Gastrostomy and Jejunostomy

Gastrostomy
• Is a surgical procedure in which an opening is created into the stomach for the purpose of administering foods and liquids via a feeding tube or for gastric decompression in the setting of intestinal obstruction.

• A gastrostomy is preferred over NG feedings in the patient who is comatose, because of gastroesophaeal sphincter remains intact, making regurgitation and aspiration less likely than with NG feedings.

• Gastrostomy tube may be placed surgically through an abdominal incision with sutures to secure the tube to the anterior gastric wall and the creation of a tunnel brought out through the abdomen to form a permanent stoma.

but the distal end extends beyond the pylorus into the jejunum. • After the procedure. and a dressing is placed over the tube. An abdominal binder is applied to protect the tube. Then you will be taken to your hospital room. an antibiotic ointment is applied to the tube site.Jejunostomy • Jejunostomy is similarly placed. .

They will also be available to assist you in caring for your tube at home. . A visiting nurse or home care company will help arrange for your feeding pump and instructions on how to use the pump at home.• Using the J-tube for feeding Feedings through a J-tube are always done using a feeding pump.

into the stomach. and through the abdominal incision • A mushroom catheter tip or internal fasteners secure the tube against the stomach wall . • After local anesthetic is administered. a cannula is inserted into the stomach through a small abdominal incision and an endoscope is inserted via the patient's mouth and upper GIT.Insertion of a Percutaneous Endoscopic Gastrostomy (PEG) • Requires the service of a provider skilled endoscopy or interventional radiology. • The PEG tube is guided down the esophagus.

. then the gastrostomy can be attempted under x-ray guidance through the abdominal wall.• If an endoscope cannot be passed through esophagus .

• Replacement of the PEG device is indicated for a clogged of fractured tube. typcally 3-6 weeks after insertion. • PEG tube no longer required (recovery of swallow after stroke or surgery for laryngeal cancer) • Persistent infection of PEG site • Failure. breakage or deterioration of PEG tube (a new tube can be sited along the existing track) • "Buried bumper syndrome" . • The PEG should be fitted securely to the stoma to prevent leakage of gastric secretions and is maintained in place through gentle traction between the internal and anchoring device.Removal of PEG • The initial PEG device can be removed and replace once the tract is well established.

• these device are inserted flush with the skin. they eliminate the possibility of tube migration and have antireflux valves to prevent gastric leakage.Alternative to PEG device • An alternative to the PEG device is a low profile gastrostomy device (LPGD) May be inserted 3-6 months after intial gastrostomy tube placement. .

. it is not possible to assess residual volumes w/ LPGDs(ie. they have one way valve).• Pt. requiring lifelong enternal support are able to conceal the feeding access site under their clothing. • However. they also require a special adaptor to connect the device to the feeding container.

and family to a change in a body image and to participate in self care. The nurse assesses the ability of both pt. . The feeding tube will bypass the mouth and esophagus so that liquid feeding can be administered directly into the stomach or intestines. ability both to understand and cooperate with the procedure.The patient with a Gastrostomy or Jejunostomy • Assessment Determined the pt. the purpose of the procedure and expected postoperative course should be explain.

the patient may find it more acceptable.• If the tube is expected to be permanent. prolonged vomiting . the patient should be made aware of this. . debilitation of an ability to eat. • The procedure is being performed to relieve discomfort .

interventions are identified to help them cope with the tube and learn self –care measures. responses to the change of body image and their understanding of the feeding method. fluid and nutritional needs to assessed to ensure proper intake and GI Function. .• In the postopreative period. • Evaluate pt. • Inspect the tube for proper maintenance and incision for signs of infection. the pt.

• Acute pain • Risk for infection related to presence of wound and tube.Diagnosis • Major diagnosis in the postoperative period may include the ff. . • Risk for impaired skin integrity at tube insertion site • Disturbed body image related to the presence of tube.

.Collaborative Problems/Potential Complication • Would infection. cellutitis. and leakage • GI Bleeding • Premature dislodgement of the tube.

Planning and goals • • • • • • Minimizing pain Preventing infection Maintaining skin integrity Enhancing coping Adjusting to change in body image Preventing complication. .

Nursing Intervention • Meeting nutritional needs • Providing tube care and preventing infection • Providing skin integrity • Enhancing body image • Monitoring and managing potential complication • Promoting home and community-based care .

Has normal electrolyte values c. . Is adequately hydrated 2.Is free from infection and skin breakdown a. b. Demonstrates intact skin surrounding the exit site. Is afebrile b. Has no drainage from the incision c.Evaluation 1. Maintains or gains wg.Maintains adequate fluid balance a.

Demonstrate skill in tube care a. Is able to discuss expected change b. Avoids complication a. Inhibits adequate wound healing b. Keeps an accurate record of I and O 5. Has no abnormal bleeding from puncture site c. Handles equipment competently b.3. Demonstrate how to maintain tube patency c. Verbalizes concerns 4. Tube remains intact for the duration of therapy . Adjust to change in body image a.

carbs. fats. • The goal of PN are to improve nutritional status. • The nutrients are complex admixture containing proteins. vitamins. establish a positive nitrogen balance. trace minerals and sterile water in a single container. . and enhance the healing process. promote wt. maintenance or gain.Parenteral Nutrition • PN is a method of providing nutrients to the body by an IV route. electrolytes. maintain muscle mass.

NaCl are added to the solution to maintain proper electrolyte balance and to transport glucose and amino acid across cell membranes.P. . Mg. • When highly concentrated Dextrose is administered. • Electrolytes such as Ca. caloric requirements are satisfied and the body uses amino acid for protein synthesis rather than for energy.Establishing (+) nitrogen balance • PN solution can provide enough calories and nitrogen to meet the patient daily nutritional needs.

Clinical Indication • The indication for PN include an inability to ingest adequate oral food or fluids w/in 7days. . Enteral nutrition should be considered before parenteral support because it assist in maintaining gut mucosal integrity and is typically associated with fewer complication.

1-3 times a week. Intravenous fat emulsion (IVFEs) may be infused site and should not be filtered. IVFEs can provide up to 30% of the total daily calorie intake.Formulas • A total of 1-3 L of solution is administered over a 24-hrs period. . Usually 500 Ml of a 10% IVFE is administered over 6-12 hrs.

acute pancreatitis. sepsis. Is unwilling or unable to ingest Adequate nutrients orally or enterally Preoperative and postopetative nutritional nutritional needs are prolonged major psychiatric illness extensive bowel surgery. postradiation high-output fistula The pt. Crohn short gut. bowel syndrome. cancer Impaired ability to ingest or absorb disease. malnutrition. food orally or enterally enteritis enteroculataneous paralytic ileus.INDICATION FOR PARENTERAN NUTRITION CONDITION OR NEED Insufficient oral or enteral intake short EXAMPLES severe burns. AIDS. .

Initiating therapy • PN solution are initiated slowly and advanced gradually each day to the desired rate as the patient’s fluid and dextrose tolerance permits. • A 24 hrs urine nitrogen determination may be prformed for analysis of nitrogen balance .

Administration methods 1. Peripheral Method(PPN) is administered through a peripheral vein. this is possible because the solution is less hypertonic than full-calorie parenteral nutrition solution lipids are administered simultaneously to buffer the PPN and to protect the peripheral veins from irritation. the usual length of therapy using PPN is 5-7 days .

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large.• Central method (CPN) • CPN have 5-6 times the solute concentration of blood (and exert an osmotic pressure of about 2000 mOsm/L). large blood vessel (eg. . Concentrated solution are then very rapidly diluted to isotonic levels by the blood in this vessel. the subclavian vein). they are administered in to the vascular sysytem through a catheter inserted into a high-flow.

Nontunneled Central Catheters -used for short term (less than 6 weeks) -subclavian vein is the most common vessel used -the jugular vein should only be used as a last resort and then only for 1-2 days -single lumen. triple lumen central catheters are available for central lines -distal lumen can be used for administration . double lumen.Four types of central venous access devices (CVADs) 1.

• Peripherally Inserted Central Catheters • PICC. and the catheter is threaded to the superior vena cava. . or home care setting. • The basilic or cephalic vein is accessed above the antecubital space. • Taking BP and blood specimens from the extrimity with the PICC is avoided. long term care.are used for intermidiate-term (several days to months) IV therapy in the hospital.

examples are the Hickmans. • These catheters are cuffed and can have single or double lumens. • They are threaded under the skin ( reducing the risk for ascending infection) to the subclavian vein and advanced into the superior vena cava. and Permacath.• Tunneled Central Catheters • Are for long term use and may remain in place for many years. . Groshong. • There catheter are inserted surgically.

.implanted ports .The end of the catheter is attached to a small chamber that is placed in a subcutaneous pocket.More expensive than the external catheters. and access requires passing a special noncoring needle through the skin into the chamber to initiate IV therapy. .Used for long term IV therepy. either on the anterior chest wall or on the forearm. .

isotonic dextrose can be administered for 1-2 hrs to prevent rebound hypoglycemia. . the nontunneled central venous catheter of PICC is removed and an occlusive dressing is applied to the exit site • Tunneled catheters and implanted ports are removed only by the physician.Discontinuing Parenteral Nutrition • PN solution is discontinued gradully to allow the patent to adjust to decrease level of glucose. • Once all IV therapy is completed. • If PN solution is abrupt terminated.

unable to tolerate oral and enteral feeding who may be candidates for PN • Indicators include significant wg. electrolyte levels. . • The nurse carefully monitors the pt.). hydration status. loss (10% or morethan of usual wg. and calorie intake.Nursing Process: Patient Recieving PN • ASSESSMENT • Nurse assist in identifying pt.

DIAGNOSIS • The major nursing diagnosis may include the ff. less than body requirements. related to inadequate oral intake of nutrients • Risk for infection related to contamination of the central catheter site of or infusion line • Risk for imbalanced fluid volume related to altered infusion rate • Anxiety related to catheter care and securement . • Imbalanced nutrition.

Fluid overload 8.Collaborative Problems/Potential Complication Most common complication are: 1.Catheter displacement and contamonation 5.Hyperglycemia 7.Embolism 3.Rebound hypoglycemia.Clotted cathter line 4. .Pneumothorax 2.Sepsis 6.

Planning • Major goals for the pt. • • • • • • Optimal level of nutrition Absence of infection Adequate fluid volume Optimal level of activity Knowledge of and skill in self-care Absence of complication .

uniform infusion of PN solution over 24 hrs period is desired • The time periods for infusion are sufficient to meet the pt nutritional and pharmacologic needs • Pt is initially weighted daily at the same of the day under the same condition for accurate comparison • Important to keep accurate I and O records and calcutaion of fluid balance • Calorie count is kept of any oral nutrients • Trace elements are included in PN solution and are individualized for each pt .Nursing intervention • Maintaining Optimal Nutrition • Continuous.

Preventing Infection • High dextrose and fat content of PN solution makes them an ideal culture medium for bacterial and fungal growth and CVADs provide port of entry • Meticulous aseptic technique is essential to prevent infection any time the IV line setup is manipulated • The primary source of microorganism for catheter related to bloodstream infections are the skin and the catheter • The catheter site is covered w/ an occlusive gauze dressing that is usually changed using sterile technique every 24-72 hrs .

an infusion pump is necessary • Designed rate is set in mL/hr. the pt does not receive the maximal benefit of calorie and nitrogen. • I and O are recorded q8 . • If the rate is too rapid.Maintaining Fluid • To maintain an accurate rate of PN administration. hyperosmolar duiresis can occur • If the flow rate is too slow . and the rate is checked every 3-4 hrs.

the pt is free to move the extremities. and normal activity should be encourage to maintain a good muscle tone .• Encourage Activity • With a catheter in the subclavian vein.

Maintains proper catheter and equipment function b. as evidenced by good skin turgor • achieve an optimal level of activity. is afebrile b.Evaluation • Expected Pt Outcomes • Attains or maintains nutritional balance • Is free of catheter-related infection a. Has no purulent drainage from the catheter insertion site • Is hydrated. within limitations • demonstrates skill in managing PN regimen • prevent complication a. Maintains metabolic balance within normal limits .

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