Version: / 2
Author: / Prepared by Nursing Matters and Associates.
Adapted for local use by:
Issue Date: / October 2012
Review date: / October 2014
Authorised by:
1.0 Policy Statement:
It is the policy of the Centre that the use and management of Percutaneous Endoscopic Gastrostomy (PEG) nutritional support for residents will be based on a person centred and evidence based approach with due regard to legal and ethical requirements.
2.0 Purpose of the Policy:
The purpose of this policy is to outline the process and procedures for use and management of PEG nutritional support in the Centre.
3.0 Objectives:
3.1 To ensure that nurses are knowledgeable in the indications for and decision making about PEG feeding in the Centre.
3.2 To provide nurses with the knowledge for providing person centred and evidence based care to residents who have PEG feeding tubes in place.
3.3 To ensure that nurses have guidance on writing an evidence based care plan for residents’ with a PEG tube,
3.4 To provide guidance for nurses on care following accidental removal of a PEG tube.
4.0 Scope:
This policy applies to all nursing and healthcare staff in the Centre that are involved in the care and maintenance of a PEG tube.
5.0 Definitions:
5.1 A Gastrostromy entails the establishment of a communication between the interior of the stomach and the skin surface for tube feeding in clients and is the most appropriate where feeding is for a period of greater than four weeks (Doughterty & Lister, 2004)
5.2 Gastrostomy Feeding Tubes: a feeding tube that has been directly inserted through the abdominal wall into the stomach. It is secured by a soft spongy balloon or bumper on the inside and a firm plastic/polyurethane fixation device on the outside. Most are inserted by the percutaneous endoscopic technique (PEG) (Clinical Resource Efficiency Support Team CREST, 2004).
5.3 Low profile button tube (LPBT)/ Mic-Key button tube: these are shorter tubes that sit flush with the skin on the abdomen and come in a variety of lengths. They have a flexible disk on the stomach end to hold the tube in place.
6.0 Responsibilities.
/Responsible Person.
This policy will be disseminated to and read by all nursing personnel involved in the care and management of gastrostomy feeding tubes and a record kept of all those who have signed the policy acknowledgement forms.
/Person in Charge/Director of Nursing.
Where a new version of this policy is produced, the previous version will be removed and filed away.
/Person in Charge/Director of Nursing.
An explanation of this policy will be given on induction to all nursing and care staff and any other health care professional involved in providing gastrostomy feeding tube care to residents. /Person in Charge/Director of Nursing.
Nurses will be provided with the opportunity to attend training /updates on management of gastrostomy feeding tubes every two years or where there is a significant change to practice in this area.
/Person in Charge/Director of Nursing.
Every resident with a gastrostomy feeding tube will be assessed on admission for the presence of care needs.
/Admitting and/or designated nurse.
Assessment and care planning to meet the nutritional and hydration and gastrostomy feeding tube needs of residents will be carried out as per this policy.
/All registered nurses.
Residents and/or residents representative(s) will be supported and provided information regarding the gastrostomy feeding tube.
/All nursing and care staff.
Nurses will maintain their competence in the care and management of gastrostomy feeding tubes and communicate any competency / knowledge deficits to their line manager/Person in Charge.
/All registered nurses
Food and fluids given via gastrostomy feeding tube to meet the nutrition and hydration needs of residents will be in accordance with the feeding plan developed by the resident’s dietician.
/All registered nurses.
Changes in a resident’s condition will be reported to the senior nurse in charge and changes to care will be communicated to all relevant healthcare professionals.
/All nurses, care assistants and other healthcare professionals involved in the resident’s care.
7.0 Gastrostomy Tube Insertion and Decision Making.
7.1 Indications for a Enteral Tube Feeding.
7.1.1 As a general rule, PEG feeding should be considered if it is expected that the patient’s oral nutritional intake is likely to be qualitatively or quantitatively inadequate for a period exceeding 2–3 weeks (ESPEN, 2005). Enteral tube feeding is indicated in the following:
· Intact GI tract but unable to consume sufficient calories to meet nutritional needs;
· Impaired swallowing related to neurological conditions e.g. stroke, Parkinson’s Disease; and
· Obstruction related to neoplasm or surgery.
7.1.2 Table 1 lists the indications for enteral tube feeding from NICE (2006).
Page 15 / Care and Management of PEG Tube Policy. / October 2012Indication for enteral
tube feeding / Example
Unconscious patient / Head injury, ventilated patient
Neuromuscular swallowing disorder / Post-CVA, multiple sclerosis, motor neurone, disease, Parkinson’s disease
Physiological / anorexia Cancer, sepsis, liver disease, HIV
Upper GI obstruction / Oro-pharyngeal or oesophageal stricture or tumour
GI dysfunction or Malabsorption / Dysmotility inflammatory bowel disease, reduced bowel length (although PN may be needed)
Increased nutritional requirements / Cystic fibrosis, burns
Psychological problems / Severe depression or anorexia nervosa
Specific treatment / Inflammatory bowel disease, for short term enteral access during surgery
i.e. head and neck cancer
Mental health / Residents with Dementia
Page 15 / Care and Management of PEG Tube Policy. / October 2012
7.2 It is recommended that Enteral tube feeding should not be given to people unless they are malnourished or at risk of malnutrition and have; inadequate or unsafe oral intake and a functional, accessible gastrointestinal tract (NICE, 2006).
7.2.1 Careful consideration should be given to the insertion of a feeding tube. Tube placement is an invasive procedure and common risks of tube feeding include:
· Pain at the tube site,
· Discomfort from tube repositioning.
· Local infection.
· Aspiration pneumonia.
· Tube occlusion.
· Nausea, vomiting, constipation and diarrhoea.
· Loss of pleasure from eating.
7.2.2 The use of enteral feeding for residents in the end stages of dementia is a controversial and an emotional issue, and it is a decision that requires individual and careful consideration by the resident’s representative and the health care team.
7.3 Decision Making Process.
7.4 In many cases, the decision to commence PEG feeding for a resident is made when the resident is in hospital. However, there are times when, while the resident is in the centre, that his/her condition requires consideration of PEG feeding as an appropriate means of providing nutritional support. In such instances, the process of decision making in the Centre involves the following:
7.4.1 Each resident will be assumed to have the capacity for decision making, unless the following conditions exist and then a formal assessment of capacity will be required:
■ The resident is unable to communicate a clear and consistent choice;
■ The resident is obviously unable to understand the information and choices provided; or
■ The resident makes a choice that seems to be based on a misperception of reality or one that doesn’t seem consistent with that person’s known beliefs and values insofar as they are known.
(HSE, 2012).
7.4.2 Where the resident is able to make the decision, he/she will be given all necessary information required so as to enable him/her make an informed decision. This includes:
■ Information being given in a language and format appropriate to the resident’s needs.
■ Information being given at an appropriate time and place when the resident is best able to understand and retain the information.
■ Explanation of the nature, purpose and expected benefits of the intervention.
■ Information about alternatives, their benefits and known adverse effects of each.
■ Explanation of any possible adverse effects/potential risks associated with the intervention.
(HSE, 2011).
7.4.3 The information will be given by the resident’s general practitioner or medical consultant.
7.4.4 Family members, significant others and other healthcare professionals will be involved in accordance with the resident’s wishes.
7.4.5 A record of discussions, information provided and outcome of discussions will be made by the medical practitioner involved in the resident’s medical record.
7.5 Where a resident lacks the capacity to make an informed decision about the procedure, decision making will involve the following:
7.5.1 The Person in Charge of the Centre or his/her deputy will arrange meetings of all relevant persons as outlined below in order to facilitate decision making.
7.5.2 Collaborative decision making involving the resident as far as he /she is able, particularly where the resident’s cognitive impairment fluctuates and there are times where there may be lucid periods.
7.5.3 Involvement of the resident’s family and / or representative with a view to ascertaining their views as well as the resident’s known or previously expressed preferences or advanced care planning.
7.5.4 Consideration of the purpose, benefit and expected outcomes of PEG feeding.
7.5.5 Consider of other options, including the option of not having nutritional support via PEG feeding.
7.5.6 Involvement of nurses and other healthcare professionals who may be involved in the resident’s care. This for example may include, a dietician and /or psychiatry of old age.
7.5.7 Deciding on which options for treatment would provide overall clinical benefit for the service user.
7.5.8 Discussions and their outcomes will be recorded and kept in the resident’s medical record.
7.6 Where the resident is a Ward of Court, the Office of Ward of Court will be contacted regarding advice.
8.0 Guidelines for care of residents with Percutaneous Endoscopic Gastrostomy (PEG)
8.1 Immediate post insertion care.
8.1.1 A PEG feeding regimen from the hospital should accompany the resident from the hospital
8.1.2 Nil via PEG for the first 6 hrs post operatively including administration of sterile water/medications.
8.1.3 Sterile Water /Medications only for next 6 h-12hrs.
8.1.4 Feeding Regimen to commence 12 hrs post insertion of PEG as per instructions accompanying the resident.
8.1.5 Nurses should comply with the feeding regime accompanying the resident from the hospital and liaise with the hospital team regarding any queries or problems encountered.
8.2 Site Care Up to 48 hours post-insertion.
Following the initial tube insertion, a channel of scar tissue forms during wound healing between the gastric wall and the abdominal wall. This process takes 10 -14 days. During this time the resident should be monitored for signs of cellulitis and peritonitis and referred to the general practitioner if any of these signs develop. Treat the entry site as a surgical wound for the first 48 hours.
8.2.1 During this period, aseptic technique non touch technique must be used when cleaning/ dressing the site.
8.2.2 Nursing and care staff must not touch site and tube for 8 – 12 hours after placement.
8.2.3 After 12 hours, nursing staff should remove dressing, observe site for signs of swelling, bleeding or infection.
8.2.4 Nursing staff should cleanse site and fixation device with sterile 0.9% Sodium Chloride solution and gently dry.
8.2.5 A dry dressing only should be applied if required to absorb exudate.
8.2.6 The fixation device must not be released.
8.2.7 Staff should adhere to manufacturer’s guidance in relation to tube rotation. Some devices should not be rotated.
8.3 After 48 hours post insertion
8.3.1 A ‘clean’ non touch technique technique using sterile equipment e.g. dressing pack with nonwoven gauze should be used until the tract has healed. This may take up to 3 weeks post-insertion.
8.3.2 The site and fixation device must be kept meticulously clean and dry.
8.3.3 The fixation device must not be released.
8.3.4 Staff must adhere to manufacturer’s guidance in relation to tube rotation.
8.3.5 Residents with an abdominal stoma for gastrostomy feeding should maintain/be assisted in maintaining a high standard of personal hygiene.
8.3.6 NOTE: Residents may shower but should not have an immersion (tub) bath until tract has healed – approximately 3 weeks post–op.
NB: For resident’s who are immunocompromised, aseptic non touch technique should continue.
8.4 Tube Care.
8.4.1 The position of the fixation device must be checked daily in relation to markings on the tube and tightened to correct position if necessary. This position should be confirmed before feeding is commenced to ensure that tube has not been displaced.
8.4.2 The tube should be rotated to 360 degrees (according to manufacturer’s guidance) within stoma tract 24 hours after insertion, then daily.
8.4.3 The external fixation device should not be opened or removed for 10 – 14 days or until the tract has healed.
8.4.4 If the tube is dislodged within the first 3 weeks before the tract has formed, it can result in peritonitis and the situation must be treated as an emergency.
8.4.5 Tubes that are sutured should be rotated following removal of the suture.
8.4.6 Document care and any changes or problems in the resident’s care plan and refer as appropriate.
8.5 Identification of Infection Associated with Enteral Feeding and Appropriate Action
8.5.1 It is important for staff to be alert to the signs of infection associated with enteral feeding.
8.5.2 Early recognition is important to permit early treatment.
8.5.3 Local infection at the stoma site can occur indicated by redness, swelling, pain and ulceration of the skin.
8.5.4 Bowel infections may present with nausea, abdominal pain, vomiting and /or diarrhoea.
8.5.5 Systemic infection may present as fever, lethargy or altered consciousness.
8.5.6 All suspected infection should be reported to the doctor and documented in the care plan.
8.5.7 In addition to the treatment of infection it is important to try and identify why the infection occurred.
8.5.8 A review and change in procedures may be required to prevent a reoccurrence.
8.6 General Care of PEG Stoma Site, when Established and Healed