Check to ensure that the tube is securely stabilized
and has not become dislodged.
Assess the tension of the tube. If there is enough
tension, the tube may leak gastric drainage around exit site.
If the tension is too great, the internal anchoring
device may erode through the skin
Nursing diagnosis
Imbalanced nutrition: less than body
requirement
Impaired skin integrity
Risk for infection
Deficient knowledge
Expected outcomes
The expected outcome to achieve when
caring for a gastrostomy tube is that the patient ingests an adequate diet and exhibits no signs and symptoms of irritation, excoriation, or infection at the tube insertion site.
In addition, the patient will be able to
verbalize the care needed for the gastrostomy tube.
Action 1.
Explain procedure to patient
2.
Perform hand hygiene. Don disposable
gloves
3.
If the tube is new and still has sutures
holding it in place, dip cotton tipped applicator into sterile saline solution and gently clean around the insertion site, removing any crust or drainage. If gastric tube insertion site has healed and the sutures are removed.
4.
Wet a washcloth and apply a small amount
of soap onto washcloth. Gently cleanse around the insertion, removing any crust or drainage. Rinse site, removing all soap.
5. Pat skin around insertion site dry
6. If the sutures have been removed, rotate the guard or external bumper 90 degrees at least once a day 7. Remove gloves and perform hand hygiene 8. Record care given, including appearance of the site, any drainage present, and the patients response
Unexpected situation and
associated interventions
Gastrostomy tube is leaking large amount of
drainage Check the tension of tube. If there is a large amount of slack between the internal guard and the external bumper, drainage can leak out the site.
Apply gentle pressure to tube while pressing the
external bumper closer to the skin. If the tube has an internal balloon holding it in place (similar to a urinary catheter balloon), check to make sure that the balloon is inflated properly.
Skin irritation is noted around the insertion
site If the skin is erythematous and appears to be broken down, the culprit could be leakage of gastric fluids from the site. Gastric fluids have a low pH and are very acidic. Stop the leakage, and apply a skin barrier
If the skin has patchy, redrash, the culprit could
be candidiasis (yeast). Notify the physician for an order to apply an antifungal powder. Ensure that the site is kept dry. Site appears erythematous and patient complains of pain at site. Notify physician; patient could be developing cellulitis at the site.