PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)

Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate (for example, because of dysphagia or sedation). This provides enteral nutrition (making use of the natural digestion process of the gastrointestinal tract) despite bypassing the mouth; enteral nutrition is generally preferable to parenteral nutrition (which is only used when the GI tract must be avoided).

Complications
-Cellulitis (infection of the skin) around the gastrostomy site.
-Hemorrhage.
-Gastric ulcer either at the site of the button or on the opposite wall of the stomach ("kissing ulcer")
-Perforation of bowel (most commonly transverse colon) leading to peritonitis.
-Puncture of the left lobe of the liver leading to liver capsule pain.
-Gastrocolic fistula: this may be suspected if diarrhea appears a short time after feeding. In this case, the feed goes direct from stomach to colon (usually transverse colon).
-Gastric separation.
-"Buried bumper syndrome" (the gastric part of the tube migrates into the gastric wall).

PEG nutrition formulas

1. Ready-made formula: All ready-made formulas contain carbohydrates, fats, proteins, and water. Certain formulas may be lactose-free, gluten-free, or low in fat or sugar. Some formulas are made for a specific disease, condition, or treatment.

2. Blenderized formula: Formula made from pureed foods. A larger feeding tube is needed to use blenderized formula. This is because the thickness of these formulas increases the risk that the tube will get clogged. Blenderized formulas are can be bought ready-made. The ready-made blenderized formulas have added vitamins and minerals. Compared to ready-made formulas, home blenderized formulas are not sterile (germ-free) and may not have all of the nutrition that your body needs.

PEG tube may also be used to give medecines (usually taken by mouth), extra water (to prevent dehydration) and flush water to clear formula or medicine from the PEG tube).

PEG replacement and care.

When replacing a gastric tube remember to apply an anesthesic jelly to facilitate insertion and minimise discomfort (not shown in the video).

Also, an X-ray should be done if the PEG tube has been replaced within the four first weeks after initial insertion to check that it is in the correct place. If the PEG tube has been in position for four weeks since the initial insertion or it has been replaced other times after initial insertion, it is not needed to do an X-ray.

We can always check, when is not needed to do an X-ray, that the PEG is in position by aspirating through the PEG tube, gastric content should flash back. To confirm that is gastric content, you can always use a pH strip.

PEG site should be cleaned with saline and dried at least once a day. If there is an infection on the PEG site, antibiotics and creams might be prescribed and it should be cleaned more often.

ENTERAL TUBE FEEDING (CARE PLAN)

Enteral tube feedings provide nutrition using a nasogastric tube, a gastrostomy tube, or a tube placed in the duodenum or jejunum.

NANDA-1: IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS

Common related factor: mechanical problems during feedings, such as clogged tube, inaccurate flow rate, stiffening of tube, delivery pump malfunction.

Common expected outcome: patient´s nutritional status improves, as evidenced by gradual weight gain or stable weight and increased physical strength.

Related risks when using a nasogastric tube, a gastrostomy tube, or a tube placed in the duodenum or jejunum.

RISK FOR ASPIRATION

Common related factor: depressed or lack of gag reflex, poor positioning of tube placement, migration of the tube, supine positioning of patient as feeding is administered, increased gastric residual volume and delayed gastric emptying.

Common expected outcome: patient maintains a patent airway, as evidenced by normal breath sounds, absence of coughing, no shortness of breath and no aspiration.