Nursing care of patient with PEG feeding
Patient Nursing Care Study Structure
Nursing is a profession whose focus is to help the client to prevent, solve, alleviate or cope with problems associated with the activities he or she carries out in order to live. Nurses and midwives may perceive humans as having certain basic (e.g., food) and advanced (support) needs. On occasions, clients may be unable to meet these needs and staff may either assist them or teach them how to meet the needs in other ways or involve family members in meeting the person’s needs. The works (1990), appear to have been influenced by the behavioral paradigm. Within the literature there are many writers who offer the unsubstantiated opinion that using theories would help to improve the quality of care.
In the context of this paper, the activities of daily living according to this model will be applied to a client who has percutaneous endoscopic gastrostomy (PEG) tube for a long term enteral nutrition. PEG tubes may be needed for patients with swallowing disorders. Swallowing disorders are common, especially in the elderly, and may cause dehydration, weight loss, aspiration pneumonia and airway obstruction. These disorders may affect the oral preparatory, oral propulsive, pharyngeal and/or esophageal phases of swallowing. Impaired swallowing, or dysphagia, may occur because of a wide variety of structural or functional conditions, including stroke, cancer, neurologic disease and gastroesophageal reflux disease ( 2000).
Mrs. Valentina, an eighty-four year old lady who is placed under percutaneous endoscopic gastrostomy (PEG) tube for a long term enteral nutrition. Valentina also has moderate impairment and is dependent to maintain her personal cleansing and dressing.
Mrs Valentina was referred to a general hospital five years ago due to food refusal. She was also reported of experiencing regurgitation after eating. For weeks her condition was investigated and different textures of food and supplements were tried to see which Valentina could tolerate. Eventually she managed to take a combination of porridge mixed with supplements and fortified pudding. Still, she finds it very hard to take most solid foods. She was then discharged to a nursing home but her condition worsened which led to re-admission at the same hospital. She was then diagnosed of having oesophageal stricture and oesophagitis. Oesophageal stricture is a narrowing of the oesophagus. In order for her to achieve the best possible nourishment, a PEG was intended for a long term enteral nutrition. Since her discharge back to a nursing home, she has managed much better.
Enteral nutritional support accesses the gastrointestinal tract and includes both oral supplementation and tube-feeding techniques. Enteral nutritional support should be considered when a patient has functioning intestines but cannot or will not eat. Most patients require a caloric intake of 25 to 35 kcal per kg per day. The choice of route of administration for tube feedings should be based brimarily on the anticipated length of therapy and patient comfort (1996). Percutaneous endoscopic gastrostomy is commonly used for long-term enteral nutrition. However, this approach is itself associated with increased risks of gastroesophageal reflux and aspiration pneumonia ( 2000).
Allowing a patient's nutritional state to deteriorate through the perioperative period adversely affects measurable outcome related to nosocomial infection, multiple organ dysfunction, wound healing, and functional recovery. Careful preoperative nutritional assessment should include a determination of the level of stress, an evaluation of the status of the GI tract, and the development of specific plans for securing enteral access (1999).
Deterioration of nutritional status in the critically ill patient undergoing major surgery is associated with reduced systemic immunity, exaggerated stress response, organ system dysfunction, poor wound healing, and delayed functional recovery. Weight loss, hypoalbuminemia, and other purported signs of protein calorie malnutrition have long been predictors of poor surgical outcome. In the past, perioperative nutritional support has been synonymous with total parenteral nutrition (TPN). A high rate of septic complications and negligible impact on patient outcome with this route of therapy have raised question about the overall utility of nutritional support and the risk of interfering with the normal adaptive metabolic response to injury. Increasing evidence suggests that the "motor" of the multiple organ failure sepsis syndrome is the GI tract, the integrity of which affects immune defenses, organ function, and whether the stress response is provoked or attenuated. Much more consistent and beneficial responses are being seen with the provision of perioperative nutritional support by the enteral route (1999).
Gastrostomy is performed in patients who require prolonged nutritional support and who are unable to maintain adequate oral intake. Enteral nutrition is easier to administer and less expensive than parental nutrition and may be associated with fewer side effects, such as infection and sepsis, than intravenous nutrition. Traditional open gastrostomy has a complication rate of 3 to 61 percent and a mortality rate as high as 37 percent. Percutaneous endoscopic gastrostomy has become a popular method of gastrostomy, supplanting the traditional method. Two advantages of percutaneous endoscopic gastrostomy are that it is technically easy to perform and can be done using local anesthesia (1992).
Administration of enteral tube feeding via a gastronomy tube is a procedure that can be delegated to assistive personnel after tube placement is verified by the nurse. However the nurse still has responsibilities to do. The nurse should ensure that the client is sitting upright in a chair or in bed and instruct the assistive personnel to infuse the feeding slowly. The assistive personnel should also be instructed to report any difficulty infusing the feeding or any discomfort voiced by the client.
Mrs. Valentina’s need for enteral tube feedings is first assessed. These needs include impaired swallowing, decreased level of consciousness, surgeries of upper alimentary tract, and need for long term enteral nutrition (2004). The rationale for this is that clients who need tube feedings should be identified before they become nutritionally depleted. Enteral feeding preserves the function and mass of the gut, promotes wound healing, diminishes hypermetabolism in burn injuries, and may decrease infection in critically ill clients ( 1994).
The aim of the nursing care for Mrs. Valentina is to provide her enteral nutrition. Enteral nutrition refers to nutrients given via the GI tract. Enteral nutrition is the preferred method of meeting nutritional needs if the client’s GI tract is functioning by providing physiological, safe, and economical nutritional support. Enterally fed clients such as Mrs. Valentina, receive formula via nasogastric, jejunal or gastric tubes. Gastric feedings may be given to clients with a low risk of aspiration.
Bowel sounds should be auscultated before feeding since absent bowel sounds may indicate decreased ability of GI tract to digest or absorb nutrients. Tube placements should be verified. In a gastrostomy tube, a syringe should be attached and gastric secretions aspirated. Appearance should be observed and the pH checked.
The results from pH testing and the aspirate’s appearance should be considered together. On occasion, color alone may differentiate gastric from intestinal placement. Because most intestinal aspirates are stained by bile to a distinct yellow color, and most gastric aspirates are not, the difference can often distinguish sites. The pH aspirate offers valuable data as well in tracking advancement of a feeding tube (Metheny & Titler, 2001).
The aspirated contents should be returned to the stomach unless the volume exceeds 100 ml. if the volume is greater than 100 ml on several consecutive occasions, the feeding should be put on hold and the physician in charge notified (1999). Gastric residual determines if gastric emptying is delayed. Delayed gastric emptying may be indicated by 100 ml or more remaining in the client’s stomach from previous feeding ( 2004).
The bed's backrest of the patient should be kept elevated to at least 30[degrees] during continuous feedings; for intermittently tube-fed persons, a head elevated position should be maintained for one to two hours afterward. There is evidence that a sustained supine position (with the head of the bed flat) increases the probability for aspiration pneumonia (1999).
When the tube-fed person is able to communicate, the nurse should ask if any of the following signs of gastrointestinal intolerance are present: nausea, feeling of fullness, abdominal pain or cramping. These signs are indicative of slowed gastric emptying that may, in turn, increase the probability for regurgitation and aspiration of gastric contents (2006).
Most serious problems associated with feeding tubes are preventable and include pyloric obstruction from tube migration, leakage, fasciaitis, and wound infection. 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 ( 1993).
Care for Mrs. Valentina is not complete until the nurse will evaluate outcomes not only of the health care process but her health status as well. If there are significant improvements in the client’s health, then the nurse can evaluate that Mrs. Valentina has responded well to the procedure. One measure would be to check levels indicated above and assess them. Evaluation reinforces correct behavior in the client. The nurse can evaluate success by observing the client’s performance of each of the expected behavior or goals set (2004). The success of the nursing care highly depends on Mrs. Valentina’s ability to meet the established outcomes and goals.
To provide for continuity of care for the patient after discharge, the nurse needs to consider the patient’s needs for assistance with care in the home setting. Discharge planning incorporates for an assessment of the patient’s and family’s abilities for self-care, financial resources, and the need for referrals and home health services ( 2004).
To ensure the continuity of care and restoration of Mrs. Valentina’s health, nurses must meet his learning needs and also those of her support people. Teaching should focus on actions to maintain comfort, to promote healing and restore wellness, and to make use of appropriate community agencies and other sources of help for Mrs. Valentina. The overall goals of nursing care during the period therefore are to promote comfort and healing, restore the highest possible level of wellness, and prevent associated risks such as infection or respiratory and cardiovascular complications.
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