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Policies,Clinical,UWHC Clinical,Department Specific,Nursing Patient Care,Gastrointestinal

Gastrostomy Tube Care and Replacement of Surgically and Endoscopically Placed (PEG) Gastrostomy Tubes (Adult) (2.17A)

Gastrostomy Tube Care and Replacement of Surgically and Endoscopically Placed (PEG) Gastrostomy Tubes (Adult) (2.17A) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Gastrointestinal

2.17A

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
September 22, 2017

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 2.17A

Original
Revision

Page
1
of 8

Title: Gastrostomy Tube Care and
Replacement of Surgically and
Endoscopically Placed (PEG) Gastrostomy
Tubes (Adult)

I. PURPOSE

A. Provide guidelines to care for the gastrostomy tube, maintain skin integrity,
prevent infection and safely reinsert/replace a surgically or endoscopically placed
gastrostomy tube. This policy does not apply to gastrostomy tubes placed in
Interventional Radiology.

II. POLICY

A. The first gastrostomy tube replacement will be performed by the surgeon or
gastroenterology provider. Thereafter, a nurse trained to replace the gastrostomy
tube will replace the tube as needed, if the tube has an inflatable internal balloon
and requires no instrumentation for placement.
B. The surgical team will change the first dressing unless otherwise specified.
Thereafter, gastrostomy care should be performed daily and as needed.
C. Sterile dressing technique is used for the first week after surgically placed
gastrostomy tube.
D. During first week after initial placement, don sterile gloves, cleanse site with
sterile water or sterile normal saline using sterile cotton-tipped applicators to
gently remove crusted drainage.

III. PROCEDURE

A. Gastrostomy Site Care - Surgically Placed
1. Equipment:
a. Adhesive tape one (1) inch or securing device
b. Adhesive remover, if indicated
c. Sterile water or sterile normal saline
d. Disposable gloves
e. Sterile cotton-tipped applicators
f. Gauze, 2x2 or 4x4 dressing or split gauze dressing (optional)
2. Explain procedure to patient.
3. Perform hand hygiene according to UW Health Clinical Policy 4.1.13,
Hand Hygiene.
4. Follow standard and transmission based precautions according to UW
Health Clinical Policy 4.1.8 Standard Precautions Isolation.
5. Consult with the provider regarding when the patient may shower or tub
bathe with the gastrostomy tube.
6. Remove old tape, using adhesive remover as needed.

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7. Sterile dressing technique is used for the first week after initial
placement.
a. Don sterile gloves, cleanse site with sterile water or sterile normal
saline using sterile cotton-tipped applicators to gently remove
crusted drainage.
8. Clean dressing technique is used one week after initial placement
a. Cleanse the skin around the tube with mild soap and water. Rinse
well and dry gently. If dried, crusted drainage is present around
tube, use warm, moist, non-fibrous washcloths to loosen drainage.
Hydrogen peroxide is no longer recommended as it is irritating and
may be cytotoxic.
b. Dry site completely after cleaning.
c. Maintain a dry dressing split gauze only if drainage is present. A
dressing is not necessary after the incisional area is healed
9. Document gastrostomy care and observations regarding the site in the
patient’s clinical record.
B. Gastrostomy Site Care - Endoscopically Placed (PEG tube)
1. Equipment:
a. Sterile normal saline or sterile water
b. Sterile cotton-tipped applicators
c. Gloves
d. Gauze
2. Explain procedure to patient. Adequate patient preparation is important
to assure understanding and cooperation.
3. Perform hand hygiene according to UW Health Clinical Policy 4.1.13,
Hand Hygiene.
4. Follow standard and transmission based precautions according to UW
Health Clinical Policy 4.1.8 Standard Precautions and Isolation.
5. Gastrostomy care should be performed daily and as needed
a. Cleanse skin with sterile saline or sterile water. Use spiral pattern
beginning next to stoma site and moving outward. Clean under
skin disc with cotton-tipped applicators. Dry thoroughly.
b. The PEG tube should not have dressings placed around or under
skin disc unless there is drainage. Cleansing should be performed
one or more times daily depending on amount of drainage. If
excess drainage occurs, notify provider..
c. Site should be left open to air unless drainage occurs. If drainage is
present, apply a 2x2 or 4x4 gauze dressing or split gauze dressing
and secure it with tape. Change dressing as ordered or as needed.
Skin must be kept clean and dry to prevent irritation and infection.
Skin irritation may result from moisture. Signs of infection should
be reported to the provider. If granulation tissue is excessive,
notify the provider as tissue may require cauterization or other
specific treatments to decrease hypergranulation tissue.
d. To prevent or treat skin breakdown, consult with the Certified
Nursing Wound/Skin/Ostomy Team
e. Surgically Placed Tubes:
i. As part of routine assessment, gently pull the catheter back
until resistance is met to be sure the balloon is against the

Page 3 of 8

wall of the stomach.
ii. If not properly secured, the balloon can migrate into the
duodenum and cause obstruction.
iii. A balloon positioned snugly against the wall of the stomach
helps prevent leakage of stomach contents from around the
tube.
iv. Secure the tube to prevent movement. Tape or commercial
devices to anchor the tubes can be used. The tube should
not be taped tautly to the side, but should come straight up
(90 degrees) out of the stoma. The commercial anchoring
device (Flexitrak) is available in Central Supply, item
#4011427
f. Endoscopically Placed (PEG) Tubes:
i. Do not loosen the external skin disc /bumper for two (2)
weeks. If external skin disc/bumper appears too tight or too
loose, contact provider. There should only be 1-2
millimeters (mm) between the skin and the bumper.
ii. Two weeks after initial placement, gently loosen the
external skin disc/bumper off skin slightly to be sure there
is a slight in-and-out play of the tube with easy clockwise
and counterclockwise rotation. Patient may gain weight
from nutrition support. Slight in-and-out play allows for
adequate external skin disc/ bumper movement and
decreases risk of the external skin disc/ bumper from
migrating up into stoma tract.
iii. Note centimeter (cm) marking where skin disc is placed.
Documenting skin disc placement helps monitor possible
tube migration.
iv. Distal end of tube may be secured to abdomen with tape or
a commercial anchoring device (Flexitrak) and available in
Central Supply (item # 4011427). Securing loose end
prevents accidental pulling on tube.
v. Starting immediately post-procedure and then daily, PEG
tube should be gently rotated 360 degrees both clockwise
and counterclockwise by rolling between thumb and index
finger. This action is a test of whether internal bumper has
adequate room to move freely and is not too tight against
gastric mucosa. If unable to gently rotate tube, discontinue
enteral feeding and notify provider as additional
assessments/diagnostic testing will be needed to check
proper placement.
6. Document gastrostomy care and observations regarding the site in the
patient’s clinical record.
C. Gastrostomy Tube Replacement – Gastrostomy tubes need to be replaced on a
routine basis. Traditional G-tubes are changed at approximately 5-6 months, and
low profile/button ones every 3-4 months.
1. If a gastrostomy tube unexpectedly falls out and it is the original PEG
tube or the tube has been in place less than 4 weeks, the GI consult team
should be notified immediately.

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D. Care of Gastrostomy Low Profile/ Button
1. Care of the gastrostomy low profile/ button is the same as that of a
traditional G-tube, with clockwise and counterclockwise rotation of the
button during daily cleaning to relieve skin pressure.
E. Management of Complications
1. Infection at the incision site
a. Usually limited to incision site, skin, and subcutaneous tissue.
b. Signs include redness, incisional drainage, odor, pain and swelling,
c. More frequent skin cleansing and drainage management with
gauze dressings may be necessary.
d. Contact provider to evaluate.
2. Bleeding
a. Bleeding may occur in the post-op period and is related to
inadequate hemostasis at the time of insertion or difficulty with
stapling or suturing.
b. Notify provider if more than small amounts of bleeding are at the
site and if there is presence of signs and symptoms of hemorrhage,
especially within 24 hours of placement.
3. Granulation tissue
a. This is an overgrowth of epithelial tissue that is pink-red in color,
inflamed, and may bleed easily.
b. The tissue may develop at the insertion site as a result of the
body’s reaction to a foreign body.
c. Excessive G-tube movement and moisture may also cause or
exacerbate the formation of granulation tissue.
d. Multiple interventions are available to treatment hypergranulation
tissue. Consult the Certified Nursing Wound, Skin/ Ostomy Team
to help formulate the appropriate treatment plan specific for the
patient.
4. Tube Dislodgement
a. Dislodgement Considerations
i. Pulling on or applying tension to the tube can cause it to
dislodge. Most tubes have internal (inside the stomach) and
external (outside the stomach) bumper. The internal
bumper keeps the tube from falling out. The external
anchor keeps the tube from being pulled into the stomach.
ii. Dislodgement or accidental removal with subsequent re-
insertion, especially during the first month after placement,
may lead to peritonitis. The GI consult team should be
contacted immediately. Do not try to replace the g-tube in
this circumstance.
iii. During tube replacement, the stomach may be pushed away
from the abdominal wall. Because the fistula tract has not
been established, formula or gastric contents may leak into
the peritoneal cavity.
iv. If dislodgement occurs after four weeks, replace the tube
within one (1) hour so the tract does not close. A urinary
catheter should only be placed as a temporary measure to
maintain the opening if the tube is more than four (4)

Page 5 of 8

weeks old.
v. Patients and caregivers should be taught how to avoid
accidental removal, how to replace the tube, or who to
notify to arrange for tube replacement.
b. Gastrostomy Tube Replacement
i. If a gastrostomy tube unexpectedly falls out and it is not the
original PEG tube and it has been in place for more than
four weeks, the nurse should place a Foley catheter of the
same size or smaller to hold the stoma open until the tube
can be replaced because stomas quickly begin to close
down.
• Equipment:
o Urinary catheter with balloon (size ordered
by physician) – balloon size 5 mL to 20 mL
depending on type of catheter. Note that the
Foley urinary catheter placed in the stoma is
only intended to be a place holder until an
actual g-tube can be replaced Foley catheters
can not be used for enteral feeding as they
not EnFit compatible.
o A physician may order a balloon type
gastrostomy tube as a replacement tube:
these replacement tubes are EnFit
compatible and can be used for enteral
feeding.
o 60 mL syringe
o One (1) inch tape
o Water soluble lubricant
o Skin prep
o Non-sterile gloves
o Sterile water for balloon inflation
ii. Perform hand hygiene according to UW Health Clinical
Policy 4.1.13, Hand Hygiene.
• Follow standard and transmission based
precautions according to UW Health Clinical
Policy 4.1.8 Standard Precautions and Isolation.
• Explain procedure to patient. Adequate patient
preparation is important to assure understanding
and cooperation.
• Position patient in supine position.
• Inject 5 mL to 20 mL of sterile water into balloon
of the new catheter to test for leak. If no water
leaks after two (2) minutes, withdraw water and
prepare patient for procedure. If balloon leaks,
discard and obtain a new catheter. NOTE: Read
instructions with tube kit for correct balloon
volumes. DO NOT over inflate.
• If the tube being replaced is a Foley catheter,

Page 6 of 8

remove tape, withdraw water from old tube, and
remove tube. Always have new tube ready prior to
removing old tube.
• Lubricate the tip of the replacement catheter with
a water soluble lubricant.
• Gently insert catheter into gastrostomy opening
about 3-5 inches. Catheter should be
perpendicular to the abdominal wall during
insertion. If resistance is met, notify physician.
• Inject specified amount of sterile water into
balloon of catheter.
• Gently pull the catheter back until resistance is
met to be sure the balloon is against the wall of
the stomach. If a replacement gastrostomy tube is
used, snug skin disc up against abdomen always
leave a gap of 1-2 mm.
o If not properly secured, the balloon can
migrate into the duodenum and cause
obstruction. A balloon positioned snugly
against the wall of the stomach helps
prevent leakage of stomach contents from
around the tube.
o If persistent vomiting or diarrhea occurs,
check tube placement. Feedings
administered via a gastrostomy tube which
is inappropriately placed in the duodenum
can produce a “dumping” phenomenon.
• Placement should be assessed by looking at the
mm mark on the tube by the bumper. Proceed
with skin care and taping of the tube according to
section III, A.
• Document the tube change and related
observations in the patient’s clinical record.
5. Leaking
a. Treatment of leakage is directed at the underlying cause and
correcting the cause of the leakage
b. If leaking occurs, the amount of water in the balloon may need to
be evaluated. The balloon may need to be reinflated with water to
the appropriate volume. Clean drainage away with a wet gauze and
dry area thoroughly.
c. For excessive exudates, use gauze around the site to absorb the
drainage. The gauze should be changed frequently to keep
moisture off the skin. Occlusive dressings are not recommended.
d. A barrier cream or foam dressing can be applied to protect the
peristomal skin. This should be discussed with the provider prior to
application.
e. Consult the Certified Nursing Wound/Skin/Ostomy Team for
additional dressing options.

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6. Skin Irritation
a. Irritation can be caused by moisture leakage on the skin, caustic
nature of leaking effluent or an external bumper that is positioned
too firmly against the skin causing pressure ulcer like damage.
b. Clean irritated skin more frequently.
c. A barrier cream or other type of barrier can be ordered and applied
to protect peristomal skin.
7. Separation of the stomach from the abdominal wall
a. Signs and symptoms include pain and bulging at the abdominal
wall. Concern for peritonitis. Notify provider.
b. Separation may occur upon reinsertion of a displaced tube or with
premature tube change before the gastrostomy tract has had time to
heal and mature. Notify provider.
8. Mechanical trauma from stripping of tape or other adhesives
a. Use adhesive removers or water to loosen adhesive.
b. Once stoma is established, avoid covering with dressings or tape.
c. Consult the Certified Nursing Wound/Skin/Ostomy Team for
additional assistance
9. Candidiasis
a. Keep the area around the tube dry.
b. Treat with a topical antifungal powder as ordered by provider or
Certified Nursing Wound/Skin/Ostomy Team.
10. Erosion
a. Erosion is the breakdown of the epidermis usually caused by
physical abrasion or inflammatory processes.
b. Erosion can be prevented by avoiding tension on the gastrostomy
site. The tube should not be taped tautly to the side, but should
come straight up out of the stoma.

IV. UW HEALTH CROSS REFERENCES

A. UW Health Clinical Policy 4.1.8 Standard Precautions and Isolation.
B. UW Health Clinical Policy 4.1.13, Hand Hygiene
C. Health Facts for You #4350, Caring for your Gastrostomy

V. REFERENCES

A. Catangui, E., Mejia, C., Amorim, A. (2014). Development and implementation of
a percutaneous endoscopic gastrostomy (PEG) nursing care plan. British Journal
of Neuroscience Nursing, 9(6), 286-290.
B. Fellows, J., Rice, M. Nursing Management of Patients with Percutaneous Tubes.
In Wound Management ( Doughty and McNichol, ed), Wound, Ostomy,
Continence Nursing Society Core Curriculum, Wolters, Kluwer, Philadelphia, PA
p 723-733, 2016.
C. Friginal-Ruiz, A. B., Lucendo, A. J.(2015), Percutaneous endoscopic
gastrostomy, a practical overview on its indications, placement conditions,
management and nursing care. Society of Gastroenterology Nurses and
Associates, 38(5), 354-366.
D. Simons, S., Remington, R. (2013). The percutaneous endoscopic gastrostomy

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tube: A nurse’s guide to PEG tubes. Medsurg Nursing, 22(2), 77-82.
E. Up to Date: Gastrostomy Tubes: Complications and Their Management,
Placement and Routine Care. Mark Delegge, MD.

VI. REVIEWED BY

Clinical Nurse Specialist, Surgical Specialties and Psychiatry
Clinical Nurse Specialist, Burn and Trauma/Surgical IMC
Clinical Nurse Specialist, General Surgery and Orthopedics
Clinical Nurse Specialist, DHC
Clinical Nurse Specialist, Wound/Skin/Ostomy
Nursing Patient Care Policy and Procedure Committee, September 2017

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive