container.

c. Observe the aspirate colour.

d. Place the pH-graded paper in the aspirate.

e. Observe the pH-graded paper for a pH of 5 or less to indicate correct position in the stomach. Note the pH could be above 5 if the patient is on acid suppression medication or continuous enteral feeding.

f. If there are any concerns regarding correct position of tube organise for a medical review before the tube is accessed for feeds, flushes or medications.

20. Apply gentle traction to the IDC so that the balloon is snug but not tight against the stomach wall.

21. Clean stoma with gauze soaked in normal saline.

22. Withdraw the IDC gently until tension is felt as balloon rests against the stomach wall. Measure:

a. The distance the base of the ‘stopper’ is positioned above skin level.

b. The external portion of the IDC from exit site to the top of the spigot.

c. Record both lengths in the patient’s clinical record.

23. Rotate the tube 360 and move in/out ½ cm of the gastrostomy tract.

24. Remove the spigot and flush the IDC with 50 mL of water. Reinsert the spigot.


26. Patient must remain semi-upright (minimum 30ᴼ) for 30 – 60 minutes after the procedure.

27. Remove PPE.


29. Feeding and medications can be commenced immediately after tube replacement and correct position confirmed.

30. Document change procedure noting manufacturer, type and Fr size of IDC, pH of gastric aspirate, skin condition, the number of cm the ‘stopper’ is positioned above skin level and the external length of the IDC, amount of water in the balloon, patient tolerance of the procedure and recommended date for next tube change (usually in 3 – 6 months) in the patient’s clinical record.


1.

Section 11 – Permanent Removal of a Gastrostomy, Gastric-Jejunostomy or Jejunostomy Tube

A medical order (treatment order for community patients) is required prior to the permanent removal of a gastrostomy, gastric-jejunal or jejunostomy tube.

The method for removal depends on the type of tube (see Table 1 and 2).

Once the tube is removed the tract should close within 2-4 days. If the tract does not heal within 1 week, or there is an output from the tract, refer the patient for a medical review.

Patients can eat and drink straight away after removal of the gastrostomy tube.

Before removing a gastric-jejunostomy or jejunostomy tube check with the MO when the patient can eat and drink after removal of the tube.

A patient with a Fresenius Kabi Freka Jejunostomy Tube may require a 12 hour fasting period after tube removal. The patient may require hospital admission for IV hydration and medications during this period.

Equipment

· Medical order documented in the progress notes or treatment order (community nursing only)



· Dressing pack


· Scissors – recommend to use scissors from a suture removal set (Cook Wills-Oglesby Gastrostomy and Shetty Gastro-jejunal tube; and Fresenius Kabi Freka Jejunostomy Tube)

· Syringe 10 mL luer slip (balloon gastrostomy tube only)

· Island dressings



Procedure

1. Check medical order to remove the tube.








9. RIG Wills-Oglesby Gastrostomy and Shetty Gastro-jejunostomy tube -

a. Remove the tube from the statlock.

b. Remove statlock from the abdomen.

c. Split the distal end of the rubber sheath with scissors then undo the thread to release the curled ‘pigtail’ tube tip.

10. Balloon gastrostomy tube only, deflate the balloon of the tube insitu with the syringe.

11. Apply counter pressure with the non-dominant hand. Remove the tube by withdrawing the tube until the tip of the tube emerges through the stoma.

12. Inspect the tube to ensure it is intact.

13. Use gauze soaked in normal saline in a spiral pattern beginning next to the stoma site and moving outward. Dry thoroughly with gauze.

14. Apply island dressing.


16. Remove PPE.


18. Document in patient’s clinical record including observation of the condition of the tip of the tube.

19. Community patients - educate patient and/or carer to remove the dressing before showering, wash area with mild soap and water, rinse and dry well with a clean towel. Leave area open if stoma site is clean and dry. If stoma site is moist, continue daily dressings until the stoma is clean and dry. Inpatients – daily dressings until the area has healed.


Section 12 – Care in the Community and Discharge Planning

Care in the Community

The patient and/or carer are responsible for management of the gastrostomy, gastric-jejunal or jejunostomy tube in the community on a 24 hour basis. Self-management includes enteral formula and medication administration, water flushes, stoma and tube care and troubleshooting.

The patient and/or carer are assessed prior to the insertion of the gastrostomy or jejunostomy tube for the capacity and suitability to manage the tube including enteral formula and medication administration, water flushes as well as patency and security of the tube and troubleshooting in the home environment. Education and support is provided to ensure independence in tube management. The patient and/or carer is educated by hospital clinicians on the key management points prior to discharge from the hospital.

Discharge Planning

Patients aged 18 years or older are referred by the discharge liaison nurse/care coordinator to community nursing for gastrostomy, gastric-jejunal or jejunostomy tube support and monitoring through Community Health Intake (CHI) (ACT residents only) or the local area health service (interstate residents).

Patients under 18 years of age in the community are supported by Paediatrics at Centenary Hospital (PatCH). When the patient is approaching 18 years of age PatCH transitions the patient to The Canberra Hospital Gastroenterology & Hepatology Unit and puts in a referral via CHI to community nursing if required (e.g. for planned balloon gastrostomy tube changes if the patient/family carer are unable or unwilling to change the tube). The patient is to provide replacement gastrostomy tubes on an ongoing basis. It is recommended to have 2 spare gastrostomy tubes on hand at all times.

Patients require referral to an appropriate dietetic service for nutrition assessment, advice and ongoing management. Patients aged 18 years or older are referred via CHI to Community Care Nutrition (ACT residents only) or the local area health service (interstate residents). Patients under 18 years of age are managed by The Canberra Hospital Acute Support Nutrition paediatric dietitians.

Information provided by the Discharge Liaison Nurse/Care Coordinator to Community Nursing - Required for Transfer of Care from Hospital to the Community

Tube type:

Manufacturer:

Fr size:

Stoma length: cm

Jejunal length: cm

External length (insertion site to base of hub): cm

Volume of water in balloon: mL Date of last balloon volume check:

Insertion date:

Last change date:

Next planned change date:


Section 13 – Contacts for Further Information

Canberra Hospital and Health Services

ACT Equipment Loan Service (ELS)

T: 6207 0658 F: 6205 2604 E: [email protected]

Address: 37 Kingsmill Street Kambah ACT 2902

Office hours for collection and return of equipment are Monday to Friday 08:30am – 5.00pm, Saturday and Sunday 11:00am – 12:00pm. Collection is subject to prior confirmation by ELS Staff that the requested equipment is available.

Canberra Hospital

T: 6244 2222 (switch)

Canberra Hospital Medical Imaging Angiography Suite

For community patients only, all referrals are to be faxed by the General Practitioner to the Angiography Booking Clerk F: 6244 2494. The Angiography Booking Clerk is available to process referrals during business hours. It is recommended to follow up the fax with a telephone call to T: 6244 4374 (business hours) to confirm the booking.

Angiography Suite T: 6244 2408 (business hours).

Medical Imaging Main Reception T: 6244 2159 for general enquiries.

For patients treated at other acute care facilities the treating MO should be contacted for enquiries.

Community Care Program Nutrition

Via Community Health Intake (CHI) T: 6207 9977

Canberra Hospital Nutrition Department

T: 6244 2211

E: [email protected]

Location: Building 15, level 2

Community Health Intake (CHI)

T: 6207 9977

F: 6205 2611

E: [email protected]

Health Care Suppliers

Bard Medical

Customer Service T: 1800 257 232

Cook Medical


Fresenius Kabi


Halyard


Medtronic


Resources

*PICS Product ID

Unit of Issue

Description

37560

Box/25

Statlock Universal Plus, 6-8.5 Fr, small

37561

Box/25

Statlock Universal Plus, 10-12 Fr, medium

37562

Box/25

Statlock Universal Plus, 12-14 Fr, large

37563

Box/25

Statlock Universal Plus, 14-16 Fr, extra large

44831

Box/5

Cook Enteral Feeding Adapter Male Luer Lock–Red Code: FTA-MLLA-R

ACT Health Supply Services - *Purchasing and Inventory Control System (PICS)


Implementation

This procedure will be communicated to relevant staff via team meetings, and will be incorporated into existing education and training programs.

The procedure will be available on the ACT Health policy register on SharePoint.


Related Policies, Procedures, Guidelines and Legislation

Legislation

· ACT Medicines, Poisons and Therapeutic Goods Act 2008

· ACT Medicines, Poisons and Therapeutic Goods Regulation 2008

· Health Practitioner Regulation Law (ACT) Act 2010

· Work Health and Safety Act 2011

Policies

· ACT Health Nursing and Midwifery Continuing Competence Policy and Standard Operating Procedure

ACT Health Waste Management Policy

· CHHS Patient Identification and Procedure Matching Policy

Consent and Treatment Policy

· Medication Handling Policy

Procedures

· ACT Equipment Loan Service Procedure

· Aseptic Non Touch Technique Procedure

· Community Care Program Referral Management

· CHHS Healthcare Associated Infections Clinical Procedure

· CHHS Clinical Procedure Nasogastric Tube (NGT) Management – Adults only


References

1. Agency for Clinical Innovation (ACI) and the Gastroenterological Nurses College of Australia (GENCA).

A Clinician’s Guide: Caring for people with gastrostomy tubes and devices:

a. From pre-insertion to ongoing care and removal. 2015.

b. Key Principles and Practice Points. 2014.

c. Frequently Asked Questions. 2015.

2. Bard. Instructions for use:

Button Replacement Gastrostomy Device. 2012.

Contacted 11 October 2017.

3. Cook Medical. Endoscopy. Patient Care Manual:

· Percutaneous Endoscopic Gastrostomy (PEG). 2011.

· Percutaneous Endoscopic Gastrostomy (PEG) Jejunostomy. n.d.

Contacted 3 October 2017.

4. Dietitians Association of Australia. Enteral nutrition manual for adults in health care facilities. 2015.

5. Fresenius Kabi. Instructions for use:

· Freka Jejunostomy Tube FCJ Set Fr 9. 2016.

Contacted 8 and 17 November 2017.

6. Halyard. Instructions for use:

· MIC-KEY Low Profile Balloon Gastrostomy Feeding Tube. Extension Sets with ENFit Connectors. 2015.

· MIC-KEY G Feeding Tube. Extension Sets with ENFit Connectors. Your Guide to Proper Care. 2015.

· MIC-KEY Low Profile Balloon Jejunal Feeding Tube. Extension Sets with ENFit Connectors. 2015.

· MIC-KEY Low-Profile Balloon Standard Gastric-Jejunal Tube – Endoscopic / Radiology Placement. 2015.

· MIC Percutaneous Endoscopic Gastrostomy (PEG) Feeding Tube with ENFit Connectors. Patient Use & Care Guide. 2017.

· MIC Gastrostomy Feeding Tubes PEGS Included. Your Guide to Proper Care. 2015.

· MIC Standard Gastrostomy Balloon Feeding Tubes. n.d.

· MIC Standard Gastric-Jejunal Feeding Tubes – Endoscopic / Radiology Placement. n.d.

Contacted 27 September 2017.

7. Lazar J. Treatment of Feeding Tube Occlusion. Corpak MedSystems. 2011.

8. Medtronic. Instructions for use:

· Kangaroo Gastrostomy Tube Skin Level Balloon. (Clinician). 2011.

· Kangaroo Gastrostomy Tube Skin Level Balloon. (Patient). 2011.

· Kangaroo Gastrostomy Tube Skin Level Cage. (Clinician). 2011.

· Kangaroo Gastrostomy Tube Skin Level Cage. (Patient). 2011.

Contacted 22 September 2017.

9. Long Khanh Dao Le, B.Pharm, MPH, MHHSMYimei Li MBBS, MPH. Evidence Summary. Percutaneous Endoscopic Gastrostomy Delivery. The Joanna Briggs Institute EBP Database, JBI@Ovid. 2017; JBI1664.

10. Statlock Universal Plus Stabilization Device. Suture-Free Stabilization for Percutaneous Drainage Catheters. 2017; C. R. Bard. [cited 30 November 2017]. Available from: http://www.bardaccess.com/products/stabilization/other-universal-plus

11. Stay Connected. Global Enteral Device Supplier Association (GEDSA) 2017. [cited 30 November 2017]. Available from: http://stayconnected.org/

ENFit [cited 30 November 2017]. http://stayconnected.org/enteral-enfit/


Definition of Terms

Buried Bumper Syndrome: migration of the gastrostomy device’s internal bumper out of the stomach and into the gastrostomy tract or peritoneum with partial or complete loss of tract patency between the device’s distal tip and stomach. This is usually due to excessive external traction on the device from a tight external flange that causes the bumper to migrate up into the tract or erode the gastric wall.

Bolus enteral feeding: bolus volume of feed solution at set amounts which are administered over 15 – 60 minutes, at intervals through the day. The amounts and frequency is determined by the dietitian.

Continuous enteral feeding: a determined amount of feeding solution as assessed by the dietitian, which is administered at a continuous rate.

In continuous enteral feeding, formula should be administered by an enteral pump. However, if no enteral pump is available, formula can be administered via gravity with a gravity giving set.

ENFit: To improve patient safety, manufacturers of enteral devices have been required to change the connection used for enteral devices. Enteral tubing misconnection occurs when enteral devices (feeding bags, tubes or syringes) are connected to non-enteral devices, such as IV lines, urinary catheters and ventilator tubing. ENFit is the new connection standard.

Enteral Nutrition: the feeding method of choice for those patients with an intact gastrointestinal system who are unable to meet their nutritional needs orally.

Fluoroscopy: a type of medical imaging that shows a continuous X-ray image on a monitor, much like an X-ray movie. During a fluoroscopy procedure, an X-ray beam is passed through the body. The image is transmitted to a monitor so the movement of a body part or of an instrument or contrast dye through the body can be seen in detail.

Gastropexy: a step in percutaneous radiologic gastrostomy in which the stomach is fastened to the abdominal wall with a gastropexy “t-fastener” / “harpoon” / similar device.

Intermittent feeding: a regime where the delivery of feeding solution is stopped for periods of the day or night and is often used during transition to oral intake.


Search Terms

Gastrostomy, gastric-jejunostomy, jejunostomy, Percutaneous Endoscopic Gastrostomy, PEG, balloon gastrostomy, percutaneous radiologic gastrostomy / jejunostomy, radiologically inserted gastrostomy / jejunostomy, feeding tube, enteral feeding, unblocking, gastropexy


Attachments

Attachment 1: Gastrostomy tubes

Attachment 2: Types of Gastric-Jejunal, Jejunostomy Tubes

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:

Date Amended

Section Amended

Divisional Approval

Final Approval

21/02/2018

Complete Review

Linda Kohlhagen, ED RACC

CHHS Policy Committee

This document supersedes the following:

Document Number

Document Name

CHHS13/117

Community Care Program Radiologically Inserted Gastrostomy and Jejunostomy Tube Management

CHHS13/114

Community Care Program Percutaneous Endoscopic Gastrostomy and Long Balloon Gastrostomy Tube Management

CHHS18/066

Doc Number

Version

Issued

Review Date

Area Responsible

Page

CHHS18/066

1

23/02/2018

01/03/2021

RACC

2 of 41

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

Attachment 1: Types of Gastrostomy Tubes, Initial Insertion, Planned and Unplanned Replacement

Internal retention device

Internal bumper

Self-retaining loop ‘pigtail catheter’

Long ~ 10 cm

Internal balloon

Tube type

Long ~ (approximately) 20 cm

Short/skin level/low profile – ‘button’

Long ~ 20 cm

Short/skin level/low profile – ‘button’

Commonly used tubes

· Percutaneous Endoscopic Gastrostomy (PEG) tube

· Bard Button

· Medtronic Kangaroo Skin Level Cage Gastrostomy Tube

· Cook Medical Wills-Oglesby Gastrostomy (WOG) tube ‘pigtail’, Radiology Inserted Gastrostomy (RIG) tube

· Halyard MIC Standard Gastrostomy Feeding Tube

· Halyard MIC-KEY Low Profile Balloon Gastrostomy Feeding Tube

· Medtronic Kangaroo Skin Level Balloon Gastrostomy Tube

Characteristics

PEG Tube Types

· Collapsible internal bumper and external flange

Note: this tube can be removed with traction removal

· Rigid internal bumper and external flange

Note: this tube must be removed endoscopically

Internal bumper and external base T-piece. The design/shape of the internal bumper will vary according to the manufacturer. Requires an extension set to access the tube. Length of the device varies and depends on the stoma tract length.

Internal pigtail loop and externally held in place with a statlock

Internal balloon and external flange

Internal balloon and external base T-piece. Requires an extension set to access the tube. Length of the device varies and depends on the stoma tract length.

Initial insertion

Endoscopy Unit or Operating Theatre

Operating Theatre

Radiology Department

Operating Theatre or Radiology Department

Planned Replacement

Endoscopy unit, replaced with a balloon tube.

Life expectancy of 12 to 18 months. Should be replaced when it starts to become worn, flattened, perished or difficult to flush.

Radiology Department,

Operating Theatre,

Medical Officers rooms or Outpatient Department. Obturator or traction removal.

Radiology Department, in most cases 1st planned replacement is with a ‘long’ balloon gastrostomy tube.

RIG life expectancy is 12 months.

Immature stoma tract (i.e. less than 12 weeks since insertion) replaced by a MO.

Mature stoma tract (i.e. greater than 12 weeks since insertion) replaced at the bedside, in a clinic or home setting can be done by RN, MO or trained family carer.

Life expectancy of 6 months.

Accidental falling out and replacement


Mature stoma tract (i.e. greater than 12 weeks since insertion) replaced with the same Fr size balloon gastrostomy tube at the bedside, clinic or home setting by MO, competent RN or trained family carer.

Can be replaced temporarily with an IDC usually the same Fr size as the prescribed gastrostomy tube), to maintain the tract until the required balloon tube is available


Operating Theatre or

Medical Officers rooms.

Can be replaced temporarily with an IDC usually the same Fr size as the prescribed gastrostomy tube, to maintain the tract until the required balloon tube is available.

Radiology Department


Mature stoma tract (i.e. greater than 12 weeks since insertion) replaced at the bedside, in a clinic or home setting can be done by RN, MO or trained family carer with the same recommended Fr size and stoma length (low profile tubes only) gastrostomy tube.

Can be replaced temporarily with an IDC usually the same Fr size as the prescribed gastrostomy tube to maintain the tract until the required Fr size balloon tube is available.

Planned removal

Endoscopy Unit


Outpatient Department or

Medical Officers rooms.

At the bedside, clinic or community setting, can be done by RN, requires a medical order.

At the bedside, clinic or community setting, can be done by RN, requires a medical order.

Attachment 2: Types of Gastric-Jejunal, Jejunostomy Tubes, Initial Insertion, Planned and Unplanned Replacement

Tube type

Non Balloon

Balloon

Long

Short/skin level/low profile

Commonly used tubes

1. Fresenius Kabi Freka Jejunostomy Tube

2. Cook Medical Shetty Gastro- Jejunal Tube

3. Cook Medical PEG-J

Halyard:

1. MIC Standard Balloon Jejunal Feeding Tube

1. MIC Standard Balloon Gastric -Jejunal Feeding Tube

Halyard:

1. MIC-KEY Low Profile Balloon Jejunal Feeding Tube

2. 2. MIC-KEY Low Profile Balloon Gastric-Jejunal Feeding Tube

Characteristics

1. Externally secured with a fixing plate and sutures or Bard statlock.

2. Externally secured with a Bard statlock

3. Secured internally with a collapsible bumper and externally with an external flange, with a jejunostomy tube within the PEG tube

1. & 2. Internal retention device (balloon) and external flange

2. Gastric decompression and jejunal feeding ports

1. & 2. Internal retention device (balloon) and external base T-piece.

Used with compatible extension sets.

Length of the jejunal part of the device varies ba

Documents

Gastrostomy, Gastric-Jejunal and Jejunostomy Tube ... · Web viewOne of the cardinal signs of a leaking/misplaced tube is abdominal pain. If after insertion of a gastrostomy, gastric-jejunal