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Welcome to The District Nurses' Gastrostomy Tube Management Training Package. The package is designed to assist teachers, teacher aides and carers,

    Gastrostomy Gastrostomy

    Tube Tube

    Management Management

    Information for Teachers and Carers Information for Teachers and Carers

    Prepared by Nikki Langman, Manager Training Services, The District Nurses, July 2004

    GASTROSTOMY TUBE MANAGEMENT GASTROSTOMY TUBE MANAGEMENT

Welcome to The District Nurses‟ Gastrostomy Tube Management Training Package. The

    package is designed to assist teachers, teacher aides and carers, who are assigned to

    look after a child with a gastrostomy tube in place.

    All persons who wish to undertake gastrostomy tube management training must have a current certificate in basic paediatric cardiopulmonary resuscitation from a recognised training organization.

To successfully complete the Gastrostomy Tube Management Training Package,

    participants must complete the following two requirements:

    1. Attendance at theoretical Session and/or completion of this reading package

    2. Competency Assessment

All the information required to complete the training program is contained in this

    booklet. The booklet does NOT contain however, any specific instructions, medical or

    pharmacological orders pertaining to any individual/child, nor does it contain any

    policies, procedures or protocols of The District Nurses or of the organization/agency

    receiving training.

For any queries relating to the program, please do not hesitate to contact Nikki

    Langman, Manager Training Services, at The District Nurses, 2 Birdwood Ave, Moonah,

    7009, telephone 6273 3000. Further information about gastrostomy management can

    be obtained from the PEG Clinic, Royal Hobart Hospital, 6222 8605; or in Northern

    Tasmania, from the Stoma Therapy Nurse, Launceston General Hospital, 6348 7111.

     1

    TABLE OF CONTENTS

    Content Page Number Gastrostomy Tube Management Training 1 Package - Introduction

    Important Information From The Department 3 of Education

    Gastrostomy General Information 4 Feed Considerations 5 Troubleshooting 6 Important Medication Considerations 7 Care of the Tube Site 8 Venting/Decompression 8 Care Plan (PEG/PEJ) 9 Feeding Regime Form 10 Contacts and Nursing Services 11 Competency Tool 12

     2

    IMPORTANT INFORMATION FROM THE DEPARTMENT OF EDUCATION

    STUDENT CARE PROCEDURES IN SCHOOL CONTEXTS STUDENT CARE PROCEDURES IN SCHOOL CONTEXTS

    GASTROSTOMY (STOMA) FEEDING GASTROSTOMY (STOMA) FEEDING

    Student Care Procedures in School Contexts General Information

Students with medical conditions requiring routine procedures during the school day

    can either access assistance for these procedures through their local district nursing

    service (see contacts list on the following page for regional contact numbers), or staff

    within the school can learn to undertake the procedure themselves through training

    and credentialing. The school‟s student resource package should be able to be

    accessed for funding such training / district nurse visits.

These procedures are very specific to the individual student and, like any medical

    procedure, carry some risk. Staff should only be permitted to undertake such

    procedures if they have been credentialed by medical staff (the student‟s doctor or

    local district nurse agency) and are willing and confident to carry out the procedure.

Staff members should never be coerced into a training program or be discriminated

    against because they choose not to undertake training for credentialing. In all schools

    there is a risk of blood or body fluid contact. Principals should ensure that all staff are

    trained in application of standard infection control precautions.

Credentialling should be undertaken annually to ensure staff knowledge is maintained

    and updated and new staff are appropriately trained.

Information included in this handbook:

This handbook includes information about gastrostomy (stoma) feeding, useful contact

    details and troubleshooting information. Competency checklists and an assessment to

    be used for credentialing staff to undertake gastrostomy feeds are included, along with

    a sample “Care Plan for Gastrostomy Tube Feeds”, which should be incorporated within

    the student‟s medical action plan (also included). Any information from the Stoma

    Clinics (contact details on following page) regarding the individual student‟s gastrostomy feed requirements should also be included within the “Care Plan for

    Gastrostomy Tube Feeds” document.

     3

    GASTROSTOMY TUBE GENERAL INFORMATION

    “Gastrostomy” refers to the surgical creation of an artificial opening into the stomach or jejunum through the abdominal wall. A gastrostomy is performed when a person is

    unable to eat normally, due to illness, injury or disability.

Tube feeding is an excellent way to ensure that a person who cannot eat normally

    receives adequate nutrition. Tube feeding goes directly into either:

    ? the stomach, through a gastrostomy tube (PEG or G-tube)

    ? the jejunum (a section of the small intestine), through a jejunostomy tube (PEJ or

    J-tube)

Tube feeds are given on two types of schedules:

    ? Continuous feeding where the formula drips through the feeding tube all day or

    all night (or both)

    ? Intermittent feeding where larger amounts of the formula are given 3 8 times a

    day.

The person‟s Dietitian and Medical Practitioner decide upon the feeding schedule and

    type of diet required.

     4

    GASTROSTOMY FEED CONSIDERATIONS

Feeds should be given only when the person is sitting upright, propped up at ? 30?, or

    whilst standing.

IMPORTANT - DO NOT lie the person flat during the feed.

    - WAIT for one hour after the feed before lying flat.

Lying down can cause the person to cough and/or vomit. This can easily lead to

    aspiration and further complications.

    WARNING

    If the person starts to cough or choke during a

    feed, or they have difficulty breathing, STOP the

    feed immediately!

    Notify a health care professional.

    There are three different ways to deliver tube feeds gravity feeding, pump feeding or bolus/syringe feeding.

    ? Gravity feeding: Formula is administered from a container suspended from an IV

    pole above the individual the formula flows through the tubing due to the

    effect of gravity.

    ? Pump feeding: A mechanical pump delivers the formula under pressure.

    ? Bolus/Syringe feeding: Formula is administered via a 60mL catheter tipped

    syringe.

Please follow the instructions given by the Dietitian or Medical Practitioner.

     5

    GASTROSTOMY TUBE - TROUBLESHOOTING

Some common problems that can occur with feeding tubes are listed below. Please

    refer to these procedures if you experience a problem with a feeding tube. If the

    problem continues, contact a health care professional.

Blocked Tube

    ? Insert a 30 60mL syringe into the end of the tube.

    ? Pull back the plunger and withdraw as much fluid as possible.

    ? Take the syringe out of the tube and discard the withdrawn fluid.

    ? Insert a syringe with 10mL warm water into the end of the tube. Moving the

    plunger back and forth, put a little water into the tube.

    ? If the tube does not clear, clamp the tube for 5 to 15 minutes.

    ? Fill the syringe with 10mL warm water. Try again to flush the tube.

    ? Repeat the procedure or call a health care professional if you are unable to

    clear the tube.

Tube Partially Out

    ? Do not use the feeding tube if it looks like it has come partway out of the tube site.

    Refer to the measurements/markings you have recorded.

    ? Call a health care professional immediately. In the event that the health

    professional is unavailable, go to the Emergency Department of your preferred

    hospital.

    ? Until you get help from a doctor, keep the tube in place by taping it to the skin.

Tube Completely Out

    ? If the tube is out it must be replaced. Otherwise, the opening to the stomach or

    intestine will begin to close within one to two hours.

    ? Cover the tube site with a small gauze dressing and tape to skin.

    ? Contact your health care professional, or go to the Emergency Department of

    your preferred hospital as soon as possible. Please remember to take the tube

    with you - this will ensure that the replacement tube is same type.

     6

    GASTROSTOMY TUBE - IMPORTANT MEDICATION CONSIDERATIONS

    Remember: medications must only be administered by an appropriately trained person.

    ? If a tablet must be crushed, or a capsule opened, don gloves and a mask to

    protect your-self from fine powder particles.

    ? NEVER crush enteric-coated or timed-release tablets or capsules.

    ? NEVER mix medication with tube feeding formula.

    ? NEVER mix medications together give them one at a time.

Medication Administration

    Most medications can be given via the feeding tube. It is recommended that:

    ? Liquid medication is used whenever possible (suspensions/elixirs).

    ? If a tablet must be crushed, be sure to crush it into a fine powder and mix it well in

    warm water.

    ? The tube is flushed with 20 30mL of warm water before and after medication

    administration.

    If more than one medication is to be given, give each separately and flush the tube

    with 5mL of warm water between medications.

    CAUTION

    Be sure to check with the pharmacist or health care professional before administering

    medication. Find out if:

    ? The medication is available in liquid form

    ? The tablet can be crushed, or the capsule opened

    ? The medication should be given on an empty or full stomach

    If the client has a J-tube/PEJ, make sure that the medication will work properly since

    it will be bypassing the stomach.

    There are a number of medications that must be separated from enteral feeds. This will involve turning the feed OFF for one hour before the dose, and NOT resuming the feed

    for at least one hour after the medication has been given. Please check with the pharmacist or health professional.

     7

    CARE OF THE TUBE SITE

It is important to check the tube site every day. Please contact a health care

    professional as soon as possible if you notice any of the following:

    ? Redness

    ? Pain or soreness

    ? Swelling

    ? Unusual drainage around the tube (such as bloody, odorous, or formula-like

    drainage

It is normal to have a small amount of serous ooze around the tube site, which may

    make the skin red. Granulation tissue, or „proud flesh‟ is often present, particularly in

    children. Unless it is painful, there is no need to have it treated.

If the tube site needs to be cleaned, please wash your hands and don gloves. Clean

    the area under the gastrostomy tube flange with warm water using a cotton tipped

    swab or face washer/gauze.

    VENTING / DECOMPRESSION

Abdominal discomfort and bloating may be caused by excessive air/gas in the

    stomach. Allowing the air to escape is called venting or decompression. The venting

    process will only take a couple of minutes and should be performed prior to each feed

    or medication administration.

PEG and Gastrostomy Tubes with Balloon

    ? Remove cap from the feeding port and attach a 60mL catheter tip syringe to the

    feeding port.

    ? Lower the syringe below the stomach.

    ? Allow contents and air (froth and bubbles) to fill the syringe.

    ? Drain the contents back into the stomach by raising the syringe above the

    stomach.

Low Profile Stomate

    ? These devices have a non-reflux valve in the tip of the tube which prevents the

    stomach contents refluxing up the tube and spilling from the feeding port.

    ? A decompression tube is inserted into the stomata, which opens the non-reflux

    valve and allows the air to escape.

    Hide-A-Port

    ? Connect the straight extension tube to the feeding port.

    ? Attach a 60mL catheter tip syringe to the extension tube and lower the syringe

    below the stomach.

    ? Allow the stomach contents and air to fill the syringe.

    ? Drain the contents back into the stomach by raising the syringe above the

    stomach.

     8

    CARE PLAN

    GASTROSTOMY/JEJUNOSTOMY TUBE

Personal Details

    Name:___________________________ D.O.B.: __/__/____ Sex: M / F

    Address:________________________________________________________________________

Gastrostomy Tube Details

    Name of tube: __________________________________________________

    Size of tube: ___________ G/Fr Measurement at skin: _________cm

    Type of tube: ? G-tube/PEG ? J-tube/PEJ Low Profile Stomate: ? Yes ? No Method of feeding: ? Gravity-drip ? Pump ? Syringe

    Schedule of feeds: ? Continuous ? Intermittent

Medication Administration

    Most medications can be given via the feeding tube. It is recommended that:

    ? Liquid medication is used whenever possible (suspensions/elixirs).

    ? If a tablet must be crushed, be sure to crush it into a fine powder and mix it well in

    warm water.

    ? The tube is flushed with 20 30mL of warm water before and after medication

    administration.

    ? If more than one medication is to be given, give each separately and flush the

    tube with 5mL of warm water between medications.

Venting/Decompression

    Abdominal discomfort and bloating may be caused by excessive air/gas in the

    stomach. Allowing air to escape (venting or decompression) should be performed prior

    to each feed or medication administration.

Positioning

    Tube feeds must only be given when the client is sitting upright, standing, or half seated

    with the head raised 30? or more. Never lie flat during a feed, and wait for one hour

    after the feed before lying down.

     9

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