Patients and caregivers in an adult percutaneous endoscopic gastrostomy (PEG) clinic have voiced concerns about PEG tube care in the home setting. What should nurses teach patients about PEG tube home care?-TD, N.J.

Deltra Muoki, PhD, APRN, AGNP-C, CMSRN, CNE responds-The pull method is commonly used to place a PEG tube into the left upper quadrant of the abdomen via the use of an endoscope.1 The endoscope is placed into the mouth and advanced into the stomach.2 The light on the tip of the endoscope transilluminates the abdominal wall to identify a safe location for placement.2 A needle is then placed through the patient's skin into the stomach and visualized within the cavity of the stomach to verify the identified placement site. The needle is removed, and an incision is made. A plastic sheath with a needle called a trocar is inserted into the incision. The needle is removed, and a guidewire is passed through the trocar. The guidewire is grasped with forceps. Using the pull method, the endoscope is removed from the mouth, which allows the guidewire to exit the mouth. The guidewire is then attached to a loop at the tapered end of the PEG tube and slowly advanced through the mouth and esophagus, into the stomach, and out of the incision until it hits the internal bumper (also called a bolster). This bumper holds the PEG tube in place inside the stomach. The external bumper is attached to the outside of the PEG tube, approximately 1 to 2 cm between the external bumper and the abdomen.1 This allows for free movement of the PEG tube and decreases the incidence of buried bumper syndrome, skin breakdown, and tissue necrosis.1 The tissue edema and secretions from the PEG tube insertion create an early gastrostomy tract, which prevents peritoneal leakage.1

Patient education

The nurse must provide PEG tube education to the patient and caregiver to help mitigate complications. This education should be initiated prior to PEG tube placement, during the planning and preoperative stages. This allows the patient and caregiver to process the information and identify any questions or concerns. Patient teaching should continue postprocedure when the nurse can demonstrate PEG tube care with a return demonstration from the patient and caregiver. The nurse should encourage the patient and caregiver to contact their healthcare team if they have any questions while taking care of the PEG tube at home.

Care of the PEG tube

Prevent dislodgement

A daily assessment, more frequent if needed, of the PEG tube and insertion site is essential to prevent complications. It is important to note that the peri-insertion area may feel "hard or firm" immediately under the skin. This is likely from palpation of the internal bumper. Nurses should teach the patient and caregiver to keep the PEG tube securely attached to the abdomen by using tape or a fixation device. This prevents accidental dislodgement.

Daily use and care

Nurses should provide education on the importance of gently rotating the bumper to prevent ulcer formation between the external bumper and abdominal wall.3 The PEG tube may need to be cleaned up to three times per day until the PEG insertion site has healed. Once the site has healed, the PEG insertion site will need to be cleaned daily and as needed with soap and water or sterile saline.1,4 The patient and caregiver should be instructed to avoid harsh soaps and chemical agents at the peri-insertion area.1 This can cause skin irritation. The nurse should inform the patient and caregiver to pat dry the area with a towel or gauze to prevent infection and skin breakdown.1,4

Nurses should inform the patient and caregivers that some leakage from around the PEG tube insertion site is normal for the first 2 to 4 weeks after insertion.3 The clinician may instruct the patient to apply a gauze dressing over the insertion site and the external bumper until the leakage has subsided.1,4 After the oozing has stopped, there is no need for a gauze dressing around the PEG tube insertion site, and it does not need to be covered while showering. Swimming is permitted in clean water once the tract is mature and healed. Nurses should teach patients and caregivers to be cognizant of where the PEG tube exits the stoma by noting the centimeter marking or guide number on the tube. This helps for early recognition of tube migration or dislodgement.

Flushing

The PEG tube should be flushed with 30-50 mL of water every 4 to 6 hours to prevent the tube from becoming obstructed if it is not being utilized.4 Nurses should emphasize the importance of flushing the PEG tube with 15 to 30 mL before and after administering bolus feedings and medications.1 When administering medications, the liquid form should be used. If this is not feasible, tablets should be crushed and completely dissolved in 10-15 mL of water.4 Enteric-coated and extended-release capsules cannot be crushed. The head of the bed should remain elevated, 30 to 45 degrees, while administering liquid through the PEG tube to prevent aspiration.4

Complications and management

Dislodgement

Once the PEG tube is inserted, it must remain in place until the tract has matured for at least 4 weeks.4 It can take as long as 6 to 8 weeks for the tract to mature if the patient has delayed wound healing. If the PEG tube is removed prior to tract maturation, gastric contents could spill through the immature tract into the peritoneal cavity. This could ultimately result in peritonitis. If the PEG tube is inadvertently removed after tract maturation, the tract will close spontaneously within approximately 4 hours if the PEG tube is not replaced.4 If the PEG tube tract closes and is still needed, the patient must undergo an esophagogastroduodenoscopy to have the PEG tube reinserted.

Infection

The site should be closely monitored for any signs and symptoms of infection, including increased redness, tenderness, and purulent discharge. If the peristomal area remains moist, a yeast infection may develop, requiring an antifungal agent. A bacterial infection will likely require an antibiotic. Therefore, the site must remain clean.

Buried bumper syndrome

This occurs as a long-term result of the external bumper being placed taunt to the skin. The internal bumper eventually embeds itself into the abdominal wall, which can cause pain, infection, and peritonitis. Pressure necrosis can also occur secondary to the impediment of blood flow.1 It is important to allow slack or space between the external bumper and the skin. The external bumper is easily adjusted with the appropriate training.

Hypergranulation tissue

There may be issues with excessive granulation tissue leading to a buildup of pink or red tissue around the PEG tube insertion site resulting in discomfort. This can be treated by using silver nitrate to cauterize that area.4 The granulation tissue will turn a grayish/white color and will slough off without additional intervention.

Obstruction

If the PEG tube becomes clogged, connect a 60 mL syringe to the PEG tube with the plunger pulled back to attempt to dislodge the obstruction.4,5 If this is unsuccessful, flush warm water through the tube in a pulsating manner.4,5 If this is also unsuccessful, clamp the tube and allow the warm water to sit for up to 60 minutes.4,5 If all these measures are unsuccessful, contact a clinician for an order for pancreatic enzymes or an enzyme declogging kit.4,5

Low-profile PEG tube

Some patients may opt for a low-profile PEG tube to avoid having a lengthy PEG tube once the tract has matured. A low-profile tube is also an option if the original PEG tube needs to be replaced. The low-profile PEG tube lays flush against the abdomen. When the patient needs to utilize the PEG tube, an extension tube is inserted in the gastric port. After use, the extension set is disconnected, and the gastric port is closed. If the patient has a low-profile PEG tube, it is recommended that the tube is routinely exchanged approximately every 3 to 4 months per the manufacturer's guidelines.4 The internal balloon on the end of the low-profile gastrostomy tube should always be filled with water to prevent dislodgment. The amount of water depends on the manufacturer, usually between 5 and 10 mL.

PEG tube removal

Due to the nature of the varying types of gastrostomy tubes, there are different methods for removal. Gastrostomy tubes can be removed via traction, endoscopically, or by deflating the internal balloon.1 Once the gastrostomy tube is removed, a clean dressing is placed over the stoma until it spontaneously closes in 24 to 72 hours.1

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