Gastrostomy, Gastric-Jejunal and Jejunostomy … · Web viewOnly ENFit syringes should be used for water flushing or administering medication or feeds through a gastrostomy, gastric-jejunal

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Canberra Hospital and Health ServicesClinical Procedure Gastrostomy, Gastric-Jejunal and Jejunostomy Tube – Nursing Management – Adults, Adolescents and Children (not Neonates)Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................3

Alerts.........................................................................................................................................3

Scope........................................................................................................................................ 4

Section 1 – General Information...............................................................................................4

Section 2 – Gastrostomy, Gastric-Jejunal and Jejunostomy Tube and Stoma Care and Monitoring................................................................................................................................ 5

Section 3 - Decompression or Venting....................................................................................13

Section 4 - Measuring the Length of a Stoma Tract................................................................14

Section 5 – Flushing a Gastrostomy, Gastric-Jejunal and Jejunostomy Tube..........................15

Section 6 – Feeding via a Gastrostomy, Gastric-Jejunal and Jejunostomy Tube in the Hospital................................................................................................................................................ 19

Section 7 – Medication Administration in the Hospital...........................................................22

Section 8 - Management of an Occluded Tube.......................................................................23

Section 9 – Planned Replacement of a Gastrostomy Tube.....................................................25

9.1 General Information..........................................................................................................25

Section 10 – Gastrostomy Tube Replacement with an Indwelling Urinary Foley Catheter (IDC) - PEG or Balloon Gastrostomy Tubes Only..............................................................................28

Section 11 – Permanent Removal of a Gastrostomy, Gastric-Jejunostomy or Jejunostomy Tube........................................................................................................................................ 31

Section 12 – Care in the Community and Discharge Planning.................................................32

Section 13 – Contacts for Further Information.......................................................................34

Implementation...................................................................................................................... 35

Related Policies, Procedures, Guidelines and Legislation.......................................................35

References.............................................................................................................................. 36

Definition of Terms................................................................................................................. 37

Search Terms.......................................................................................................................... 38

Doc Number Version Issued Review Date Area Responsible PageCHHS18/066 1 23/02/2018 01/03/2021 RACC 1 of 40

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

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Attachments............................................................................................................................38

Attachment 1: Types of Gastrostomy Tubes, Initial Insertion, Planned and Unplanned Replacement.......................................................................................................................39

Attachment 2: Types of Gastric-Jejunal, Jejunostomy Tubes, Initial Insertion, Planned and Unplanned Replacement.....................................................................................................41



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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

ENFitOnly 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 PainOne 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 PatientsIf staff have concerns post-procedurally for CHHS Angiography patients, they can contactAngiography 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



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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 FeedingBolus 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 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



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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.

Procedure1. 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.



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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.



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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 ChangeThe 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.

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 Disposable sheet / bluey



E.g. 8 cm

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.

Insertion Site

Base of Hub

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Non transparent rubbish bag Scissors (to trim statlock if required) Dressing pack (if required) Normal saline (if required).


Policy on the policy register.2. Attend to hand hygiene using soft pre-moistened cloths and ABHR.3. Don safety eyewear.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 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 removedd. 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.



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

15. Discard equipment.16. Remove PPE.17. Attend to hand hygiene.18. Document in the patient’s clinical record.

2.4 Balloon Volume CheckingGeneral 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.


Policy on the policy register.2. Attend to hand hygiene using soft pre-moistened cloths and ABHR.3. Don safety eyewear.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.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. 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



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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.16. Discard equipment.17. Remove PPE.18. Attend to hand hygiene.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 CareEquipment 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 Disposable sheet / bluey Non transparent rubbish bag.


Policy on the policy register.



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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. Carefully remove the old dressing.8. Inspect the surrounding skin for redness, tenderness, swelling, irritation, purulent

drainage or gastric leakage.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.11. Attend to hand hygiene and don 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.15. Discard equipment.16. Remove PPE.17. Attend to hand hygiene. 18. Document in the patient’s clinical record.

Ongoing Care after 48 hours from Initial InsertionThe 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 AdapterThe 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 Soft pre-moistened cloths (community only) and ABHR PPE including safety eyewear or shield and clean gloves Y-port adapter



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Scissors (optional) Disposable sheet / bluey Non transparent rubbish bag.


Policy on the policy register.2. Attend to hand hygiene using soft pre-moistened cloths and ABHR.3. Set up equipment. Ensure caps are closed on the new adapter.4. Don safety eyewear.5. Place blue sheet to protect patient’s clothes.6. Attend to hand hygiene and don gloves.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.11. Discard equipment.12. Remove PPE.13. Attend to hand hygiene.14. The PEG tube is ready for use immediately after adapter replacement.15. Document in the patient’s clinical record.

2.8 Removal of a Gastropexy Suture DeviceA 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) Soft pre-moistened cloths (community only) and ABHR 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 Disposable sheet / bluey

Non transparent rubbish bag.

Procedure1. Check medical order to remove the gastropexy suture device.2. Explain the procedure to the patient and obtain consent as per Consent and Treatment

Policy on the policy register.3. Attend to hand hygiene using soft pre-moistened cloths and ABHR.4. Don safety eyewear and gown.5. Set up equipment.



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6. Place blue sheet to protect patient’s clothes.7. Attend to hand hygiene and don gloves.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.

11. Discard equipment.12. Remove PPE.13. Attend to hand hygiene. 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 Soft pre-moistened cloths (community only) and ABHR PPE including safety eyewear or shield, clean gloves and gown Disposable sheet / bluey Low Profile Devices:

o Bard Button – decompression tube extension seto Halyard MIC-KEY Low Profile Balloon Gastrostomy Tube – bolus extension set o Medtronic Kangaroo Low Profile Balloon – bolus extension seto Medtronic Skin Level Cage - bolus feeding set

Syringe 60 mL ENFit x 2 Clean container of tap water (or sterile water if appropriate)

Process1. Check medical order for decompression or venting.2. Explain the procedure to the patient and obtain consent as per Consent and Treatment

Policy on the policy register.3. Perform hand hygiene using soft pre-moistened cloths and ABHR.4. Don safety eyewear and gown.5. Set up equipment.6. Place blue sheets to protect patient’s clothes.7. Attend to hand hygiene and don gloves.8. Verify correct tube placement.



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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.18. Attend to hand hygiene.19. Document in the patient’s clinical record.


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 Soft pre-moistened cloths (community only) and ABHR PPE includes, safety goggles or face shield, clean gloves and gown Dressing pack Normal saline 30 mL (at body temperature warmth) Stoma measuring device (e.g. PICS 71353 Halyard MIC-KEY Stoma Measuring Device) Syringe luer slip 5 mL Water soluble lubricant Sterile water ampoule Disposable sheet / bluey Non transparent rubbish bag


Policy on the policy register.2. Attend to hand hygiene using soft pre-moistened cloths and ABHR.



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3. Set up equipment. Moisten the stoma measuring device with lubricant or water.4. Attend to hand hygiene. 5. Don safety eyewear and gown.6. Position patient supine and flat.7. Place blue sheet to protect patient’s clothes.8. Attend to hand hygiene and don gloves.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.18. Discard equipment.19. Remove PPE.20. Attend to hand hygiene.21. Document in the patient’s clinical record.


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



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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 compromised2. In critical care3. Under 12 months of age in hospital4. 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 Soft pre-moistened cloths (community only) and ABHR 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) Disposable sheet / bluey

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.



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4. Set up equipment.5. Draw up water into the syringe.6. Place blue sheet to protect patient’s clothes.7. Attend to hand hygiene and don gloves.8. Inspect the surrounding skin for redness, tenderness, swelling, irritation, purulent

drainage or gastric leakage.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.

13. Discard equipment.14. Remove PPE.15. Attend to hand hygiene.16. Document in the patient’s clinical record.




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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 Disposable sheet / bluey PPE includes, safety goggles or face shield and clean gloves.

Procedure



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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) Attend to hand hygiene, don safety eyewear and gloves. 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). Re-check position of the feeding tube.

6.4 Administration of a Feed via Bolus Push Method and ENFit Syringe (if ordered by Dietitian) Attend to hand hygiene, don safety eyewear and gloves. Using a non-touch technique, connect the ENFit syringe to the feeding tube. Ensure connections are secure.



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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). Re-check position of the feeding tube.

6.5 Administration of Continuous Feeding via Enteral Feed Connection Set (if ordered by Dietitian) Attend to hand hygiene, don safety eyewear and gloves. Using a non-touch technique, connect the enteral feed giving set to the formula, enteral

pump and feeding tube. Ensure connections are secure. Refer to Dietitian order and administer amount according to orders. On completion of feed flush the feeding tube with ordered volume of water. Re-check position of the feeding tube. 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.Doc Number Version Issued Review Date Area Responsible PageCHHS18/066 1 23/02/2018 01/03/2021 RACC 20 of 40


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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.

AlertSome 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.

Procedure1. 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.9. Don safety eyewear.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.



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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.27. Attend to hand hygiene.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

AlertIt 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 Soft pre-moistened cloths (community only) and ABHR PPE including safety eyewear or shield, clean gloves and gown Syringe 60 mL ENFit Water (or sterile water if appropriate) room temperature Syringe 2, 5 or 10 mL luer lock (Cook RIG/RIJ only) Extension set (low profile tubes only) Activated Pancreatic enzyme solution if required Sodium bicarbonate if required Disposable sheet / bluey Clean container to expel flush solution Non transparent rubbish bag


Policy on the policy register.2. Attend to hand hygiene using soft pre-moistened cloths and ABHR.3. Don safety eyewear and gown.



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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.6. Attend to hand hygiene and don gloves.7. Verify correct tube placement.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.17. Attend to hand hygiene and don 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.



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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. 26. Discard equipment.27. Remove PPE.28. Attend to hand hygiene. 29. Document in the patient’s clinical record.


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:o PEG tubes are removed in the Endoscopy Unit and replaced with a balloon

gastrostomy tube.o 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



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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 Soft pre-moistened cloths (community only) 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 Disposable sheet / bluey 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 Extension set (low profile tubes only)

Water-soluble lubricant Non transparent rubbish bag.


Policy on the policy register.2. Attend to hand hygiene using soft pre-moistened cloths and ABHR.3. Place patient semi-upright (minimum 30ᴼ) during the procedure.4. Place blue sheet to protect patient’s clothes.5. Attend to hand hygiene.6. Don safety eyewear and gown.7. Set up equipment. 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:



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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.11. Attend to hand hygiene and don gloves.12. Inspect surrounding skin for redness, tenderness, swelling, irritation, purulent drainage

or gastric leakage.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.



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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.

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

procedure.32. Remove PPE.33. Attend to hand hygiene.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



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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) Disposable sheet / bluey Non transparent rubbish bag.


Policy on the policy register.2. Attend to hand hygiene using soft pre-moistened cloths and ABHR.3. Place patient semi-upright (minimum 30ᴼ) during the procedure.4. Place blue sheet to protect patient’s clothes.5. Attend to hand hygiene.6. Don safety eyewear and gown.7. Set up equipment.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’.



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12. Apply water-soluble lubricant to the tip of the IDC.13. Attend to hand hygiene and don clean gloves.14. Inspect the surrounding skin for redness, tenderness, swelling, irritation, purulent

drainage or gastric leakage.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.25. Discard equipment.26. Patient must remain semi-upright (minimum 30ᴼ) for 30 – 60 minutes after the

procedure.27. Remove PPE.28. Attend to hand hygiene. 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.




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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) Soft pre-moistened cloths (community only) and ABHR 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 (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 Disposable sheet / bluey

Non transparent rubbish bag.

Procedure1. Check medical order to remove the tube.2. Explain the procedure to the patient and obtain consent as per Consent and Treatment

Policy on the policy register.3. Attend to hand hygiene using soft pre-moistened cloths and ABHR.4. Don safety eyewear and gown.5. Set up equipment.6. Place blue sheet to protect patient’s clothes.7. Attend to hand hygiene and don gloves.



1.

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

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.15. Discard equipment.16. Remove PPE.17. Attend to hand hygiene. 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 CommunityThe 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 PlanningPatients 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



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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 CommunityTube type: Manufacturer:Fr size: Stoma length: cmJejunal length: cmExternal length (insertion site to base of hub): cmVolume of water in balloon: mL Date of last balloon volume check: Insertion date: Last change date:Next planned change date:




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Section 13 – Contacts for Further Information

Canberra Hospital and Health ServicesACT Equipment Loan Service (ELS)T: 6207 0658 F: 6205 2604 E: [email protected] Address: 37 Kingsmill Street Kambah ACT 2902Office 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 HospitalT: 6244 2222 (switch)

Canberra Hospital Medical Imaging Angiography SuiteFor 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 2211E: [email protected]: Building 15, level 2

Community Health Intake (CHI) T: 6207 9977F: 6205 2611E: [email protected]

Health Care Suppliers Bard MedicalCustomer Service T: 1800 257 232

Cook Medical Customer Service T: 1800 777 222

Fresenius Kabi



mailto:[email protected]

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Customer Service T: 1300 732 001

Halyard Customer Service T: 1800 101 021

MedtronicCustomer Service T: 1800 252 467

Resources*PICS Product ID

Unit of Issue

Description

37560 Box/25 Statlock Universal Plus, 6-8.5 Fr, small37561 Box/25 Statlock Universal Plus, 10-12 Fr, medium 37562 Box/25 Statlock Universal Plus, 12-14 Fr, large37563 Box/25 Statlock Universal Plus, 14-16 Fr, extra large44831 Box/5 Cook Enteral Feeding Adapter Male Luer Lock–Red Code: FTA-

MLLA-RACT 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



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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: o Percutaneous Endoscopic Gastrostomy (PEG). 2011. o 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:

o Freka Jejunostomy Tube FCJ Set Fr 9. 2016.Contacted 8 and 17 November 2017.

6. Halyard. Instructions for use:o MIC-KEY Low Profile Balloon Gastrostomy Feeding Tube. Extension Sets with ENFit

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

Care. 2015.o MIC-KEY Low Profile Balloon Jejunal Feeding Tube. Extension Sets with ENFit

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

Placement. 2015.o MIC Percutaneous Endoscopic Gastrostomy (PEG) Feeding Tube with ENFit

Connectors. Patient Use & Care Guide. 2017.o MIC Gastrostomy Feeding Tubes PEGS Included. Your Guide to Proper Care. 2015.o MIC Standard Gastrostomy Balloon Feeding Tubes. n.d.o 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:



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o Kangaroo Gastrostomy Tube Skin Level Balloon. (Clinician). 2011.o Kangaroo Gastrostomy Tube Skin Level Balloon. (Patient). 2011.o Kangaroo Gastrostomy Tube Skin Level Cage. (Clinician). 2011.o 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



http://stayconnected.org/enteral-enfit/

http://stayconnected.org/

http://www.bardaccess.com/products/stabilization/other-universal-plus

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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 tubesAttachment 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

RACCCHHS Policy Committee

This document supersedes the following: Document Number Document NameCHHS13/117 Community Care Program Radiologically Inserted Gastrostomy and Jejunostomy

Tube ManagementCHHS13/114 Community Care Program Percutaneous Endoscopic Gastrostomy and Long

Balloon Gastrostomy Tube Management



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

Internal retention deviceInternal bumper

Self-retaining loop ‘pigtail catheter’

Long ~ 10 cm

Internal balloonTube type Long ~ (approximately) 20

cmShort/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 flangeNote: this tube can be removed with traction removal

Rigid internal bumper and external flangeNote: 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

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

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.



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Internal retention deviceInternal bumper

Self-retaining loop ‘pigtail catheter’

Long ~ 10 cm

Internal balloonTube type Long ~ (approximately) 20

cmShort/skin level/low profile – ‘button’

Long ~ 20 cm Short/skin level/low profile – ‘button’

difficult to flush. months.

Accidental falling out and replacement

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 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

Radiology Department,Operating Theatre orMedical 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 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 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 Radiology Department,Outpatient Department orMedical 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.



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

Tube type Non Balloon BalloonLong 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 Tube1. MIC Standard Balloon Gastric -Jejunal Feeding

Tube

Halyard:1. MIC-KEY Low Profile Balloon Jejunal Feeding

Tube2. 2. MIC-KEY Low Profile Balloon Gastric-

Jejunal Feeding TubeCharacteristics 1. Externally secured with a fixing plate

and sutures or Bard statlock. 2. Externally secured with a Bard statlock3. 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 based upon clinical need.2. Gastric decompression and jejunal feeding ports.Length of the gastric part of the device varies and depends on the stoma tract length.

Initial insertion 1. Operating Theatre or2. Radiology Department3. Endoscopy Unit

Radiology Department Radiology Department

Planned Replacement 1. & 2. Radiology Department 3. Endoscopy Unit


Accidental falling out and replacement

1. & 2. Radiology Department3.Endoscopy Unit


Planned removal 1 & 2. Bedside or clinic3. Endoscopy Unit

In-patient if fasting after tube removal is required, otherwise in a clinic or the home setting.

In-patient if fasting after tube removal is required, otherwise in a clinic or the home setting.



Documents

Gastrostomy, Gastric-Jejunal and Jejunostomy … · Web viewOnly ENFit syringes should be used for water flushing or administering medication or feeds through a gastrostomy, gastric-jejunal