Principles of caring for residents with feeding tubes: guide to a growing clinical challenge.

Care of residents with feeding gastrostomy and jejunostomy tubes presents a special challenge in extended care. Increasing numbers of elderly persons have feeding tubes placed in outpatient settings. Enterostomies are created to establish an opening between the stomach or jejunum and the abdomen to provide nutrition to residents who are unable to swallow or tolerate oral feedings.|1~ Candidates for feeding tubes are often malnourished and frail, adding to their demands for care, and are at high risk for infection and skin breakdown.

Extended care nurses are faced with dealing with a variety of tubes in different shapes and sizes. Additionally, feeding enterostomies may be temporary or permanent, and may be placed surgically or endoscopically into the stomach or small bowel. Understanding the differences in tube placement and function is essential to provide safe care and to prevent potentially serious consequences from occurring. Management of residents with feeding tubes requires knowledge of basic principles and proactive nursing interventions.

A variety of methods for establishing a tube feeding enterostomy exist. The most common enterostomies are outlined in Table 1. The decision to place a feeding tube should be the result of a careful assessment of the many factors involved, including the residents' diagnosis, prognosis and informed consent. Nurses play a crucial role in the assessment of the residents' needs and in communicating with the physician and family.

A permanent enterostomy is a surgically created mucosal-lined stoma that will not close when the feeding tube is removed.|2~ This procedure results in the creation of a permanent stoma, which allows the caregiver the ability to insert/withdraw the feeding tube for bolus feedings. Permanent stomas need to be assessed for viability (adequate blood supply) by observing color. A healthy stoma is beefy red, moist and secretes small amounts of mucous. A dark stoma or the presence of a necrotic covering should be reported promptly to the physician. Permanent enterostomies are advantageous for residents who are confused and likely to pull on feeding tubes. Permanent jejunostomies are also useful in residents at risk for aspiration pneumonia.|3~

Temporary enterostomies may be surgically or endoscopically created and result in serosa-lined tracts that will close spontaneously within hours, if the feeding tube is withdrawn.|4~ Temporary percutaneous enterostomies are often the method of choice for tube placement in residents who are not candidates for general anesthesia. Temporary percutaneous enterostomies are considered safe, cost-effective alternatives to major abdominal surgery.|5~ The Percutaneous Endoscopic Gastrostomy (PEG) is an example of a temporary enterostomy procedure that can be performed on an outpatient basis in an endoscopy unit or ambulatory surgery with intravenous sedation and local anesthesia.

Management of feeding tubes can best be accomplished if the enterostomy is well constructed and if three basic principles of care are maintained. First, all feeding tubes must be stabilized against the abdomen. Secondly, the skin must be protected from gastric or jejunal drainage. Lastly, care must be given to prevent infection.

Feeding tubes must be stabilized against the abdomen to prevent tube migration both inward and outward and to prevent leakage. Serosa-lined tracts surrounding temporarily placed feeding tubes generally heal within two weeks following insertion. The feeding tube must be stabilized to allow for healing of the tract from the skin to the stomach or the jejunum. Movement of the feeding tube can also cause enlargement of the tract, which results in leakage around the feeding tube.|6~

Do not attempt to replace the feeding tube if the enterostomy is less than two weeks old without first contacting the physician. If the tube should become dislodged before the tract is healed, surgery may be necessary to reinsert the feeding tube and/or repair the abdominal defect.|7~ If the site is well healed and the tube becomes dislodged from a temporary enterostomy, it must be replaced as soon as possible, to maintain tract patency.

Tubes can be stabilized with an assortment of retention devices. All PEG tubes have internal retention bolsters and external retention discs that are adjusted to keep the tube stabilized at the time of insertion. Do not adjust the retention disc on new PEGs for 1-2 weeks following insertion to prevent disruption of the healing tract. If the tube has a crossbar-type retention disc, however, it should be rotated 45 degrees daily to prevent pressure erosion on the skin. After the tract is healed, the retention disc should be adjusted to keep the disc snugly against the abdomen.

If a Foley catheter is used as a feeding tube, an additional retention device should be applied to keep the tube stabilized. The Hollister |C~ Drain Tube Attachment Device |TM~ and Cook |C~ Molnar |TM~ discs are commercial devices that are effective tube stabilizers. Tape may also be effective|8~ and best used to stabilize tubes in well healed tracts.

The skin must be protected from leakage of gastric contents and digestive enzymes. A common cause of tube leakage is a deflated balloon. Do not fill balloons with air. Feeding gastrostomy tubes with balloons should have the volume checked weekly and filled to the maximal volume with appropriate solutions. Once leakage occurs, chemical destruction of the skin will ensure rapidly unless the cause of the leakage is corrected and aggressive intervention towards maintaining skin integrity are implemented.

Intact skin can be protected with skin sealants such as the United |C~ Skin Prep |TM~ or Bard |C~ wipes. If skin erosion has already occurred, pectin wafers or skin barriers, such as the Hollister |C~ Premium Wafer |TM~ can be used to protect the skin and facilitate moist wound healing while the cause of the leakage is corrected. If the drainage is excessive, an ostomy pouch may need to be placed around the tube, feedings discontinued and hyperalimentation started until the tract heals. Enterostomal Therapy nurses are excellent resources to provide assistance with managing feeding tube sites.

Lastly, infection can be prevented by regular cleansing and careful inspection of the tube and skin. Tube sites should be cleaned daily; particular care should be given to aseptic technique with appropriate solutions until the site is well healed, after which soap and water is sufficient. Hydrogen peroxide is also effective to remove crusty drainage. Care should be taken to clean under retention devices with cotton-tipped applicators. Tube sites should be cleaned in a circular pattern starting from the center and working outward to prevent cross contamination. Dressings are generally not necessary and should not be placed under retention devices. Dressings can also trap moisture and create the perfect environment for the development of fungal infections on the skin.

Most serious problems associated with feeding tubes are preventable and include pyloric obstruction from tube migration, leakage, fasciaitis, and wound infection.|9-11~ These complications can rapidly result in significant morbidity and unnecessary discomfort for the resident if the cause is not determined and if corrective actions are not instituted quickly. The length of the feeding tube should be measured at regular intervals to confirm tube position. Gastric contractions can draw a feeding tube inward towards the pylorous which can result in signs and symptoms of bowel obstruction and acute protracted vomiting. If tube migration is suspected, the caregiver should deflate the balloon, pull the catheter back into the stomach, reinflate the balloon and secure the tube snugly against the abdomen. In well-healed tracts, the tube may also be completely withdrawn and reinserted.|12~

The care of the feeding tube and surrounding skin is one component of many for residents receiving enteral nutrition. Knowledge of the type of each tube, how it is placed, why it is there and who will be responsible for its care are issues that must be addressed on an individual basis. Maintaining basic principles of enterostomy care -- 1) tube sterilization; 2) skin protection; and 3) prevention of infection -- will result in optimal outcomes. Care of the resident with a feeding enterostomy is a challenge and calls for competent, caring nursing actions.

References

1. McGee L. Feeding gastrostomy: Indications and complications. Journal of Enterostomal Therapy 1987; 14(20):73-8.

2. McGee L. Feeding gastrostomy: Indications and complications. Journal of Enterostomal Therapy 1987; 14(20):73-8.

3. Brewer C. Jejunostomy: Highlights of care. Journal of Enterostomal Therapy 1987; 14(4):163-7.

4. Brewer C. Jejunostomy: Highlights of care. Journal of Enterostomal Therapy 1987; 14(4):163-7.

5. Starky J, Jefferson P, Kibry D. Taking care of percutaneous endoscopic gastrostomy. American Journal of Nursing 1988; 88(1):42-5.

6. McGee L. Feeding gastrostomy: Nursing care. Journal of Enterostomal therapy 1987; 14(2):73-8.

7. Shellito D, Malt R. Tube gastrostomy: Techniques and complications. Annals of Surgery 1984; 201(2):180-4.

8. Faller N, Lawrene K, Ferraro C. Gastrostomy, replacement, feeding tubes: The long and short of it... Wound/Ostomy Management 1993; 39(1):26-33.

9. Shellito D, Malt R. Tube gastrostomy: Techniques and complications. Annals of Surgery 1984; 201(2):180-4.

10. Llaneza P, Menendz A, Roberts R, et al. Percutaneous endoscopic gastrostomy: Clinical experience and follow-up. Southern Medical Journal 1988; 81(3):321-4.

11. Pereira M, Mersick K. Foley catheter gastrostomy tube migration: Small bowel obstruction relieved by percutaneous balloon aspiration. Gastro-intestinal Endoscopy 1989; 37(3):372-4.

12. Starky J, Jefferson P, Kirby D. Taking care of percutaneous endoscopic gastrostomy. American Journal of Nursing 1988; 88(1):42-5.

TABLE 1

PERMANENT FEEDING ENTEROSTOMIES (Mucosa-lined tracts)

TYPES

Janeway Gastrostomy

* Surgical procedure

* Anterior gastric flap fashioned as stoma on abdomen

* No anti-reflex mechanism

Roux-en-Y Jejunostomy

* Surgical procedure

* Jejunum severed and distal portion exists as stoma on abdomen; proximal end anastomosed to bowel

ADVANTAGES

* Can withdraw tube after feedings

* Permanent route for enteral feedings

* Less risk for aspiration pneumonia (jejunostomy)

DISADVANTAGES

* Requires extensive surgical procedure to create or takedown

* Potential for skin irritation from mucous drainage from stoma or leakage in between feedings

KEY POINTS

* Administer feedings slowly; jejunal feedings are better tolerated given continuously

* Skin sealants and protectants should be started early

TEMPORARY FEEDING ENTEROSTOMIES (Serosa-lined tracts)

TYPES

Stamm Gastrostomy

* Surgical procedure

* Stomach sutured to abdominal wall

* Feeding tube placed into stomach through subcostal incision

Percutaneous Endoscopic Gastrostomy (PEG)

* Endoscopic placement

* Suture material inserted into stomach through percutaneous hollow needle and brought up through oral pharynx with endoscope; feeding tube connected to suture and pulled down through oral pharynx and out small incision made at percutaneous needle site

Percutaneous Endoscopic Jejunostomy (PEJ)

* Requires existing PEG

* Small caliber jejunal feeding tube inserted into PEG tube and placed into jejunum with endoscope

Witzel Jejunostomy

* Surgical procedure

* Jejunum sutured to abdominal wall

* Subserosal tunnel constructed through which feeding tube is placed and sutured to skin

* Percutaneous placement referred to as needle jejunostomy

ADVANTAGES

* Requires less complex surgical procedure or endoscopic placement without general anesthesia

* Cost-effective

DISADVANTAGES

* Spontaneous tract closure if tube becomes dislodged

* Small caliber feeding tubes prone to blockage

KEY POINTS

* May need to add stabilization device to some tubes

* Feeding tubes must be repaced quickly to maintain tract

* Bulk forming agents and pills should not be put into tubes

TABLE 2

PRINCIPALS OF ENTEROSTOMY CARE

1. Stabilize the feeding tube. 2. Protect the surrounding skin. 3. Prevent infection.

TABLE 3

FREQUENTLY OCCURRING PROBLEMS WITH FEEDING TUBES

Problem               Corrective Action

1. Leakage            1. Check tube position. Be
   around tube           sure that retention device is
                         holding tube snugly against
                         the abdomen. Check balloon
                         volume and fill to correct
                         volume. Apply skin
                         barrier to protect skin from
                         corrosive drainage. Consider
                         inserting smaller tube
                         to allow tract to contract
                         and close inward.

2. Skin erosion       2. Adjust retention disc to prevent
                         excessive pressure on
                         the skin. Correct cause of
                         leakage. Apply
                         skin wafers for protection
                         and healing.

3. Tube migration     3. Deflate balloon. Pull tube
                         back into stomach. Reinflate
                         balloon and pull tube snugly
                         up against abdominal wall.
                         Apply retention device.
                         Check for placement per
                         institution policy prior to
                         resuming feedings.

4. Local infection    4. Keep tube and tube site
                         clean and dry. Avoid use of
                         dressings. Topical antifungal
                         powder (per MD order
                         for yeast rashes). Report S/S's
                         promptly to MD.

Marty Murray, RN, BSN, CETN, is a Nurse Clinician in the Enterostomal Therapy Department, St. Vincent Medical Center, Toledo, OH.