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

Gastrostomy Care (Pediatric) (2.17P)

Gastrostomy Care (Pediatric) (2.17P) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Gastrointestinal

2.17P

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
July 31, 2017

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 2.17P

Original
Revision

Page
1
of 7

Title: Gastrostomy Care (Pediatric)

I. PURPOSE

A. To provide guidance to stabilize the gastrostomy tube, maintain skin integrity and
prevent infection in the pediatric population.
B. To provide guidance for reinsertion of a gastrostomy tube.

II. POLICY

The first tube change will be performed by the Pediatric Surgery or Gastroenterology
provider. Thereafter, a registered nurse (RN) will change the tube as needed (if it
becomes plugged or dislodged) or if the tube is inflatable and requires no
instrumentation (such as using a urinary catheter).

III. PROCEDURE

A. Gastrostomy Site Care - Surgically Placed
1. Equipment:
a. Adhesive remover, if indicated
b. Sterile water or sterile normal saline (sterile procedure)
c. Sterile gloves (sterile procedure)
d. Soap and tap water (clean procedure)
e. Towel and washcloth (clean procedure)
f. Disposable gloves (clean procedure)
g. Cotton-tipped applicators
h. Gauze, 2x2 or 4x4 dressing or split gauze dressing (optional)
i. Measuring tape
j. Universal securement device
2. Explain procedure to patient’s family.
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. The surgeon will change the first dressing. Thereafter, gastrostomy care
should be performed daily and as needed. Bath time is an optimal time
for the procedure. The patient may take a tub bath or shower after the
incision has healed (2 weeks after the surgery). If complications arise,
check with the provider before submerging in the tub.
6. Remove securement device, using adhesive remover as needed.
7. Sterile procedure:
a. During first week after initial placement, using sterile gloves,

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cleanse site with sterile water or sterile normal saline using sterile
cotton-tipped applicators to remove dried drainage.
8. Clean procedure (beyond one week after initial placement)
a. Cleanse the skin around the tube with tap water and soap. If there
is dried, crusted drainage around tube, use warm, moist washcloths
as compress to loosen drainage.
b. Dry site completely after cleaning. Maintain a dry dressing split
gauze initially only if drainage is present. A dressing is not
recommended after the incisional area is healed because it can
keep the area moist and cause skin breakdown.
c. Hydrogen peroxide is not recommended as it is irritating and may
be cytotoxic.
d. DO NOT apply ointments, medicines, or any other solutions on the
site unless prescribed by a provider.
9. Inspect the skin at least once every 8 hours for signs of excoriation,
erythema, drainage, induration, edema, bleeding, tube stability and fit,
and granulation tissue.
a. Signs of infection should be reported to the provider.
b. Skin irritation may result from moisture. Rotation of the tube in the
securement device and more frequent gastrostomy care may be
indicated. If granulation tissue is excessive, notify the provider as
tissue may require cauterization.
c. To prevent or treat skin excoriation, consider various types of skin
care products and consult with the Pediatric General Surgery Nurse
Practitioners.
d. Gently pull the catheter back until resistance is met to be sure the
balloon is against the wall of the stomach. If not properly secured,
the balloon can migrate into the duodenum and cause obstruction.
i. A balloon positioned snugly against the wall of the stomach
helps prevent leakage of stomach contents from around the
tube.
e. To secure the tube, use a universal securement device instead of
tape to prevent movement. Tubing can be tucked under clothing to
prevent accidental pulls. Alternatively, a piece of tape can be
wrapped around the end of the tube and this can be fastened to
clothing.
10. 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.
11. Tube placement and patency should be checked every four (4) hours and
as needed for continuous feedings and every four (4) hours and prior to
giving an intermittent feeding.
12. Document gastrostomy care and observations in the patient’s clinical
record.
B. Gastrostomy Site Care - Endoscopically Placed (PEG tube)
1. Equipment:
a. Sterile normal saline
b. Cotton-tipped applicators
c. 2x2 or 4x4 split gauze

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d. Gloves
2. Explain procedure to patient’s family.
3. The PEG tube should not have dressings placed around or under skin
disc. Cleansing should be performed daily and as needed depending on
amount of drainage. If excess drainage occurs, consult Pediatric General
Surgery or Pediatric GI service. Bath time is an optimal time for G-tube
care. A shower or tub bath may be taken after several days depending on
appearance and healing of incision.
4. Perform hand hygiene according to UW Health Clinical Policy 4.1.13
Hand Hygiene.
5. Follow standard and transmission based precautions according to UW
Health Clinical Policy 4.1.8, Standard Precautions and Isolation.
6. Inspect the skin at least once every 8 hours for signs of excoriation,
erythema, drainage, induration, edema, bleeding, tube stability and fit
and granulation tissue.
a. Signs of infection should be reported to the provider.
b. Skin irritation may result from moisture. Rotation of tube in the
securement device and more frequent gastrostomy care may be
indicated. If granulation tissue is excessive, notify the provider as
tissue may require cauterization.
c. To prevent or treat skin excoriation, consider various types of skin
care products in consultation with the Pediatric General Surgery
Nurse Practitioners.
d. Use a universal securement device instead of tape to secure tube.
7. Cleanse skin with sterile normal saline. Use spiral pattern beginning next
to stoma site and moving outward. Clean under skin disc with cotton-
tipped applicators. Dry thoroughly.
8. Do not move the external bumper. If tube appears too tight or too loose,
contact Pediatric General Surgery provider. There should only be 1-2
millimeters (mm) between the skin and the bumper.
a. Skin must be kept clean and dry to prevent irritation and infection.
b. 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.
c. Change dressing as ordered or as needed.
d. When patients are at home and/or the wound is healed, the site can
be washed with soap and water (i.e., when in the tub or shower).
9. Because of the internal bumper, some gastrostomy tubes must be
endoscopically removed. DO NOT ATTEMPT TO REMOVE
THROUGH STOMA SITE BY PULLING ON TUBE. Tissue trauma
would result. Once a balloon type replacement GI tube is in place, the
nurse may change the tube at the bedside as needed. NOTE: Once the
tube is out, the tract closes down rapidly and if replacement is needed, it
should be performed within an hour of removal.
10. Tube stabilization: A variety of methods can be used to stabilize the tube
to ensure excessive movement does not occur. These methods include
use of foam dressings, tube attachment devices (universal securement
devices), taping, and tucking the tube under clothing or diaper.
11. Starting immediately post-procedure and then daily, PEG tube should be

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gently rotated 360 degrees 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.
12. Distal end of tube may be taped to abdomen. Securing loose end
prevents accidental pulling on tube.
13. TWO WEEKS AFTER INITIAL PLACEMENT, BACK SKIN DISC
OFF SKIN SLIGHTLY TO BE SURE THERE IS SLIGHT IN-AND-
OUT PLAY OF TUBE AND EASY ROTATION. Patient may gain
weight from nutrition support. Slight in-and-out play allows for adequate
bumper movement and decreases risk of bumper migrating up into
stoma tract.
C. Changing Gastrostomy Tube (G-tube) (the first tube change must be done by a
provider)
1. Equipment:
a. Urinary catheter with balloon or other balloon type gastrostomy
tube (size ordered by provider) – balloon size 5 mL to 20 mL
depending on type of catheter
b. Two (2) syringes
c. Tap water
d. One (1) inch tape
e. Water soluble lubricant
f. Skin prep
g. Red slide clamp (if using Foley urinary catheter)
h. Non-sterile gloves
2. For all skin-level balloon-type buttons, follow instructions on the
individual package insert for correct procedure and balloon volume for
inflation.
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. Explain procedure to patient.
6. Position patient in supine position.
7. Inject appropriate amount of 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.
8. If the tube being replaced is a Foley catheter, remove securement device,
withdraw water from old tube and remove tube.
9. Lubricate the tip of the replacement catheter with a water soluble
lubricant.
10. Gently insert catheter into gastrostomy opening about 2 to 3 inches.
(Red slide clamp should be placed on urinary catheter before insertion to
prevent tube migration). Catheter should be perpendicular to the
abdominal wall during insertion. If resistance is met, notify provider.
11. Inject specified amount of sterile water into balloon of catheter.
12. Gently pull the catheter back until resistance is met to be sure the

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balloon is against the wall of the stomach. If a replacement gastrostomy
tube is used, snug skin disc up against abdomen.
a. 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.
b. 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.
13. Clean the site with tap water. It is normal for some stomach secretions
and a few drops of blood to be expelled during the tubing change. If
there are more than a few drops of blood, notify the provider.
14. Proceed with skin care and securing of the tube according to section III,
A.
15. Document the tube change and related observations in the patient’s
clinical record.
D. Care of Gastrostomy Button
1. Care of the button is the same as that of a G-tube, with 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, discharge, swelling, soreness and odor.
c. Clean more frequently with mild soap and water.
d. Use a gauze dressing if drainage is present.
2. Bleeding
a. Bleeding may occur in the postop period and is related to
inadequate hemostasis at the time of insertion or difficulty with
stapling or suturing.
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 may also cause or exacerbate the
formation of granulation tissue.
d. Topical application of silver nitrate sticks may be used to treat
granulated tissue.
e. Applying petroleum ointment to normal skin around the granulated
tissue helps to prevent irritation from the silver nitrate.
4. Dislodgement
a. 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) anchors. The internal anchor keeps the tube from
falling out. The external anchor keeps the tube from being pulled
into the stomach.
b. Dislodgement or accidental removal with subsequent reinsertion,
especially during the first two weeks after placement, may lead to

Page 6 of 7

peritonitis.
c. 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.
d. If dislodgement occurs, replace the tube within 4 hours so the tract
does not close.
e. Parents should be taught how to avoid accidental removal, how to
replace the tube, or who to notify to arrange for tube replacement.
5. Leaking
a. If leaking occurs, balloon inflation may need to be evaluated.
Clean drainage away with a wet gauze.
b. 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.
c. A barrier cream or foam dressing can be applied to protect the
peristomal skin.
d. Unsecured extension sets are often the preventable cause for
leakage.
6. Irritation
a. Irritation can be caused by leakage moistening the skin or an
external anchor that is positioned too firmly against the skin.
b. Clean irritated skin more frequently.
c. A barrier cream or other type of barrier can be applied to protect
peristomal skin.
7. Separation of the stomach from the abdominal wall
a. 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.
8. Mechanical trauma from stripping of tape or other adhesives
a. Use adhesive removers or water to loosen adhesive.
9. Candidiasis
a. Keep the area around the tube dry.
b. Treat with a topical antifungal powder.
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. UWHC CROSS REFERENCES

A. Health Facts for You 4277, Caring for Your Child’s Gastrostomy Tube
B. UW Health Clinical Policy 4.1.8, Standard Precautions and Isolation
C. UW Health Clinical Policy 4.1.13, Hand Hygiene




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V. REFERENCES

A. Browne, N. T., Flanigan, L. M., McComiskey, C. A., & Piper, P. (2007). Nursing
Care of the Pediatric Surgical Patient (2nd Ed.). Sudbury, MA: Jones and Bartlett
Publishers.
B. Longobucco, D. B. (2007). Gastrostomy Tube Placement. In Neonatal Surgical
Procedures. A Guide for Care and Management. Santa Rosa, CA: NICU Ink.
C. Verger, J. T., & Lebet, R. M. (Eds.) (2008). AACN Procedure Manual for
Pediatric Acute and Critical Care. St. Louis, MO: Saunders Elsevier.

VI. REVIEWED BY

Clinical Nurse Specialist, Universal Care Unit & Float Team
Advanced Practice Nurses, Pediatric General Surgery
Nursing Patient Care Policy and Procedure Committee, May 2017

SIGNED BY

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