Nursing Procedure 7.19
- Managing a Gastrostomy/Jejunostomy Tube
Provides a patent access for the delivery of nutrients
Nursing Procedure 7.19
Provides a patent access for the delivery of nutrients
Assessment should focus on the following:
Nursing diagnoses may include the following:
Outcome Identification and Planning
Sample desired outcomes include the following:
Special Considerations in Planning and Implementation
Do not allow air to enter tube when irrigating, checking for residual, or during medication administration. Irrigate with 30 to 60 mL of water before or after checking for residual, before and after medication administration, and before and after feeding. Use aseptic technique when caring for the insertion site until healed; thereafter, soap and water may be used. If client reports GI distress or is experiencing abdominal distention and an increase in residuals, stop feeding and notify doctor. Administer feeding at room temperature (see Nursing Procedure 7.20).
To promote comfort and to lessen the potential for dislodgment, consider using a low-profile tube, also known as a gastrostomy button. Enlist the aid of an additional person to help prevent infants or toddlers from pulling at or pulling out the tube. Consider the developmental stage and age of a child when teaching about the tube. Discussion should center on the need for placement of the tube, allowing child to understand that he or she is eating and receiving nourishment in a very special way. Closely monitor infants and young children who are vulnerable to fluid volume deficit and overload. Assess for diarrhea. Use care when flushing tube, carefully recording the exact amount of water used. If an enteral tube is being used for feeding of children, see Nursing Procedure 7.20.
Always check for gastric residuals in the elderly clients because of decreased gastric emptying and to prevent or decrease regurgitation and aspiration during feeding. Due to fragility of skin, be particularly careful in monitoring for breakdown and for diarrhea. Provide frequent oral care to prevent drying and cracking of mucous membranes for clients who cannot orally ingest liquids.
Assess for client desires and ability for feeding and hydration by nonnatural means. Review benefits and disadvantages concerning fluids and nutrients for dying clients for palliative purposes and for the management of symptoms associated with dehydration. Provide scrupulous mouth care.
Teach client and caregiver how to clean insertion site daily with warm water and mild soap. Instruct caregiver or client to remove any buildup of crusts around site with hydrogen peroxide diluted with water (50% H2O2:50% H2O) and cottontipped applicators for cleansing around and under the stoma site. Have client or caregiver use a clean washcloth to cleanse the stoma site once healed. Teach caregivers to crush pills thoroughly and to adequately mix with water before administration through tube, particularly if using a large-bore tube. Emphasize the need to prevent air from entering the tube when irrigating before and after medications, feedings, and checks for residual. Instruct caregivers to keep records of daily I&O.
Assess cultural view of feeding per gastrostomy/jejunostomy.
Use a 60-mL syringe when possible because the plastic outer casing that holds the syringe can be used to hold irrigation fluid, thus eliminating the need for an irrigation kit.
Maintenance and care of gastrostomy/jejunostomy tubes may be delegated to unlicensed assistive personnel who have been trained, if agency policy allows. However, the patency of the tube should always be checked and verified by licensed personnel.
| Action | Rationale | |
|---|---|---|
| 1 | Perform hand hygiene and organize equipment. | Reduces microorganism transfer; promotes efficiency |
| 2 | Confirm doctor’s order for formula frequency, route and rate of any feedings, and residual volume parameters. Assess for allergies to food. | Ensures accuracy of treatment; prevents allergic reactions |
| 3 | Provide privacy and explain procedure to client. | Alleviates anxiety; helps to build knowledge base, establish rapport, and foster client participation in care |
| 4 | Adjust bed to comfortable working height. | Prevents back and muscle strain in nurse |
| 5 | Place or assist client into appropriate position. If client is receiving continuous feedings, maintain head of bed elevation at 30–45 degrees at all times, even when performing site care. Elevate the head of the bed in high Fowler’s position during and for at least 30 min after feeding. Position head in lateral position if elevation is prohibited. | Prevents aspiration |
| 6 | Assess abdomen, noting presence of bowel sounds. Assess skin at tube insertion site. | Verifies GI functioning; reduces complications of skin breakdown, such as from pressure or weight of tube, drainage, or secretions |
| 7 | Don gloves. | Prevents contamination of hands; reduces risk of infection transmission |
| 8 | Remove old dressing over site if in place, discard, and inspect insertion site and surrounding area. | Allows for early detection of infection |
| 9 | Remove gloves and discard. Perform hand hygiene, and apply a clean pair of gloves. | Avoids cross-contamination; reduces microorganism transfer |
| 10 | Measure tube length at regular intervals. | Verifies tube position; if gastric contractions draw tube toward pylorus, signs and symptoms of bowel obstruction may be evident (e.g., acute protracted vomiting); if tube migration has occurred or is suspected, deflate balloon and notify doctor |
| 11 | Assess for placement of tube and patency every 4 hr for continuous feeding and every 4 hr and before feedings for intermittent feeding. | Verifies placement and patency of tube |
| 12 | Check the residual volume (aspirating with a large-bore syringe). Clamp or crimp tube and place tip of syringe into end of appropriate port of tube; release clamp and withdraw GI fluid content. Place a small amount (2–5 mL) of residual in small cup and set aside to check pH. | Determines if feeding solution is being propelled through the GI tract |
| Prevents fluid and electrolyte imbalance | |
| 13 | Assess pH of gastric contents every 4 hr. For clients who have jejunostomy tubes, aspirate intestinal contents, observing for appearance and checking for pH. | Determines acidity; for continuous feedings, pH may be elevated; a client who has not had a gastric inhibitor and has fasted for 4 or more hours usually will have a pH varying from 1 to 4 |
| 14 | Withdraw water from water receptacle and flush tube with 30 mL of water at least every 4–6 hr; also perform flushing before and after administering medications. | Prevents clogging of tube |
| 15 | Reclamp end of ostomy tube. | Prevents backflow of GI contents through tube |
| 16 | Rotate gastrostomy tube daily by gently twisting between thumb and first finger. Notify doctor if unable to rotate tube. | Alleviates pressure on skin; inability to rotate could indicate displaced tube |
| 17 | Remove gloves and discard. Perform hand hygiene, and apply a clean pair of gloves. | Avoids cross-contamination; reduces microorganism transfer |
| 18 | Cleanse tube insertion site with soap and water, saline, or ordered solution in circular pattern beginning at center and working outward using aseptic technique until site is healed. | Prevents cross-contamination; helps reduce risk of infection |
| 19 | Leave site open to air unless drainage occurs, or apply clean dressing if indicated and secure with tape. Change dressing as often as necessary or as ordered. | Prevents reservoir for moisture conducive to the growth of microorganisms; promotes cleanliness and healing |
| 20 | Elevate head of bed unless contraindicated, raise side rails, position client appropriately, and place call light within reach. | Prevents regurgitation and aspiration; provides for safety and comfort; facilitates communication |
| 21 | Remove and discard gloves, discard equipment, and perform hand hygiene. | Reduces microorganism transfer |
Were desired outcomes achieved? Examples of evaluation include:
The following should be noted on the client's record:
Transcultural 
Cost-Cutting Tip