TUBES R US. Enteral Access & Management

Transcription

1 TUBES R US SHEILA BELL, MS, RN, CPNP PC Christine Gangi, RN, CPN Center for Gastrointestinal Motility and Functional Disorders Division of Pediatric Gastroenterology & Nutrition Enteral Access & Management 3 1

2 4 5 IF THE GUT WORKS USE IT OR LOSE IT. 6 2

3 GASTROSTOMY 8 LAPEG PEG (Percutaneous Endoscopic Gastrostomy) with direct visualization of gastric wall GOAL: AVOID colonic piercing (gastro colonic fistula) Technique: 10 millimeter Intraumbilical Laparoscopic port placement Critical to visualize anterior gastric vessels 9 3

4 ENTERAL ACCESS MAINTENCE CATHETER CARE SKIN PROTECTION TRACT CARE GRANULOMA PREVENTION CARE OF TUBES Knowing location and purpose of tube is essential Gastrostomy tubes = stomach Gastro jejunal tubes = jejunum via stomach Primary jejunal tube = jejunum Cecostomy tube =Cecum (used for antegrade enema NOT feeding) 11 CARE OF TUBES STABILIZATION OF TUBES IS ESSENTIAL!!! Prevents skin erosion/irritation Prevents stomach contents leakage Prevents tube migration Minimizes formation of granulation tissue 12 4

5 CARE OF TUBES Flushing of Tube is important Prevents blockage flush before and after feedings or medications Use recommended amount of water followed by small push of air Use liquid medication whenever possible Mix finely crushed meds in feed/formula then thin out consistency with water/liquid 13 DAILY SKIN CARE Clean skin with normal saline or soap and water Dry skin thoroughly Assess skin daily and apply protective creams or ointments as needed Bathing allowed one week after tube placement, swimming in pool 6 8 weeks CARE OF GJ TUBES Need to be changed or replaced in radiology Should NEVER be rotated Need to be replaced every 3 to 6 months Good flushing after all meds and feeds G port can be used for venting 5

6 Low Profile G J tubes 16 FEEDING METHODS G tube Bolus (syringe, gravity, pump) Continuous drip G J tube or J tube Continuous drip only NEVER bolus Bolus Feeds May administer using syringe, gravity feeding bag or pump Give feeding over 20 to 30 minutes or longer as tolerated by patient 6

7 Continuous Feeds Night time drip feeding only can use pump that is plugged in at all times For daytime or night time continuous feeds in the active. mobile child use portable pump (Zevex Enteralite Infinity) Feeding Problems / Intolerance Check tube patency Try venting patient Check for residual in stomach May need slower rate May need different enteral formula Delayed gastric emptying or outlet obstruction Troubleshooting GRANULATION TISSUE Cauterize with Silver Nitrate Apply Mometasone furoate (Elocon) 0.1% cream Apply Triamcinolone (Aristocort, Kenalog) 0.5% cream 7

8 Granulation Tissue 22 Troubleshooting Leakage at the Tube site Make sure balloon/bolster is snug against stomach wall and disc if present is against abdomen Check water in balloon (leak or break) Make sure tube is stabilized Malfunctioning anti reflux valve Troubleshooting Skin site red, irritated or draining Increase cleansing regime Keep area dry Apply stomadhesive powder and/or protective ointments to the site Keep tube stabilized Re evaluate fit of tube 8

9 Troubleshooting Skin site red and itchy with raised rash Likely fungal Keep area dry Treat with anti fungal such as Nystatin or Mycolog Troubleshooting Cellulitis of site Tube lodged in subcutaneous tissue Tube cannot be moved or rotated easily Site reddened, swollen, indurated, draining, tender to touch Change tube and start antibiotics (IV or PO depending on severity) Cellulitis 27 9

10 28 Troubleshooting Bleeding at the tube site Inspect for evidence of granulation tissue Determine source of bleeding (peristomal, up the tube, within tract) Treatment is determined after source of bleeding is identified Blocked Tubes Try flushing briskly Using pulsing technique or push pull method Can try carbonated water If unable to open tube then replacement is indicated 10

11 Clog Buster Crush one sodium bicarbonate tab (325 mg) & mix in 10 ml warm water. Empty the contents of one Zenpep 5000 cap into this solution. Allow to dissolve completely. Instill to clogged tube and let dwell for 60 min. After 60 min, withdraw, & flush tube with water. (This would require a prescription) 31 Tube Accessories Other brands of similar pads include: Tube Feeding Friends button pads, belts, backpacks, quilts, and pillows Patchwork Peddler G Tube Pads, Belts & Accessories Snap EZ cloth g tube pads Tubie Whoobies G tube Pads cloth g tube pads Belly Buttons and Belts Tube protection Soft Hard Long tube tube ja10g g tube protective belt/ 33 11

12 THANK YOU Special thanks to Dr. Alex Flores for sharing his expertise and many of his photos and slides. 12