TROUBLE SHOOTING GUIDELINES FOR GASTROSTOMY TUBES by hcj

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									      TROUBLE SHOOTING GUIDELINES FOR GASTROSTOMY TUBES


POTENTIAL PROBLEM            NURSING INTERVENTION                                                     OUTC
Stoma site is red and        1. The stoma should be cleaned with a mild soap and gauze daily.         Preven
inflamed.                    2. It is advised that the patient should not bathe or immerse the area
                                in water while the stoma is healing. After 2 weeks the patient
(Non qualified nurses/carers    may bathe as normal.
should follow steps 1-4.     3. Clean twice daily paying attention to meticulous hygiene.
Contact the District Nurse   4. Always ensure the area is dried thoroughly afterwards to prevent
or the Endoscopy unit for       infection.
advise regarding steps 5-8) 5. If the stoma site becomes red and inflamed, take a swab of the
                                site for microbiological culture.
                             6. Inform doctor, as antibiotics may be needed.
                             7. If site is infected with MRSA, contact infection control for
                                advice.
                             8. The site will need to be re-screened for MRSA. If in doubt,
                                contact the Infection Control Nurse
Stoma site is leaking        1. Ensure the external fixator (disc) is snug to the skin and the tube   Preven
                                is secure (movement of the gastrostomy in and out of the              conten
(Non qualified nurses/carers    stomach will cause leakage of gastric contents).
should follow steps 1-4.     2. Ensure the skin around the gastrostomy site is cleaned twice a
Contact the District Nurse      day with soap and water, then dried thoroughly.
or the Endoscopy unit for    3. Protect the surrounding skin with Cavilon spray/swab/cream.           Preven
advise regarding steps 5-7) 4. Note when patient last had their bowels opened. Leakage may be
                                due to excessive pressure in the abdomen.
                             5. Ensure patient is on an acid suppressing drug to reduce acidity of
                                gastric contents (recommend Zoton Fas tab).
                             6. For balloon gastrostomy devices, check water volume in the
                                balloon. Note volume of water in the balloon and compare with
                                recommended volume. Replace with recommended volume of
                                water. Leakage may stop if the balloon is inflated a further 2mls.
                             7. Dressings can be applied to the PEG stoma when leakage is
                                excessive. Recommend using an absorbent dressing to absorb
                                moisture, recommend Mepilex dressings. (contact tissue
                                viability nurse for advice).
Potential pain and           1. Each patient should receive a strong analgesia immediately post
discomfort following PEG        procedure and for the following 24-48 hours depending on
insertion or change.            patients’ pain experienced.
                             2. Pain assessment should be done regularly throughout the days
(Non qualified nurses/carers    following the PEG insertion.
should seek the advice of    3. The use of moderate pain relieve is advisable for the hours 48
the District nurse/GP           hours post insertion.
regarding pain control)      4. After 4-5 days the patient should only experience mild
                                discomfort from the PEG tube. A patient who is experiencing
                                        severe pain needs urgent referral to the doctor.
                                   5. Following PEG tube changes or gastrostomy changes, mild pain
                                        relief e.g. paracetamol may be helpful.
Overgranulation around             1. Observe the stoma site daily and ensure the site is cleaned as                     Ensuri
the stoma site                          indicated,                                                                       secure
                                   2. If overgranulation is noted, ensure the tube is secure and the                     movem
(Non qualified nurses/carers            fixator is snug to the skin.                                                     inciden
should seek the advice of          3. Refer to doctor regarding type of treatment, which may be
the District nurse/GP                   helpful. “Maxitrol” may be recommended which needs to be                         Treatin
regarding overgranulation)              prescribed by the GP.                                                            reduce
                                   4. Discontinue treatment once overgranulation has gone.                               compli
Tube displacement                  1. Stop the feed immediately,                                                         If the t
(Before 3 weeks)                   2. For patients in the community contact your District Nurse                          before
                                        urgently or attend the Accident and Emergency department                         establi
                                        at your local hospital.                                                          of feed
                                   3. Try and insert Foley catheter into the stoma and contact the                       into th
                                        Gastroenterologist or Gastro Registrar on call before attempting
                                        to use the device.
---------------------------------- -----------------------------------------------------------------------------------   --------
After 3 weeks                      1. Stop the feed immediately.
                                   2. For patients in the community contact your District Nurse
                                        urgently or attend the Accident and Emergency department
                                        at your local hospital.
                                   3. Keep the stoma open by inserting a Foley catheter through the
                                        stoma and inflating the balloon in the stomach.
                                   4. After inflating the Foley catheter, ensure the Foley catheter
                                        rotates with ease and enters in and out of the stomach smoothly.
                                   5. Check position of the Foley catheter by aspirating gastric
                                        contents and testing with PH paper. Also test using air
                                        auscultation method.
                                   6. If in any doubt about the position of the catheter, DO NOT USE!
                                        Keep patient nil by tube/mouth and refer to Endoscopy Unit. A
                                        Foley catheter should only be used as a temporary device and not
                                        as a replacement gastrostomy.
                                   7. Keep the patient hydrated with IV/S/C fluids as required. For
                                        patients in the community, guidance regarding IV or
                                        subcutaneous fluid provision should be sort through GP, District
                                        nurse or hospital specialist.


Damaged tube,                1. Spare connections/extension sets for in-patients can be obtained                         Preven
connectors/extension set.       from the Endoscopy Unit .                                                                patient
                             2. Please ensure patients at home have spare connectors/extension                           admiss
(Non qualified nurses/carers    sets for button gastrostomy tubes in stock or at least have direct
should seek the advice of       access if required (e.g. via district nurse).
the District nurse/GP)       3. Replacement connectors/extension sets are available from the
                                  company. (see separate order sheet).
                             4.   DO NOT rely on the hospital to provide spare
                                  connectors/extension sets for patients at home, as they may be
                                  unavailable.
                             5.   If you are unable to repair the tube, contact your district nurse or
                                  the Endoscopy Unit.
Potential                    1.   Check feeding position/technique.                                     Feed is
absorption/aspiration        2.   Ensure the patient is sat up during feeding and at least 1 hour       effecti
problems.                         post feeding (patients’ head should be elevated 30-40 degrees).       compli
                             3.   Check when patient last had their bowels opened.
(Non qualified nurses/carers 4.   Check for other causes, e.g. infection, antibiotic therapy, etc.
should follow steps 1-3 then 5.   Suggest medication which increases gastric motility and
seek advice from the              prevents/reduces vomiting (discuss with doctor, District
District nurse/GP)                nurse/GP).
                             6.   Contact dietitian for advice regarding the type or rate of feed.
                             7.   If patient is at risk of aspiration they should be fed during the day
                                  when they can be closely monitored.
                             8.   If continues to be a problem contact Gastro team.
Pump alarming                  1.   Check clamp is not on.                                                Feedin
                               2.   Observe tube/giving set for kinks.                                    regime
                               3.   Ensure drip chamber is not overfilled.
                               4.   Refer to trouble-shooting guide provided with your pump.
                               5.   If unable resolve contact company representative.
Tube Blockage                  1.   Always ensure the tube is flushed with 50-60mls sterile/cooled        The fe
                                    boiled water before and immediately after feeding, and before         regular
                                    and after administering medication.                                   occurr
                               2.   If the tube becomes blocked try warm water.
                               3.   Give the tube a reasonably firm flush.
                               4.   Try flushing the tube with carbonated drinks.
                               5.   Try flushing the tube with pineapple juice.
                               6.   Ask the GP to prescribe “Pancrex V”. This contains pancreatic
                                    enzymes and helps to clear blocked tubes. Caution must be taken
                                    not to get this medication on the hands and skin.
                               7.   Do not insert guidewires down the tube in attempt to unblock it
                                    as they may damage the tube or cause trauma to the patient.
                               8.   If all recommended methods to unblock the tube have failed,
                                    contact your district nurse or Endoscopy Unit.
Problems with diarrhoea        1.   Observe any changes in bowel habits or existing problems with
                                    bowel.
(Non qualified staff/carers    2.   If patient has diarrhoea, a specimen should be sent for culture
should contact the patients’        and sensitivity.
District Nurse or GP).         3.   Check medication, which could be contributing to diarrhoea, e.g.
                                    antibiotics, antacids, elixirs, etc…
                               4.   If stool sample is negative, then antidiarrhoeals can be used.
                                    Consult GP/hospital doctor/District nurse.
                               5.   Always ensure good hygiene standards are maintained when
                                    handling the tube or delivering the feed.
                               6.   Refer to dietitian – who may recommend a fibre feed.
                               7.   If patient has gut atrophy (no enteral intake for 72 hours or
                                    more), the only way to overcome it is to persist with feed –
                                    antidiarrhoeals if cultures are negative.
Constipation                   1.   Monitor bowel function regularly.
(Non qualified staff/carers    2.   If patient is constipated, try extra flushes of fluids via the PEG,
should contact the patients’        advice should be sort from the dietitian.
District Nurse or GP).         3.   Contact the dietitian who may be able to advise on types of feed
                                    required.
                               4.   Consult Dietitian, District Nurse or GP if problem persists, they
                                    may suggest laxatives.
Patient is alert and           1.   Check when Speech and Language Therapist (SALT) last saw
motivated and staff feel            the patient.
that swallowing may have            2. Phone the relevant Speech and Language Therapy
improved                                 department, who will discuss the patient with you and
(Non qualified staff/carers              arrange a follow up appointment as appropriate (the number
should contact the patients’             is on this document).
District Nurse or GP).




ADMINISTERING MEDICATION VIA FEEDING TUBES

GENERAL GUIDELINES

   N.B. Carers employed by the Social services department are not permitted to
    administer medication via a PEG tube. It is suggested that the district nurse be
    contacted.

   Always contact pharmacist regarding drug administration.

Some drugs should be taken on an empty stomach, ensure you read the administration
instructions provided with the medication. Discontinue the feeding 15-30minutes before
giving the medication to allow time for the stomach to empty.

Which medication can be crushed?

      Drugs available in liquid form or alternatively soluble tablets if available.

      Sugar coated tablets may be crushed with a pestle and mortar to a fine powder.
       However, it is important not to confuse them with enteric-coated tablets, which
       must never be crushed. Always read the label on the medication box or bottle.

      The crushed tablets should be mixed thoroughly with 15-30mls for adults and 5-
       10mls for children, and then administered through the feeding tube.

Which tablets can you not crush?

      BUCCAL OR SUBLINGUINAL: GTN, Isosorbide, these are intended to avoid
       the gastrointestinal tract for various reasons.

      ENTERIC COATED: These are designed to release the drug in the intestine
       rather than the stomach, thus crushing a tablet would interfere with the
       mechanism (e.g. prednisolone).

      UNCOATED GASTRIC IRRITANTS: e.g. Aspirin. When crushed these drugs
       are more likely to cause adverse gastro-intestinal reactions. Medical staff should
       be asked to prescribe an alternative form.
      SUSTAINED RELEASE TABLETS: These are designed to release medication
       slowly, hence they usually contain 2-3 doses of medication. If crushed all of the
       drug would be released at once.

It is advisable to contact the pharmacist to check if certain drugs can be crushed.


ADMINISTRATION OF CAPSULES

The method of administration may affect the absorption of the medication. Please consult
the pharmacist before use.

Hard gelatin: Can be split open and powder mixed thoroughly with water (e.g.
Amoxycillan).

Soft gelatin: Can be prepared for administration by drawing up the contents in a syringe.
Alternatively the capsule may be dissolved in warm water (15-30 minutes) and then the
drug may be administered. Dissolving the capsule may take up to 1 hour)


SPECIAL CONDITIONS

      ANTACIDS: Should only be administered into the stomach – not into a tube
       placed beyond the pylorus (e.g. PEG with jejunal extension or a jejunostomy
       tube). Any other medication should be given 15 minutes before an antacid to
       avoid potential interactions.

      ANTIBIOTICS: some should be given with food, others on an empty stomach.
       Please read your instructions before use or check with a pharmacist.

      BULK FORMING AGENTS: certain agents, e.g. Metamucil may congeal and
       clog the tube.

      PHENYTOIN: has a narrow therapeutic range and enteral feeding can interfere
       with absorption. It may be appropriate to discontinue tube feeding for 1-2 hours
       before and the same after the phenytoin is given to enhance absorption. It is
       advised to carefully monitor phenytoin levels and patient response, especially
       after changes in the tube-feeding regime, as the dose may require adjusting.

      THEOPHYLLINE: This drug may be poorly absorbed with continuous feeding
       and it may be necessary to monitor levels.

      WARFARIN: Enteral feeding contains Vitamin K. Vitamin K and Warfarin
       antagonises each other pharmacologically. Prothrombin times should be
       monitored.
It is important to flush the feeding tube with 50mls of water prior to and following the
administration of medicines. The tube should be flushed with a minimum of 10mls in
between at drug administered.

It is important to ensure the patient gets safe and effective treatment, this requires close
collaboration between doctors, nurses, pharmacists and dietitians.


ENDOSCOPY UNIT CONTACT NUMBERS:-

Royal Lancaster Infirmary          01524 583724 / 01524 583629

Westmorland General Hospital       01524 585522 / 01524 585521

Furness General Hospital           01524 584066 / 01524 581112



LOCAL AUTHORS

Staff Nurse Pamela Bailey, Lancaster Endoscopy Unit

Dr Colin Brown, Consultant Gastroenterologist, MBHT

Adapted for Morecambe Bay with permission from a document developed by Alison
Young, Nurse Consultant from Royal Liverpool and Broadgreen University Hospitals

SIGN-OFF DATE:                         25th July 2005

REVISION DATE:                         1ST September 2005

								
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