Download Tricks of the Trade

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Tricks of the Trade:
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Bag of Tricks
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10/12/11
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Sign in
Evaluation
Disclosure
Certificate
Leakage
Irritant Dermatitis
Hypergranulation
Gastric Lining
Bacterial infection
Fungal Infection
Buried Bumper
Tube malfunction
Tube Obstruction
Tube Displacement
What should a Gastrostomy site look like?
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Clean, dry (not too dry)
Skin intact ± no ulcerations
Minimal erythema
No swelling or induration
No lesions
No tissue growth
Tube intact
Assessment of the Gastrostomy :
,·OOUHYLHZDVVHVVPHQWZLWKHDFKSUREOHP!
!
a What
a
a
a
a
a
When
a
a
a
a
At least once a day
During bath and dressing changes
Problems going on
How
a
a
a
a
!
Stoma and peri-stomal or peri-tubular area
Tube/button
Abdomen
Overall condition of the patient
Look - inspection
Listen -history
Touch - palpation
Smell - odor
Look at the big picture 'RQ¶WMXVWIRFXVRQWKH
G-tube/button
Leakage
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leak some
FACT: leakage is one of the most
common gastrostomy problems
Leakage: Causes
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Any increase in intra-abdominal
pressure, the &¶V:
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Constipation
Coughing (also heavy
breathing, vent kids)
Crying
Change in weight or abdominal
girth (gas/air)
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Balloon has deflated
Incorrect size, improper
stabilization
Feeding intolerance/
vomiting
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Underlying disorder like
slow motility
Inability to decompress
Excessive torsion on
external bolster; Buried
bumper syndrome
Tube displacement
Poor wound healing
Positioning
Body structure: scoliosis
Spasticity/seizures
Pulling on tube/button
Activity
Leakage: Assessment
History:
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Timing/Positioning
Recent history of weight gain or loss, increase in height?
Constipation/Gas retention?
Has the patient had a recent infection? Respiratory/GI?
New medication? Antibiotics?
Formula regimen
New therapy: PT, CPT?
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Has any treatment made problems better or worse?
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Physical Exam:
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If the patient has a button:
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Is there water in the balloon? How many cc? (for balloon GB)
Check the device in both supine and sitting positions, make sure fitting
correctly -Any difficulty rotating the button? Is it too loose?
Are tubes stabilized?
What does the leakage look like? What color? Is it formula? From
stoma, tube and/or tissue if present
Look at the entire abdomen ±is the gastrostomy located in between skin
folds? ; Is the pt. distended?; Palpate for firmness/ tenderness
* The right size:
‡
Should rotate w/o difficulty
‡
Should have a slight amt. of in and out play
‡
6KRXOGILWFORVHWRVNLQZaRQHGLPH¶VZLGWK-3mm)
between the external bolster and skin surface
Leakage: Treatment
„
Treat underlying cause
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1Button
Buddies
Change to right size and/or
new button (change length
not Fr. Size).
Stabilize tubes: ensure
tube/button secure in the
tract
Add more water to the
balloon ± can go up to 6-7
cc (> 14 Fr) ±not in small
infant
PPI/Prokinetic med
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Protect skin
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Barrier Products: Powder,
Creams, Liquid Maalox
Dressings: gauze, foam,
reusable pads1,
menstrual/incontinence pads
Stabilize tubes/tape
extensions if needed
Pouch
Remove tube and place
smaller Fr. Catheter in and
allow stoma to stricture (needs
to be supervised)
Stabilizing the G-tube
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Extremely important!
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Goal: keep tube from being pulled and
maintain a 90 degree angle
Prevents migration of tube
Prevents rocking motion and tension on
the stoma which can cause leakage and
granulation tissue
Some tubes have a stabilization device
already
Some tubes need external stabilizer
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Hollister® drainage tube
attachment device
Sausage roll
i.e. Hollister clamp, sausage roll, baby
nipple
Dressing the tube flat against the abdomen
causes enlargement of the stoma
External
bolster
!!!!!!!!!!!!!!!!
!
Leakage: Treatment continued
Venting the tube/button:
‡Some buttons have specific
adapters for decompression
‡Farrell Valve ® Gastric Pressure
Relief Device is recommended to
use with continuous feeds.
‡May need to change
rate and/or route of feeds
‡May need a G-J tube
Farrell Valve
Irritant Dermatitis
Irritant contact dermatitis occurs when chemicals or
physical agents damage the surface of the skin faster
than the skin is able to repair the damage. There may
be redness, itching, swelling, blistering and scaling of
the damaged area.
DermNet
Irritant Dermatitis
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Cause:
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Primarily from leakage of gastric or intestinal contents*
Can also be from harsh cleansers, antibacterial
creams/soaps, external bolster too tight, friction
* Jejunal contents very caustic
pH of Soap/Cleansers
The skin has a pH of 4.5-6.5
Cleanser
Cetaphil
Dove
Lever 2000, Ivory
Camay, Dial
Zest, Palmolive
pH
6.5
7.0
9.0
9.5
10.0
Most baby
soaps are pH
balanced
Anything > 9.0 is alkaline and can be irritating to the skin
Irritant Dermatitis: Assessment:
History:
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Skin care regimen: cleansers,
products, topical meds
New detergents?
History of skin problems?
Is there drainage?
Is there pain, itching or
burning?
Dressings? How often changed?
Swimming? Source of water.
Has any treatment made
problems better or worse?
Physical Exam:
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Erythema: uniform? Streaky?
Lesions? Irregular borders?
Pattern of button or leakage?
Skin moist or dry? Scaly? Firm?
Tough? Intact?
Check the device in both supine
and sitting positions, make sure
fitting correctly
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Any difficulty rotating the
button? Is it too loose?
Is there leakage? What does it
look like?
Look at the entire abdomen
Irritant Dermatitis
Irritant Dermatitis
Oh My!
Irritant Dermatitis
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Treatment:
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Correct the cause
Eliminate products that are irritating
Apply barrier products: creams, powders
Use meds to reduce acid oral/topical
Low dose steroids
Absorptive dressings
Building a Barrier:
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Purpose:
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Keeps good moisture in and bad
moisture out
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Protects the skin from caustic fluids
Products:
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Intact ± zinc oxide, petrolatum , skin
prep
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Non-intact ±add barrier powder
Technique: (as important as the products)
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Put medications on first
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If using powder put on before barrier
creams and sprays ±dust of excess
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Apply creams thick like icing
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Layer if needed
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'RQ¶WZLSHFRPSOHWHO\RIIGDLO\EORW
and reapply
The 3 amigos
2
1
3
Barrier Products
1. powder
2. cream
3. prep
Hypergranulation Tissue
1Granulation
tissue is a normal healing reaction to injury.
1Hypergranulation tissue is a prominent growth of
granulation tissue.
1It consists of capillaries, inflammatory cells and scar
tissue that form around the stoma and inside the tract.
Hypergranulation Tissue
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Common problem seen
Extra growth of pink-red tissue;
sometimes grainy or bumpy
looking
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drainage, bleeding
Sometimes friable
May be painful
Often mistaken for an infection
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Cause:
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incorrect stabilization
excessive moisture
Peroxide use
Dilantin
Occlusive dressings
Hypergranulation Tissue: Assessment
History:
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Skin care regimen: cleansers,
products, topical medications
History of problems?
Pain? Where and when?
Drainage? Bleeding? From
tissue or stoma?
Dressings?
Current medications
Has any treatment made
problems better or worse?
Physical Exam:
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Any difficulty rotating the
button? Is it too loose?
Are tubes stabilized?
What does the tissue look like?
Is it around the entire stoma or
just a section? Is it coming from
within the stoma? Is it thick? Is it
smooth or globular?
Is there leakage? What does it
look like? Any bleeding?
Ouch!
Peroxide use
Hypergranulation Tissue: Treatment
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Treatment:
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silver nitrate application
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Q 3 days (usually)
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Protect healthy skin
Steroid creams: Triamcinolone
0.5% (short term use)
Stabilize tube, change size of
EXWWRQGRQ¶WOHDYHH[WHQVLRQVRQ
when not in use, tape extensions
when in use
Stomahesive powder: absorption
Foam dressings (expensive)
Compression dressing
Surgical excision if severe and not
responding to treatment
Chemical cauterization
with Silver nitrate
Hypergranulation Tissue: Treatment
Before:
After:
Remedies?
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Triamcinolone 0.5 % TID for 10 days
Menthol: Calmoseptine
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Antipuretic
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Analgesic
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Anti-inflammatory
Eucalyptus oil/Tea Tree oil
Maalox/Desitin/Preparation H
Antibacterial ointment
Carafate suspension
Cholestryramine
Silver dressings (expensive)
Make-up sponges
Gastric Lining Protrusion
Gastric tissue protrudes through
the gastrostomy tract
Gastric Lining Protrusion
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Cause: usually from the G-button
being too short or from the child
pulling on it or pulling it out,
underlying condition i.e. motility
issues, malnutrition
Not harmful but it can bleed
Sometimes hard to distinguish
from granulation tissue
May resolve but usually not
Gastric Lining: Assessment
History:
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Is the child pulling on the
tube/button or pulling it out?
Are extensions on for long
period of times ?
Is the child very active?
Is there drainage or bleeding
from the tissue or stoma?
Is the child malnourished or has
underlying motility condition?
Has any treatment made
problems better or worse?
Physical Exam:
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Check the fit of the button/tube.
Any difficulty rotating the
button? Is it too tight?
'RHVWKHWLVVXHORRNOLNHLW¶V
coming from within the stoma?
Is there drainage or bleeding?
Treatment:
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Protect it, Maalox topically QID,
stabilize the tube, surgical repair
if severe
Oooooh!
G-tube Site Infections
Bacterial
Fungal
Not as common as most people think
Bacterial Infection
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Appearance:
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Red streaking, spreading
erythema
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Swelling/induration around
site
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Palpable hard knot
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Fluid filled lesion
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Green/purulent drainage
Other symptoms:
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Increased tenderness
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May or may not have fever
Cause:
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MRSA common source
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Contaminated water
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Excessive pressure between
bolsters
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Treatment:
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Clean w/ sterile water or
saline 2-3x/d
Oral/IV antibiotics
Bactroban
Keep G-tube out of
ostomy/diaper
Bathe in clean water
Avoid lakes, rivers, ponds
M ost critical time ±first 2
weeks after G-tube surgery
Bacterial Infection
Bacterial Infection
Fungal Infection
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Appearance:
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Causes:
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Red papular rash, often has satellite
lesions.
Trapped moisture
Hot, humid environment
G-tube located deep in a skin fold
chronic moisture, immunosuppression, cortico-steroids and DM
TX:
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Keep area clean and dry
Antifungal (powder preferred):
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Nystatin 100,000U TID 7-10 d
Miconazole 2% ointment BID 2- 4
weeks (broader spectrum, better for
larger affected areas) -Zeasorb
Barrier powder after anti-fungal
treatment
Infection: Assessment
History:
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Skin care regimen
History of skin problems?
Leakage and or sweating
(moisture)? Texas Heat
Weather: Hot, humid environment?
Pain or itching?
Fever? (not always indicative of
infection).
H/o of Immuno-suppression,
cortico-steroids or Diabetes?
Swimming? Water source.
Has any treatment made problems
better or worse?
Physical Exam:
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What does the site look like? red
streaking? spreading erythema?
Irregular borders? Bumpy rash?
Satellite lesions? Swelling?
Fluid filled lesion?
Is the button/tube too tight? Is
the G-tube located deep in a skin
fold?
Is there drainage? What does it
look like? Is it purulent? Is there
an odor?
Look at the entire abdomen,
palpate for firmness/ tenderness.
Is there a palpable knot or
induration around site?
What is it?
Bumper !cars
The external and internal bumpers (bolsters)
keep the G-tube/button in place.
Problems can occur if the bumpers are
too taut
Buried Bumper Syndrome
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Cause: excessive tension on
bumpers, internal
bumper/balloon pulled up into
the gastric mucosa, overinflated balloon*
S/S: abd. pain, site tenderness,
palpable bolster, resistant flow,
infection
*Balloon should be ~ 5cc
Other Bumper Problems
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Pressure Necrosis/Pressure
Ulcer
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Caused from the external bolster
being tight, excessive tension,
sutured bumpers
Skin red, ulcerated, indentation
marks seen
Gastric Outlet Obstruction
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Caused from balloon/internal
bolster blocking pylorus
Bumper Problems: Assessment
History:
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Pain? Where? Timing.
Fever?
Drainage?
Problems with the flow of the
formula?
Vomiting?
Physical Exam:
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Is the tube/button tight?
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Any difficulty rotating the
button?
Erythema?
Swelling or induration?
Is there drainage? What does it
look like?
Look at the entire abdomen,
palpate for firmness/ tenderness.
Palpable and/or visible
bolster/balloon?
Bumper Problems: Treatment
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Adjust the bolster
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Loosen external bolster
increase length of G-button
Decrease the balloon
volume
Remove any tension
Make sure tubes are in
place
Remove/change out tube if
necessary
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Antibiotics may be needed
EGD and even surgery if
not resolved
Externally:
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barrier powder (good for
non-intact skin
Foam dressingssoft/absorbant
Tube Problems
Malfunction
Obstruction
Dislodgement
Tube Problem: Assessment
History:
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Flushing routine-when and how
much? Problems flushing?
What type of water are they using?
What medications are they on and in
what form?
Leakage from the tube/button? From
the stoma?
Do they leave extensions on? Do
they tuck tubes in diapers or pants?
Is the patient pulling on the
tube/button? Recent trauma to the
site?
Physical Exam:
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:KDW¶VWKHFRQGLWLRQRIWKH
tube/button?
If the patient has a balloon
button:
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Is there water in the balloon?
+RZPDQ\FF¶V?
Is there leakage? Where is it
coming from?
Having any problems flushing
through it?
Tube malfunction
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Signs:
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Treatment:
Leaking formula from
within the button
Balloon leaks/bursts
Piece breaks off or loosens
&DQ¶WGHIODWHWKHEXWWRQ
Crack or hole on G-tube
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Wear & tear
Meds/formula/gastric pH
Residual formula
Repeated pulling
Trauma
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‰ Causes:
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Replace device as soon as possible
BARD button: decompression extension
Use water-proof tape if cap broken
,IWKHEXWWRQ¶VEDOORRQEXUVWV\RXFDQ
put the G-button back in and tape it in
place until you can get a replacement.
'RQ¶WIHHGWKURXJKWKLVDVLWPD\
migrate.
Balloon port: clean the port , paper clip
to open valve, cut it
For GJ tubes they need replacement
under fluoroscopy
Tube Obstruction
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Causes:
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Inappropriate med
administration, thick
formulas, failure to flush,
pill fragments, viscous
meds, defective tubing
Smaller French tubes
Prevention
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Liquid med administration
=$33!)>6%!!?@!'*7%93
?@BCD!'*7%93
E*+$!)>6%!CD!'*7%93
„
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Before/after meds & feeds
Every 4-6 hours
<RXU&KLOG·V:HLJKW
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Flush well:
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Treatment:
"#$%&'!$(!()%*+!($,!
-./!'%01
A@!4;
AD!4;
?@!4;
„
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Check for kinks, make sure
not clamped
Flush with warm water, use
30-60 cc syringe
Push-pull method
Milk the tubing
De-clogging methods (see
separate slide)
Change out extensions/
button if possible
Check placement, dye study
Tube Obstruction: De-clogging
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Instill 10-15 ml of
decaffeinated/sugar free
carbonated beverage or club
soda and leave for approx. 20
minutes then try flushing.
Also she can use 1/8 teaspoon
baking soda dissolved in 5ml of
warm water and let it sit for 30
minutes.
No cranberry juice.
Tube Dislodgement:
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Causes:
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Balloon deflates
Gets pulled out:
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EARLY
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Ace bandage, tape,
binder, clothing
< 3-6 weeks
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Purposefully
Accidentally
Prevention:
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Tract not well formed
Forcing a tube may
disrupt stomach from
abdominal wall
LATER
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6-12 weeks?
FACT:
*Tract matures quicker when stomach
stitched to the abdominal wall
*The stoma can start to close in 1-2 hours
S.O.S! (Save our Stoma)
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Without something in the
stoma it can start to close in 12 hr or sooner on some kids
There may be an edematous tract
Sometimes tubes are easier to get
in than buttons
May have to dilate stoma:
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Foley catheter
Hegar dilators
AM T ® I ntroducer
When to get a radiologic study?
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If the PEG tube, G-tube, or button is traumatically
removed
Post first conversion of a surgical G-tube or PEG
tube to a button
If a surgically placed G-tube or button comes out
less than 3 weeks post-operatively
For signs of complications post placement such as:
no gastric aspirate, abdominal pain, tenderness and
or rigidity, or if the stomal tract had to be dilated to
insert a new tube/button
Real !" #$%&' Stories
†
Reasons for dislodgement
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Mom sat on the tube
Tube got caught in seatbelt of
car seat
Child pulled the external bolster
off
Child pulled the button out and
chewed on it/used it like a
pacifier
Button got caught on a ladder
toddler was climbing
Child pulled the button out
and hid it from mom
Sibling/cousin/schoolmate
pulled it out
Crawling on belly
Contact sports
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Stoma Savers
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Straw
Cotton tipped applicator
NG tube
Stoma Busters
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Balloon broken and Gbutton not taped down
G-button not rotated, in 3
years
Not able to put more than 2
cc in the balloon
Protecting the G- Tube/button
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Stretchy gauze/netting
ACE bandage/coban
Wraps/binders
Clothing
Positioning of tubes
Foam donut
Blankets
Tape is not the first choice
for protection but if necessary
use a non-irritating tape.
Universal Wrap
‡Customizes size
‡Made of cotton/lycra bend
‡In solid and color prints
‡$34 95 (no insurance accepted)
Gus Gear
www.gusgear.net
724-513-4497
Red Flags
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Abdominal pain, tenderness and/or rigidity especially with or after
feedings
Vomiting, gagging and/or choking with feedings
Difficulty with the flow of formula or medications
The G-button protrudes out more but is stationary/immobilized ± it
should move in and out of the stoma
The G-EXWWRQGRHVQ¶WVLWHYHQO\RQWKHVNLQ
Redness with swelling around the gastrostomy within first 3 weeks
post-op
Fever with any of the above problems
Take home points:
a
Assess:
a
a
a
a
a
a
Never assume
Try to fix underlying problems
Protect the skin/keep dry
Stabilize tubes
a
a
a
2QHVL]HGRHVQ¶WILWDOO
Flush, flush, flush
Create a plan of care:
a
a
a
No tension on the tube/stoma
Correct size
a
a
Look at the big picture
Look, Listen, Touch and Smell
Consider family finances/
access to supplies
Be creative and resourceful
Educate and re-educate
G-tube Resources: Web Sites
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American Pediatric Surgical Nurses www.apsna.org
Applied M edical Technology www.amtinnovation.com
Complex Child http://complexchild.com/
M ic-key G-button www.mic-key.com
The Oley Foundation www.oley.org
Parent: www.parent-2-parent.com
Special Child www.specialchild.com
G-tube Resources at CMC
±under construction
†
Patient Education:
„
„
†
New G-J button (English)
Revised G-tube home care
instructions in progress
Clinical Education
„ Staff teaching aids
Questions?
Thank you for your attendance!