NCM 116A: CARE OF CLIENTS W/ PROB IN NUTRITION, & GASTRO-INTESTINAL, METABOLISM &

ENDOCRINE, PERCEPTION & COORDINATION (RLE)

January - May 2024

GASTRIC LAVAGE On completion of lavage:

Indications 1. Provide mouth and nares care.
- According to Baw, Oczkowski, Klimaszyk and 2. Continue to monitor vital signs, abdominal status, and
Jankowski (2020), gastric lavage is indicated in cases other assessment data.
where significant amounts of tricyclic antidepressants, 3. Document the procedure.
labetalol, organophosphates, and toxic alcohols have
been ingested.
- Crouch, Carters, Dawood, and Bennett (2017) mentions JANUARY 25, 2024
that lavage is used for the instillation of warmed fluid GASTRIC LAVAGE
in hypothermia. - labas (siphon out gastric contents)
Contraindications Goal
- According to Baw, Oczkowski, Klimaszyk, and - minimize toxicant absorption
Jankowski (2020), gastric lavage is contraindicated in - promote excretion
cases of poisoning with corrosives, volatile substances, - assessment: obtain history and time
hydrocarbons, or detergents, unconscious patients, Indications
patients with significant psychomotor agitation, and - Hyperthermia (40 deg C) - iced saline
those who refuse or resist treatment. - Ingestion of drugs
- Crouch, Carters, Dawood, and Bennett (2017) adds that - Bleeding
the procedure is also contraindicated in patients with - Surgery to prep patient
esophageal varices (liver cirrhosis) or other - Sputum collection for infants up to 12 year olds if they
pre-existing medical or GI problems. have PTB
Four techniques to know that NGT is intact
TEKTURNA is a direct renin inhibitor. Direct renin inhibition with 1. Auscultation of bowel sounds
TEKTURNA works at the first and rate-limiting step of the 2. pH strip - red (acidic)
renin-angiotensin-aldosterone system (RAAS), limiting the 3. Roentgenogram (x-ray) — standard
formation of angiotensin I. 4. Aspiration of gastric contents
PERIPROCEDURAL CARE Check for bubbles
In terms of patient preparation: *semi-fowler’s sa ngt
1. The procedure must be explained to the patient, and left side lying sa lavage
verbal consent gained. Recovery
2. Reassure the patient that the tube will be immediately - best to do within 1 hour of oral ingestion
removed if any problems are encountered. - 90% recovery within 5 mins post-ingestion
3. The patient should be undressed and put in a gown. - 45% recovery within 10 mins
4. Transfer the patient to an appropriate area with O2, - 30% recovery within 19 mins
suction, and monitoring. - 8% recovery within 1 hour
5. Position them in the left lateral position with a 15-20%
head down tilt. after 1 hour - NO - esophageal perforation
Solution
The equipment needed are: - saline with 0.9% NSS in children to avoid hyponatremia
1. Hand sanitizer - warm H2O
2. Gloves - activated charcoal — special form of carbon — binds to
3. Towels other substances
4. Rubber sheets or underpants - 1 tsp - total surface area of football field
5. Emesis/kidney basin and tissue paper - water, sweet beverage
6. Asepto syringe
7. Medicine cup with cover Acetaminophen → antidote is Acetylcysteine
8. Litmus paper or pH indicator strips
9. Stethoscope unconscious/can't protect airway → intubate
10. Saline solution size: 36-40 french (adults)
11. Activated charcoal (ihahalo sa NSS) Opioids: morphine, oxycodone, fentanyl, heroin, codeine
give Naloxone, if no effect then do lavage
Na - brain
K - heart
Ca - muscles
Mg - muscles
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NCM 116A: CARE OF CLIENTS W/ PROB IN NUTRITION, & GASTRO-INTESTINAL, METABOLISM &
ENDOCRINE, PERCEPTION & COORDINATION (RLE)
January - May 2024

JAN 26, 2024 5. Stoma size

COLOSTOMY - Edematous or swollen after surgery
- stoma into the colon through abdomen - It subsides for 6 weeks
- Effluent: liquid, formed stool, and gas - measure it after 3 months cos it is healed na
- Purpose: fecal diversion, stool bypass - 2.5 cm or 1 inch

Types 6. Disturbed Body Image

1. Ascending - Involve pt and s/o in colostomy care.
Location: low to middle right side of the abdomen - Goal: if pt is removing it and looking at the stoma, and
Output: liquid, semi-liquid even cleaning it by themselves
2. Transverse
Location: center of abdomen above umbilicus NEXT WEEK: colostomy quiz
Output: Mushy, pasty, gas is common
3. Descending
Location: Left lower middle of the abdomen
Output: Pasty to formed, semi-formed, gas
4. Sigmoid
Location: Left lower middle of the abdomen
Output: Pasty to formed, semi-formed, gas
5. Ileostomy (can be temporary or permanent)
Location: lower right side of the abdomen
Output: Liquid

STOMA/COLOSTOMY CARE
1. Assess color.
Normal: dark red/brick red, pink
Abnormal: dark brown, purple, blue, dusky (poor
circulation is cyanosis)
2. Assess diet.
Low residue diet like peanuts, cabbage, berries
Low fiber like meat, fish, poultry, protein, milk, cheese,
bread, cereals, grains, vegetables and potatoes
Deodorizers like spinach and parsley
Avoid gas forming foods
bismuth subcarbonate tablet - decreases odor

3. Skin (done before surgery)

- clean and dry
- soap mild to clean the stoma
- gauze/dressing
KARAYA powder to maintain the site dry
Changing of pouch as necessary esp if soiled

4. Monitor I&O
- drain before the stool touches the stoma
- stool is measured since it is watery
Colostomy bag - can swim, jog
prior they drain it and best if they don't eat prior the
activity

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NCM 116A: CARE OF CLIENTS W/ PROB IN NUTRITION, & GASTRO-INTESTINAL, METABOLISM &
ENDOCRINE, PERCEPTION & COORDINATION (RLE)
January - May 2024
FEBRUARY 22, 2024
PERCUTANEOUS ENDOSCOPIC GASTROSTOMY
(PEG) STOMA CARE
Addressing Nutritional Deficiency
- Parenteral
- Nasogastric (NGT) - check patency through x-ray
- Naso-enteric or naso-jejunal tube feeding
- Percutaneous endoscopic gastrostomy (PEG) or
gastrojejunostomy tube - no need assessment but
check aspiration or the aspirate coming back from
asepto syringe, ibalik ang aspirate for nutrition
GASTROSTOMY
- Surgical procedure involving the creation of an opening
into the stomach for the purpose of administering
foods and fluids.
- It is a commonly employed method of access due to its
relative ease of placement in most patients and overall
tolerability.
- Preferred for prolonged nutrition (greater than 3 to 4
weeks) or when oral feeding is no longer possible such
as in the elderly or debilitated patient and in the
comatose patient because the gastroesophageal
sphincter remains intact.
- NGT q week changing
- Regurgitation and aspiration are less likely to occur
with a gastrostomy than with other feeding methods.
- PEG placement via endoscopy is now much more
widely used than surgical insertion.
- When compared with nasogastric access, PEG has
been shown to be a more reliable enteral access tube,
allowing patients to receive more calories daily bec of
a reduction in tube dysfunction.
- In PEG, enteral tube feeding refers to delivering
nutrition via a tube directly into the stomach,
duodenum or jejunum.
- In most cases of poor oral intake and inability to
swallow, enteral feeding is a viable option during the
course of hospitalization.PEG has become the most
commonly employed method of enteral access, due to
its relative ease of placement in most patients and
overall tolerability,
The three main indications for gastrostomy
placement are the ff:
1. Long term feeding
2. Gastric decompression (done usually may obstruction;
pts with lason – tinatanggal yung pressure)
3. A combination of the above
Gastrostomy in Adults
- Clinical conditions requiring gastrostomy include
dysphagia from a variety of causes including:
a. Elderly and debilitated patients unable to tolerate oral
and NGT feeding;
b. Neurogenic indications such as stroke, brain injury,
brain tumors and neurodegenerative syndrome; and
c. Non-neurological indications include head and neck
cancer, surgery to the mouth and throat, aspiration,
Crohn’s disease, severe burns, decompression of the
stomach in obstructing intra-abdominal malignancy.
- Neurogenic dysphagia secondary to stroke is the most
common cause for PEG insertion in adults.
- Multiple sclerosis (MS) is also associated with
progressive dysphagia prompting the use of PEG
(severe muscular weakness), so they're given
acetylcholine and dopamine.
Gastrostomy in Infants and Children
- The primary indication for PEG is the need for long
term (>3-6 months) primary or supplemental enteral
feeding.
- They can be subdivided into the two most common
groups of gastrostomy tube candidates:
a. Those with severe dysphagia: those with
neurologic dysfunction that impairs normal
swallowing
b. Failure to thrive (FTT): potential causes of FTT
include short gut syndrome, GI
malabsorption, malignancy, trauma and
congenital heart disease among others
- Gastrostomy may also be considered in patients with
pulmonary disease due to frequent aspiration oral
feeds.
The Major Contraindication for PEG placement is bowel
obstruction.
Contraindications for Gastrostomy Placement also includes:
- Neoplastic, inflammatory and infiltrative diseases of
the gastric and abdominal walls
Complications of PEG
1 Wound infection, cellulitis, and abdominal wall abscess.
Causes:
a. Patients who require PEG are often malnourished and
have other comorbidities that make them more
susceptible to wound infection.
b. Factors that contribute to the development of infection
may include gastric acid leakage and pressure areas
from excessively tight tubes.
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NCM 116A: CARE OF CLIENTS W/ PROB IN NUTRITION, & GASTRO-INTESTINAL, METABOLISM &
ENDOCRINE, PERCEPTION & COORDINATION (RLE)
January - May 2024
2 GI bleeding due to organ puncture during insertion.
Causes:
a. Unsuccessful passage of the needle could have caused
the gastric artery branch laceration or due to a liver
laceration.
b. It presents with unexplained post-procedure
hypotension thus early recognition and treatment are
essential.
Trendelenburg if there’s hypotension, elevate the feet so
blood flow will go to the heart and not in the peripheral sites.
If bleeding, notify the physician immediately.
3 Pneumoperitoneum
Causes:
a. Can occur after insertion.
b. Due to air escaping into the peritoneal cavity during
the puncture of the abdominal wall and the stomach
but is of no clinical significance and does not warrant
any further intervention.
4 Peritonitis
Causes:
a. Intraperitoneal leakage of gastric contents, wound
dehiscence and delayed stoma closure can cause
peritonitis.
b. Carries a high mortality rate.
Signs of sepsis: high fever,
Intestines are highly supplied with blood, so if there is infection,
mabilis kumalat ang infection.
Wound dehiscence: place sterile gauze
5 Excessive leakage at the peristomal site.
Causes:
a. One of the more commonly encountered complications.
b. It can result from mechanical factors such as torsion or
twisting on the tube or a malpositioned tube.
6 Buried Bumper Syndrome
Causes:
a. Defined as the migration of the PEG Tube into the
gastric wall and the subsequent epithelization of the
site.
NURSING GOALS AND INTERVENTIONS
Meeting Nutritional Needs
a. The first fluid nourishment is administered soon after
surgery and usually consists of tap water and 10%
glucose.
b. At first, only 30 to 60 ml (1 to 2 oz) is given at one time,
but the amount is increased gradually.
c. By the second day, 180 to 240 ml (6 to 8 oz) may be
given at one time, provided it is tolerated and no
leakage of fluid occurs around the tube.
d. Water and milk can be instilled after 24 hours for a
permanent gastrostomy.
e. High calorie foods are added gradually.
f. Blenderized foods are added gradually to clear liquids
until a full diet is achieved.
CLEAR LIQUID DIETS - no solid foods like broth, clear fruit juice,
black tea, water, coffee, popsicles, gelatin
FULL LIQUID DIET - milk, yogurt, pudding, ice cream,
smoothies, fruit and vegetable juice
MECHANICAL SOFT DIET - banana, finely chopped meat, soft
fruits, watermelon, vegetable pwedeng icrush, rice, pasta, egg,
cottage cheese
4-6 hours PEG tube, di pwede pakainin
Providing tube care, preventing infection
and providing skin care
Providing tube care and preventing infection
a. A small dressing can be applied over the tube outlet,
and the gastrostomy tube can be held in place by a
thin strip of adhesive tape that is first placed around
the tube and then firmly attached to the abdomen.
b. The nurse verifies the tube’s placement, assesses
residuals, and rotates the tube or stabilizing disk once
daily to prevent skin breakdown.
c. For gastrostomy tubes that have balloons that are
inflated with water to anchor the tube in the stomach,
the adequacy of balloon inflation is checked weekly by
deflating the balloon using a Luer-tip syringe.
Providing skin care
a. Wash the area around the tube with soap and water
daily, removes any encrustation with saline solution,
rinses the area well with water and pats it dry.
a. Once the stoma heals and drainage ceases, a dressing
is not required.
Enhancing body image
a. Calm discussion of the purposes and routines of
gastrostomy feeding can help keep the patient from
feeling overwhelmed.
b. Talking with a person who has had a gastrostomy can
also help the patient to accept the expected changes.
c. Adjusting to a change in body image takes time and
requires family support and acceptance thus
evaluating the existing family support system is
necessary.
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NCM 116A: CARE OF CLIENTS W/ PROB IN NUTRITION, & GASTRO-INTESTINAL, METABOLISM &
ENDOCRINE, PERCEPTION & COORDINATION (RLE)
January - May 2024
Monitoring and Managing Potential Complications
a. The most common complications is wound infection
including cellulitis and abscesses in the abdominal wall.
b. Bleeding from the insertion site in the stomach may
also occur. Report any signs of bleeding promptly.
Teaching patients self-care
a. Assess the patient’s knowledge, interest in learning
about the tube feeding and stoma care, and ability to
understand and apply the information before providing
detailed instructions.
b. Written materials for patients and caregivers are
designed to outline stoma care instructions.
c. Demonstration of tube feeding (including checking for
residual) and stoma care.
d. The gastrostomy tube may be an annoyance to the
patient and must be instructed to avoid spending time
in the prone position.
Premature removal of tube
a. If the tube is removed prematurely, the skin is cleansed
and a sterile dressing is applied. The nurse immediately
notifies the physician. The tract will close within 4-6
hours if the tube is not replaced promptly.
EVALUATION AND EXPECTED PATIENT OUTCOMES
Patient is free from infection and skin breakdown and avoids
complications
a. Is afebrile
b. Has no drainage or bleeding from the insertion site
c. Inspiects twice a day
d. Tube remains intact for the duration of therapy
Adjusts to change in body image
a. Is able to discuss expected changes
b. Verbalizes concerns
c. Asks to speak with someone who has experienced this
procedure
Demonstrates skills in managing feeding regimen
a. Adminsteres feeding or does so independently
b. Demonstrates how to maintain tube patency
c. Cleans tubing as needed
d. Keeps an accurate record of intake
IN SUMMARY
- PEG feeding represents the most effective and safest
option for feeding patients with an impaired or
diminished swallowing ability.
- The nurse must recognize risk factors for complications
after PEG tube placement.
- PEG complications are mostly prevented by
appropriate nursing care.
- Stoma care should be done daily.
PERCUTANEOUS ENDOSCOPIC GASTROSTOMY
- PEG is a procedure done by a surgeon and a nurse with
specialty skills. After administering a local anesthetic,
the surgeon inserts an endoscope via the mouth to
visualize the site of insertion within the stomach wall
and complete the entire process.
- PEG tube diameters vary. Commonly used times range
from 6 mm to 8 mm. Small diameter tubes should be
avoided in patients with poor gastric emptying who
require intra-gastric administration of medications.
UNEXPECTED SITUATIONS AND ASSOCIATED
INTERVENTIONS
- We, as nurses taking care of patients with Gastrostomy
tubes in place, must be ready to act in unexpected
situations. Here are some examples and interventions.
Tube is found not to being stomach or intestine
- Refer to attending surgeon and prepare steps to
replace the tube.
- Instruct the patient on appropriate actions if the tube
comes out. In the event the gastrostomy time is pulled
out, teach the patient to clean the area with water,
cover the opening with a clean dressing, tape in place,
and call the primary care provider immediately.
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 tube while pressing the external bumper
closer to the skin.
- 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
- If the skin is erythematous and appears to be broken
down, this could indicate leakage of gastric fluids from
the site. Stop the leakage and apply a skin barrier such
as Zinc Oxide.
- Notify physician as the patient could be developing
cellulitis at the site.
SPECIAL REMINDER
- The initial PEG device can be removed and replaced
once the tract is well-established (10-14 days after
insertion).
- Replacement of the PEF device is indicated to provide
long-term nutritional support, to replace a clotted or
migrated tube, or to enhance patient comfort.
- When it is no longer required, the gastrostomy tube is
removed and the stoma permitted to close. The stoma
usually closes rapidly however occasionally this can
take several weeks and be problematic due to profuse
leakage of gastric content.
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NCM 116A: CARE OF CLIENTS W/ PROB IN NUTRITION, & GASTRO-INTESTINAL, METABOLISM &
ENDOCRINE, PERCEPTION & COORDINATION (RLE)
January - May 2024

NURSING DIAGNOSIS: PEG

- Imbalanced Nutrition
- Deficient Knowledge
- Nausea
- Impaired Skin Integrity
- Alteration in Comfort
- Risk for Infection

EXPECTED OUTCOMES
- The patient ingests an adequate diet and exhibits no
signs and symptoms of irritation, excoriation or
infection at tube insertion site.
- The patient verbalizes little discomfort related to tube
placement.
- The patient will be able to verbalize and understand the
care needed for his/her gastrostomy tube.
- The patient verbalizes no pain when the guard is
rotated.
- The skin remains pink without any sign of skin
breakdown.
- The patient participates in care measures

DOCUMENTATION
- Record the condition of the site, including the
surrounding skin.
- Note if any drainage was present, recording the
amount and color.
- Note the rotation of the guard.
- Comment on the patient's response to care, if any pain
was felt, and if an analgesic was given.
- Record any instruction that was ordered or given for
PEG nutrition and care.

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