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.

Jejunostomy
Jejunostomy is similarly placed, but the distal end extends beyond the pylorus into the jejunum. After the procedure, an antibiotic ointment is applied to the tube site, 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.

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

Insertion of a Percutaneous Endoscopic Gastrostomy (PEG)

Requires the service of a provider skilled endoscopy or interventional radiology. 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.

The PEG tube is guided down the esophagus, into the stomach, and through the abdominal incision A mushroom catheter tip or internal fasteners secure the tube against the stomach wall

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

Removal of PEG
The initial PEG device can be removed and replace once the tract is well established, typcally 3-6 weeks after insertion. Replacement of the PEG device is indicated for a clogged of fractured tube. 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. 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"

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. these device are inserted flush with the skin; they eliminate the possibility of tube migration and have antireflux valves to prevent gastric leakage.

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

The patient with a Gastrostomy or Jejunostomy Assessment

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

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

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

Diagnosis
Major diagnosis in the postoperative period may include the ff. Acute pain Risk for infection related to presence of wound and tube. 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

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

3. Adjust to change in body image

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

Parenteral Nutrition

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

Establishing (+) nitrogen balance

PN solution can provide enough calories and nitrogen to meet the patient daily nutritional needs. When highly concentrated Dextrose is administered, caloric requirements are satisfied and the body uses amino acid for protein synthesis rather than for energy.

Electrolytes such as Ca,P, Mg, NaCl are added to the solution to maintain proper electrolyte balance and to transport glucose and amino acid across cell membranes.

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.

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

INDICATION FOR PARENTERAN NUTRITION

CONDITION OR NEED Insufficient oral or enteral intake short

EXAMPLES severe burns, malnutrition,

bowel syndrome, AIDS, sepsis, cancer

Impaired ability to ingest or absorb disease, food orally or enterally enteritis enteroculataneous

paralytic ileus, Crohn short gut, postradiation high-output fistula

The pt. 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, acute pancreatitis.

Initiating therapy
PN solution are initiated slowly and advanced gradually each day to the desired rate as the patients 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

 Central method (CPN)

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

Four types of central venous access devices (CVADs)

1. 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, double lumen, triple lumen central catheters are available for central lines -distal lumen can be used for administration

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

 Tunneled Central Catheters

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

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

Discontinuing Parenteral Nutrition

PN solution is discontinued gradully to allow the patent to adjust to decrease level of glucose. If PN solution is abrupt terminated, isotonic dextrose can be administered for 1-2 hrs to prevent rebound hypoglycemia.

Once all IV therapy is completed, 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.

Nursing Process: Patient Recieving PN

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

DIAGNOSIS
The major nursing diagnosis may include the ff.
Imbalanced nutrition, 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

Collaborative Problems/Potential Complication

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

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

Nursing intervention
Maintaining Optimal Nutrition Continuous, 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

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

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

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

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