Skill 11-4

Caring for a Gastrostomy Tube

When enteral feeding is required for a longer period (at least 4 to 6 weeks) (Bischoff et al., 2020), an enterostomal tube may be placed through an opening created into the stomach (gastrostomy tube ) or into the jejunum (jejunostomy tube ). Placement of a tube into the stomach or small intestine can be accomplished by a surgeon or gastroenterologist via endoscopy (percutaneous endoscopic gastrostomy [PEG] tube and percutaneous endoscopic jejunostomy [PEJ] tube ) or via surgery (open or laparoscopically). Providing care at the insertion site and validating tube patency are nursing responsibilities. Site care is the same for a gastrostomy and a jejunostomy. Box 11-3 in Skill 11-3 provides criteria to evaluate enteral feeding tolerance.

Delegation Considerations

The care of a gastrostomy tube, in the postoperative period, is not delegated to assistive personnel (AP) in the acute care setting. The care of a healed gastrostomy tube site in some settings may be delegated to assistive personnel (AP) who have received appropriate training, after assessment of the tube by the registered nurse. Depending on the state's nurse practice act and the organization's policies and procedures, the care of a gastrostomy tube may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Nonsterile gloves
Additional PPE, as indicated
Washcloth, towel, and skin cleanser or cotton-tipped applicators and sterile saline solution (depending on patient circumstances)
Gauze (if needed)

Assessment

Assess the gastrostomy or jejunostomy tube site, noting any drainage, pressure injury, erythema, inflammation, erosion, or hypergranulation tissue. Assess for pain. Assess the tube position and the position of the external fixation device. Refer to details in the Implementation section of this Skill. Check to ensure that the tube is securely stabilized and has not become dislodged. Assess the tension of the tube. If the tension is too great, the internal anchoring device may erode into the gastric wall (Roveron et al, 2018). Excessive traction may also contribute to enlargement of the stoma and development of leakage around the tube (Roveron et al., 2018).

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Knowledge deficiency
Altered skin integrity
Infection risk

Outcome Identification and Planning

The expected outcomes to achieve when caring for a gastrostomy tube are that the patient does not exhibit signs and symptoms of drainage, pressure injury, erythema, inflammation, erosion, or hypergranulation tissue at the tube insertion site, and the tube remains in place. In addition, the patient verbalizes little discomfort related to tube placement and verbalizes an understanding of the care needed for the gastrostomy tube, as appropriate.

Implementation

Action	Rationale
1. Gather equipment. Verify the prescribed interventions or facility policy and procedure regarding site care.	Assembling equipment provides for an organized approach to the task. Verification ensures the patient receives the correct intervention.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Explain the procedure to the patient. Answer any questions, as needed.	Explanation facilitates patient engagement.
5. Assess for presence of pain at the tube-insertion site. If pain is present, offer the patient analgesic medication per the prescribed interventions and wait for the medication to take effect before beginning insertion-site care.	Feeding tubes can be uncomfortable, especially in the first few days after insertion. Analgesic medication may permit the patient to tolerate the insertion site care more easily. After the first few days, pain at the site should diminish (Roveron et al., 2018).
6. Pull the patient's bedside curtain. Assemble equipment on the bedside table, within reach. Raise the bed to a comfortable working position (VHACEOSH, 2016).	This provides for privacy. Assembling equipment provides for organized approach to the task. An appropriate working height facilitates comfort and proper body mechanics for the nurse.
7. Put on gloves. Assess the gastrostomy site, as described above.	Gloves prevent contact with blood and body fluids. Assessment is vital to detect changes in the patient's condition before initiating the intervention.
8. Measure the length of the exposed tube, comparing it with the initial measurement after insertion. Alternatively, examine the mark on the tube at the skin; the mark should be at skin level at the insertion site.	Tube length should be checked and compared with the initial measurement or marking daily (Roveron et al., 2018). A change in the length of the exposed tube may indicate displacement.
9. Beginning 24 hours after placement of the tube and for the first week, cleanse the stoma and peristomal skin with sterile saline to remove any discharge or material around the tube (Bischoff et al., 2020; Roveron et al., 2018) (Figure 1). Pat the skin around the insertion site dry. If necessary, cover the stoma with sterile gauze to absorb exudate or other fluids (Roveron et al., 2018).	Cleaning the new site with sterile saline solution prevents the introduction of microorganisms into the wound (Roveron et al., 2018). Crust and drainage can harbor bacteria and lead to skin breakdown. Drying the skin thoroughly prevents skin breakdown. Gauze absorbs drainage.
10. After the first week to 10 days, wet a washcloth and apply a small amount of skin cleanser onto the washcloth. Gently cleanse around the insertion, removing any crust or drainage (Bischoff et al., 2020; Roveron et al., 2018) (Figure 2). Rinse the site, removing all cleanser. Pat the skin around the insertion site dry. If necessary, based on facility policy and patient situation, place a gauze dressing above the external fixation device. Alternatively, if the exterior fixation device is 5 mm above the skin, the dressing may be placed under the exterior fixation device, if the dressing is not too thick (Roveron et al., 2018).	Crust and drainage can harbor bacteria and lead to skin breakdown. Removing the cleanser helps to prevent skin irritation. If able, the patient may shower and cleanse the site with soap and water. Drying the skin thoroughly prevents skin breakdown. Placing the dressing above the external fixation device avoids excessive tension (Roveron et al., 2018). Gauze absorbs drainage.
11. After the first 24 hours, gently rotate the position of the gastrostomy tube 360 degrees. Rotation of the tube should be done at least once a week and no more than once a day (Roveron et al., 2018).	Rotation of the tube prevents adherence to the tract and adhesion (Roveron et al., 2018).
12. After the first 7 to 10 days, loosen the exterior fixation device and gently push the tube into the stomach 2 to 3 cm, then gently pull it back until it reaches the area of minimal resistance (the gastric wall). Push/pull of the tube should be done at least once a week and no more than once a day (Bischoff et al., 2020; Roveron et al., 2018). Assess that the guard or external bumper is not digging into the surrounding skin. The external fixation device should be 0.5 to 1 cm above the skin (Bischoff et al., 2020; Roveron et al., 2018). Avoid placing any tension on the tube.	The gastrocutaneous tract heals in 7 to 10 days (Roveron et al., 2018). This maneuver reduces the risk for buried bumper syndrome (Bischoff et al., 2020; Roveron et al., 2018). Proper placement prevents/avoids excessive tube movement and enlargement of the stoma (Roveron et al., 2018). The external fixation device should be 0.5 to 1 cm above the skin to avoid excessive tension between the interior and exterior fixation devices and to reduce the risk of ischemia, necrosis, infection, and buried bumper syndrome (Bischoff et al., 2020; Roveron et al., 2018). Excessive distance between the external fixation device and the skin could lead to fixation of the gastric wall to the abdominal wall and formation of a gastrocutaneous fistula (Roveron et al., 2018). Excessive traction may contribute to enlargement of the stoma and the development of leakage around the tube (Roveron et al., 2018).
13. For most patients, the site can be left open to air unless there is drainage. Avoid the use of creams or powders around the stoma (Roveron et al., 2018).	Dressing is not necessary in the absence of drainage (Bischoff et al., 2020; Roveron et al., 2018). Avoiding use of creams or powders around the stoma prevents growth of pathogens (Roveron et al., 2018).
14. If the tube is not in use, check that the cap is securely in place.	The cap should remain closed when the tube is not in use to deter entry of microorganisms and prevent leakage from the tube.
15. Secure the gastrostomy tube to the patient's abdomen in a way that stabilizes the tube and avoids excessive traction (Boullata et al., 2017; Pars & Çavuşoğlu, 2019; Roveron et al., 2018). Assess the integrity of the tape or device used to secure the tube to the stomach.	Excessive friction may result in development of peristomal hypergranulation tissue (Bischoff et al., 2020; Roveron et al., 2018). Excessive traction may contribute to enlargement of the stoma and the development of leakage around the tube (Roveron et al., 2018).
16. Remove gloves. Perform hand hygiene. Lower the bed and assist the patient to a position of comfort, as needed.	Removing gloves reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms. Lowering the bed and assisting the patient ensure patient safety and comfort.
17. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.

Evaluation

The expected outcomes have been met when the patient has not exhibited signs and symptoms of drainage, pressure injury, erythema, inflammation, erosion, or hypergranulation tissue at the tube-insertion site, and the patient has verbalized little discomfort related to tube placement as well as an understanding of the care needed for the gastrostomy tube, as appropriate.

Documentation

Guidelines

Document the site care that was provided, including the substance used to cleanse the tube site. Record the assessment of the site, including the surrounding skin and measurement of length of external tube and comparison to length on insertion. Note the presence of any drainage, recording the amount and color, and pressure injury, erythema, inflammation, erosion, or hypergranulation tissue. Note the rotation and/or push/pull of the tube. Note the external fixator position. Comment on the patient's response to the care, if the patient experienced any pain, and if an analgesic was administered. Record any patient instruction that was provided.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Gastrostomy tube is leaking large amount of drainage: Check tension of tube. If there is a large amount of slack between the internal guard and the external bumper, drainage can leak out of site. Apply gentle pressure to the tube while pressing the external bumper closer to the skin (0.5 to 1 cm from skin) (Bischoff et al., 2020; Roveron et al., 2018). If the tube has an internal balloon holding it in place (similar to a urinary catheter balloon), check to make sure that the balloon is inflated properly.
Skin irritation is noted around insertion site: Investigate the cause of the irritation. Address the cause of the leakage; apply skin barrier or zinc oxide-based skin protectant (Bischoff et al., 2020). If the skin is erythematous and appears to be broken down, gastric fluids may be leaking from the site. Gastric fluids have a low pH and are very acidic. Address the leakage. If the skin has a patchy, red rash, the cause could be candidiasis (yeast). Consult with the health care team regarding the use of an antifungal powder. Ensure that the site is kept dry.
Site appears erythematous and patient reports pain at site: Consult with the health care team; the patient could be developing an infection at the site.
Patient reports severe pain that does not respond to routine analgesics; when the tube is used for feeding/hydration; or when site care is provided during the first 72 hours after placement of the tube: Discontinue any type of administration through the tube and notify the health care team (Roveron et al., 2018).

Special Considerations

General Considerations

Feeding tubes should be flushed with at least 30 mL of water before starting and after completion of bolus feedings, every 4 to 8 hours during continuous feeding, and before and after medication administration (Bischoff et al., 2020; Boullata et al., 2017; Pars & Çavuşoğlu, 2019; Roveron et al., 2018), based on the patient's fluid needs and restrictions (Boullata et al., 2017).
Avoid occlusive dressings at gastrostomy site; occlusive dressings promote a moist wound environment and can lead to skin maceration (Bischoff et al., 2020).
Glycerin hydrogel or glycogel dressings may be used as an alternative to gauze dressings (Bischoff et al., 2020). Use of this type of dressing removes the need for daily dressing changes (Bischoff et al., 2020).
Do not place a dressing between the skin and external fixation device unless drainage is present. Change the dressing immediately when soiled, to prevent skin complications.
If the length of the exposed tube has changed or marking on tube is not visible, do not use the tube. Consult with the health care team regarding the finding.
If the patient experiences pain during nutritional infusion, prolonged pain after the procedure, passage of nutritional formula or medications through the stoma, or bleeding from the site, stop the enteral nutrition feeding immediately and consult with the health care team (Roveron et al., 2018, p. 331).

Community-Based Care Considerations

Advise patients and caregivers to stop the enteral nutrition feeding immediately and contact their health care provider if the patient experiences pain during nutritional infusion, prolonged pain after the procedure, passage of nutritional formula or medications through the stoma, or bleeding from the site (Roveron et al., 2018, p. 331).
For patients with a well-healed exit site, showering, bathing, and swimming (it is advisable to cover the site with a waterproof dressing when swimming in public pools) is possible after a few weeks (Bischoff et al., 2020).
All information related to home enteral nutrition should be provided to patients and family members/caregivers verbally and in writing and/or pictures (Bischoff et al., 2020).

EVIDENCE FOR PRACTICE

Clinical Practice Guidelines for Nursing Management of Percutaneous Endoscopic Gastrostomy and Jejunostomy Tubes

The Italian Association of Stoma care Nurses and the Italian Association of Gastroenterology Nurses and Associates Clinical Practice Guidelines for Nursing Management of Percutaneous Endoscopic Gastrostomy and Jejunostomy Tubes (PEG/PEJ) in Adult Patients guidelines provide recommendations for nursing management of percutaneous endoscopic gastrostomy or jejunostomy (PEG/PEJ) tubes based on the available evidence and expert consensus. These guidelines provide best practices related to preparation for PEG/PEJ procedures and perioperative monitoring, monitoring during the initial 72 hours after tube placement, management of the stoma and tube, administering nutrition and medications, preventing reflux or aspiration of gastric contents, nursing management of common complications, education for patients and caregivers, and tube replacement and methods to assess tube position.

EVIDENCE FOR PRACTICE

ASPEN Safe Practices for Enteral Nutrition Therapy

Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii-Wolfe, C., Sullivan, J., Wood, A., Malone, A., Guenter, P., & ASPEN Safe Practices for Enteral Nutrition Therapy, American Society for Parenteral and Enteral Nutrition. (2017). ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15-103. https://doi.org/10.1177/0148607116673053

Refer to details in Skill 11-3, Evidence for Practice.

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Skill 11-4

EVIDENCE FOR PRACTICE

EVIDENCE FOR PRACTICE