1. The Management of an Individual with a Percutaneous Endoscopic Gastrostomy Mike Lawrence Clinical Nurse Manager Bro Morgannwg NHS Trust Learning Disabilities Directorate

2. Aims of the Day To provide up to date evidence based knowledge of the management of an individual with a PEG. To address some of the issues that effect nurses around PEG support. The course will not deem you competent in the skills required.

3. Prevalence of Malnutrition In Hospital 40% Malnourished on admission 78% Malnourished deteriorated on discharge. (1994 McWhirter & Pennington, BMJ) Malnourished on admission: 50%Surgical 40%Medical (Kings Fund Consensus of Literature1992)

4. Financial Cost Malnutrition costs the NHS an estimated £266 m / year (Kings Fund,1992) Estimated cost of £26,000 to care for a grade 4 sacral pressure sore. (McSweeny, 1994, Nursing Standard)

5. Physical Effects of Poor Nutrition People become malnourished because their nutritional intake does not meet their nutritional requirements resulting in: Impaired immune response Increased risk of pressure damage Increased respiratory infection Poor growth often associated with Malnutrition. Severe dehydration.

6. A Percutaneous Endoscopic Gastrostomy. A P.E.G. is the siting of a tube through the wall of the abdomen and into the stomach. An individual will then receive all of his/her nutrition, fluids and medication via this tube.

7. Indications for a PEG Dysphagia: The impaired movement of material from the mouth through the pharynx and into the stomach. Difficulty in swallowing. Aspiration: The inhalation of food and fluids into the lungs Inability to maintain adequate nutritional intake on a long term basis.

8. These indications can occur in a number of conditions: Cerebral Palsy CVA Motor Neurone Disease Cancer Trauma Parkinson’s Disease

9. PEG Management Management of the PEG Site Tube Management

10. PEG Management Peg Site- Stoma Care Skin Care Signs of Infection Tube Care- Tube Flushing Clamp Tube Rotation Tube Measurement Positioning Plate Peg end/Funnel adapter

11. Control Of Infection Increase in the number and severity of Hospital acquired infections. Only use single use devices ONCE Wash hands Do not let feeds hang more than 12 hours New giving set every 24 hrs

12. Principles of Nutritional Administration Types of nutritional support Types of administration - Pump - Bolus Positioning of the individual Temperature of the food The Administration of medication

13. The Administration of Medication Recommended that medication should be administered in solution or dispersible forms. Suspensions. Syrups. Tube must be flushed with 30mls of water after medication to prevent blockage. Crushed tablets and opening capsules.

14. Frequency of tablet crushing or capsule opening (n = 540) Every drug round Every day Never Weekly Twice a week (Nursing Standard - July 3rd 2002)

15. Unlicensed Medication A product licence (or marketing authorisation) includes the dose, route, manner and form of the medication when it is granted. By altering any of these, including crushing tablets or opening capsules, you may make its use unlicensed.

16. Implications of Tablet Crushing or Capsule Opening Opening capsules or crushing tablets may make their use unlicensed. Effectiveness or nature of the medication may be altered. Medication may be released inadvertently in the stomach. Prescriber authorisation must be gained before opening capsules or crushing tablets. (Wright, D. Nursing Standard, Dec, 2002)

17. Medication administration is not a routine, mechanical task………. The nurse must have considered the dosage, method of administration, route and timing in the context of the condition of the patient. If a medicine is unlicenced …. You should be satisfied that you have sufficient information to administer it safely….. Nursing & Midwifery Council

18. 1.3You are accountable for your practice, regardless of directions from another professional. 1.4You have a duty of care to your patients 8.1You must work with other members of the team to promote safe, therapeutic and ethical practice.

19. Is there a liquid alternative? Is there a non oral alternative route or a ‘special’ available? Yes No Can the medicine be safely crushed or opened? No Ask prescriber to reconsider therapy Yes Unlicenced action always obtain written authorisation from the prescriber in conjunction with the pharmacist Prescriber willing to prescribe? Yes No Yes Licenced action get prescription changed and record the reason. Adapted from Wright, 2002 Flowchart for administration

20. Is the liquid dose equivalent to the solid form dose? i.e. 90mgs of Phenytoin liquid = 100mgs tablet. Will medication interact with the feed? particularly if advised ‘to give with or after food’ Might be advisable to stop continuous feeds for 30 mins before and 1 hour after administration. Advice on the Administration of Liquid Medications

21. Complications Tube Blockage Leakage Oesophageal Reflux Diarrhoea Constipation Oral Hygiene Taste

22. Monitoring Clinical Weight Fluid Balance Blood Biochemistry Urine Biochemistry Physical Swallow Assessment PEG Site Tube Care Important to monitor an individual’s independent abilities (PEG Clinic) Nutritional Intake assessed against individual calculated requirements

23. Ethical Concerns PEG Feeding The taste & sensation of food & drink