GASTROSTOMY FEEDING
Gastrostomy is an operation to create an opening into the stomach for the purpose of administering food and fluids.
Commonly employed feeding gastrostomies
1. The Stamm (temporary and permanent) gastrostomy requires purse-string sutures to secure a tube to the anterior gastric wall. A stab wound exit is created in the left upper abdomen to provide for the gastrostomy.
2. Janeway (permanent) gastrostomy a tunnel is created and brought out through the abdomen to form a permanent stoma (called a gastric tube).
3. Percutaneous endoscopic gastrostomy (temporary) The physician inserts a cannula into the stomach through an abdominal incision, using local anaesthesia. The physician then threads a nonabsorbable suture through the cannula. A second physician, looking through an endoscope, uses the endoscopic snare to grasp the end of the suture and guide it up through the patient's mouth. The suture is knotted to the dilator tip at the end of the PEG tube. The endoscopist then advances the dilator tip through the patient's mouth while the other physician pulls the suture through the cannula site. The attached PEG tube is guided down the oesophagus into the stomach and out through the abdominal incision. The mushroom catheter tip and internal crossbar secure the tube against the stomach wall. An external crossbar keeps the catheter in place. A tubing adaptor is in place between feedings and a clamp is used to close or open the tubing.
Gastrostomy feeding: Liquid feedings are administered directly into the stomach by means of a rubber, or plastic tube or a prosthesis.
Indications
1. May be performed to relieve discomfort, prolonged vomiting, debilitation and inability to eat
2. Performed on elderly or a comatose patient who cannot tolerate nasogastric feedings
Method: Either with a syringe or a funnel.
General Instructions
1. The first fluid nourishment (tap H₂O & 10% glucose) is administered soon after surgery. 30-60 ml/ feed is given and gradually increased.
2. By the second day, 180-240 ml may be given at a time, if tolerated.
3. Check for leakage of fluid around the tube.
4. After 24 hours, water and milk can be instilled.
5. Gradually high-calorie liquids are added.
6. In some settings, the gastric secretions are aspirated and reinstilled, after adding enough feedings to bring the volume to the desired total. By this gastric dilatation is avoided.
7. Blenderized foods are gradually introduced. The fibre and residue are similar to a normal diet.
8. Intake of milk is avoided in patients with lactase deficiency.
9. The tube can be held in place by a thin strip of adhesive that is first twisted about the tube and then firmly attached to the abdomen.
10. A catheter plug or rubber tipped haemostat is used to close the outlet of the tube immediately after a feeding to prevent leakage.
11. A small dressing can be applied over the tube outlet, the tube can be coiled and held in place by Montgomery straps or a firm abdominal binder. This protects the skin surrounding the incision from the seepage of gastric acid contents and the spillage of feedings. The dressing is changed every 2 or 3 days
12. Daily washing with soap and water around the tube and the application of a bland ointment e.g. Zinc oxide or petrolatum prevents the skin from becoming irritated by the enzymatic action of gastric juices
13. A long term gastrostomy may require application of stomahesive wafer to maintain the integrity of the skin around the tube, protect it from gastric secretions and stabilize the entry site.
14. Evaluate the skin daily for signs of breakdown, irritation or excoriation.
15. Talking with the patient helps him accept the expected changes.
16. Family support and acceptance is necessary.
Nurse's Responsibilities
1. Evaluate the skin daily for signs of breakdown, irritation or excoriation.
2. The dressing around the tube outlet should be changed every 2-3 days.
3. Talking with the patient helps him accept the expected changes.
4. Assess the patient's level of knowledge, interest in learning about the procedure and ability to understand and apply the information.
5. Teach formula preparation and management of tube feedings.
6. Teach tube feedings and evaluate by questioning and return-demonstrations.
7. All feedings are given at room temperature.
8. Check for residual content before each feeding. 9. The tube is marked at the skin level. Advise the patient to monitor the tube's length and notify the physician, if the tube outside the body becomes shorter or longer
10. Flush the tube with 30ml of H₂O after each bolus or medication administration to keep it patient
11. Care of the irrigation set daily cleaning with warm soapy H₂O and rinsing after each use.
Procedure
1. Check for residual gastric content before feeding.
2. Determine the patency of the tube by administering H₂O at room temperature before and after feeding to clear the tube of food particles, which could decompose if allowed to remain in the tube.
3. Feedings are given at room temperature.
4. The liquid (for bolus feeding) is introduced into the catheter by a funnel or a barrel of a syringe.
5. The receptacle is tilted to allow air to escape while the liquid is initially being instilled.
6. The feeding is allowed to flow into the stomach by gravity, as the syringe/barrel fills with liquid.
7. The barrel/syringe is held perpendicular to the abdomen at 45 cm (18") above the abdominal wall.
8. Usually 300-500 ml (bolus feeding) is given for each meal and requires 10/15 mins. to complete.
9. The amount is determined by the patient's reaction. If he feels "full" - give smaller amounts more frequently.
10. Elevate the head of the bed for at least 4 hr. after feeding facilitates digestion and decreases the risk of aspiration.
11. Note any obstruction and notify the physician.
12. Some patients smell, taste and chew small amounts of food before the tube feedings to stimulate flow of salivary and gastric secretions and gives a sensation of normal eating. The chewed food is then deposited into the funnel of the gastrostomy tube and not swallowed.
13. Tube feeding may also be given by intermittent or continuous pressure by a feeding pump. Most enteral feeding systems have built-in alarms that signal when the bag is empty, when the battery is low or if an occlusion is present.
