1. Specialized G/J Tube Training
Developed according to MAP policies by
Judy Spencer RN
North Shore ARC

2. Feeding and Medication Administration Through a G-Tube
G-tube Training
Only nurses and staff who have been trained and cleared by a Health Services nurse may a administer feeding or medication through a G-tube
Feeding and Medication Administration Through a G-Tube

3. Objectives The participants will demonstrate understanding of :
The purpose of G-Tube
The equipment
The procedure for feeding and medication administration
Placement and troubleshooting
Site care and maintenance

4. Purpose of the G-Tube To ensure : Normal growth and development
Maintenance of health and wellness
Individuals need to be weighed as directed.

5. Candidates for a G - Tube
Unable to meet nutritional needs thru oral intake
If an individual is unable to take food or fluids by mouth or is unable to swallow normally &/or safely.

6. Reasons for inability to swallow safely may include:
Stroke
Dementia e.g. Alzheimer's disease)
Medication side effects (dry mouth, motility problems)
Cerebral Palsy.
Muscular Dystrophy
Many different medical problems are treated with gastrostomies when the person cannot eat enough to meet nutritional requirements.
Medications side effects (e.g. dry mouth; motility problems with esophagus, stomach & bowel; neurological side effects resulting in decreased ability to swallow).
Birth defects of the mouth, esophagus or stomach and problems with sucking or swallowing.

7. Overview of Various types of FeedingTubes
Gastrostomy (G-Tube)
A flexible tube or button
Placed into the stomach
Through an opening in the abdominal wall
Provides feeding and medication administration
Provides venting & drainage
Placed in the stomach and has a tube that remains on the outside.
The dome has an anti-reflux valve to prevent leakage of stomach contents.
Gastrostomy also performed to provide drainage for the stomach when it is necessary to bypass a long standing obstruction of the stomach outlet into the small intestine.
Obstructions may be caused by peptic ulcer, scarring or tumor.
Allows venting of stomach gas.

8. The Mic – Key * A Low Profile G -Tube
Inserted into stomach through the abdominal wall
Inflatable balloon
External base
Anti – reflux valve
Individual measured to ensure correct size
A skin-level G-tube button.
A short feeding tube that comes out level with the skin.
It has a cap that opens and closes and a tube that is attached just for feedings.
Allows intake of food, meds and water/venting.
Inflated balloon at one end (in stomach) and an external base at the other (outside on skin) – both hold tube in place.
The EB hold the tube in place, yet allows air circulation to the skin around and underneath it. The bottom of the base should rest just above the skin surface. A good fit is considered 1/8” (3mm) above the skin, or approx the thickness of a dime.
Gently rotate the Mic-key in a full circle when you perform daily care, this will prevent the tube or balloon from adhering to the skin.
They will last up to 6 months.
The anti-reflux valve is located inside & toward the top of the feeding port. This helps prevent stomach contents from leaking out of the tube.
The extension set will open or unlock the valve.
Balloon volume should be checked weekly (via nursing).
Be sure residual formula is not left to pool & dry inside the valve opening – this can clog the tube, flush the tube after all feedings and meds.

9. Overview of Various types of FeedingTubes
Jejunostomy Tube ( J – Tube)
Placed in the jejunum (middle section of the small bowel)
Through an opening in the abdominal wall or
Through a specific port on a G – tube
Provides food and liquids directly in the jejunum
Necessary for individuals who cannot obtain adequate nutrition through the stomach and have:
severe gastric reflux
stomach obstructions
intestinal motility problems

10. Different Types of Tube Feedings
Intermittent gravity
Continuous/Pump
Syringe bolus

11. Intermittent gravity tube feeding
Given by bottle or bag
Hooked to a feeding tube set
Administer at specific times of the day

12. Continuous Tube Feeding
Given by a bottle, bag or pump
Hooked to feeding set
Administered:
around the clock or
at specific times over a set time
Method of tube feeding, rate and time may not be changed without a doctor’s order.

13. Syringe Bolus Tube Feeding
The term feeding tube is interchangeable with enteral feeding tube.
Enteral simply refers to a feeding tube that is placed in the GI tract.
Given thru a syringe
Administered at specific times

14. Preparation of Tube Feeding
Check the formula label
Shake container well
Wipe the top of the can
Check the expiration date
Warm formula to room temperature.
Cover and refrigerate any unused formula. Be sure to date/time unused formula. Discard after 24 hrs.
Never change brand of formula without MD order.

15. Administration of Bolus Feedings
Check health care provider orders
Gather equipment
Wash hands
Put on clean gloves
Explain procedure
Wash hands with soap and water for 20 seconds.
Clean the work area to help prevent infection

16. Administration of Bolus Feedings
Position individual appropriately
Connect extension tubing
Check for residual and placement
Replace residual and clamp/plug tube
Sit up at least 45 degrees during and 1 hr. after feeding to prevent aspiration (tube feeding coming backup from the stomach into the lungs).
Hold button while inserting extension tubing (make sure extension tubing locks in place).
Residual: The amt of formula & gastric fluid left in the stomach 4 hrs after feeding (to determine if previous feeding has been digested.) Stomach contents are normally yellow or clear unless there is food in the stomach.
Residuals indicate slow gastric emptying; therefore, increased probability for regurgitation and aspiration of gastric contents.
The stomach may not always empty completely.
The amount will vary depending on activity level or position.
Always replace residual to prevent possible electrolyte imbalance after noting color and amt.
If residual > 100cc hold the feeding & call the nurse. (Nurse may instruct staff to recheck in 1 hr. if residual still > 100cc staff may need to contact the doctor).
If individual c/o nausea check residual. If residual > 100cc call nurse.
Checking Placement: The appearance of gastric contents implies that the tube is patent and in the stomach.
You should routinely check for proper placement.
If no gastric content appears, the tube may be against the lining of the stomach or the tube may be obstructed.
If you meet resistance as you aspirate for stomach contents, stop the procedure and check with nurse.

17. Administration of Bolus Feedings
Flush with warm water
Pour feeding into syringe
Hold syringe approximately 8 – 10” above button
Infuse slowly
Avoid air entering tube
Pour prescribed amt of water into barrel of syringe, unclamp/unplug the tube & allow water to slowly enter the stomach by gravity.
Pinch tube just prior to the syringe being completely empty.
Slowly pour formula into barrel of syringe, unclamp the tube to allow the formula to enter the stomach.
Continuously refill the barrel before it completely empties to prevent air from entering, until all of the prescribed amt of formula has been poured into the syringe.
Pinch the g-tube just prior to syringe being completely emptied.
It normally takes 20 – 40 minutes to bolus feed. This method resembles a normal feeding pattern.

18. Administration of Bolus Feedings
Flush extension tubing until clear & clamp
Disconnect the extension set
Reinsert plug
Keep individual upright for 1 hour
Facilitates the downward flow into the individuals stomach & assists to prevent esophageal reflux.
Clamp g-tube when syringe has just completely emptied of water.
May need to vent the tube after feeding to remove excess air or fluid and reduce leaking (check with nurse).

19. Administration of Bolus Feedings Upon completion of feeding:
Document procedure and individual’s tolerance
Clean equipment with warm soap and water
Dry and store equipment in clean container

20. Administration of Medication via a G- tube
Wash hands
Prepare medications (check 5 rights)
Assemble equipment
Explain procedure to individual
Pills will need to be finely crushed and dissolved in small amount of warm water

21. Administration of Medication Via G- tube
Position individual appropriately
Put on gloves
Connect extension tubing
Check for residual /placement
Replace residual and clamp tube
Withhold medications if residual > 100 cc and beep the nurse. (Nurse will instruct staff to recheck in 1 hr. if residual still > 100cc staff will need to contact the doctor).
An excessive amt of residual may indicate an intestinal obstruction.

22. Administration of Medication via a G- tube
Flush tube with warm water
Dissolve medication in warm water
Pour medication into syringe
Rinse med cup with water and administer
Allow to flow slowly by gravity
Flush tube with warm water & clamp
Flush tube with 30cc of water
Dissolve meds separately in 30cc of water
Flush tubing with 30cc of water after each med
Final Flush with 30cc of water

23. Administration of Medication thru a G- tube
Following medication/flush:
Disconnect the extension set
Reinsert plug
Keep individual upright for
1 hour
Document procedure & observe
Document administration on medication sheets
Clean equipment with warm soap and water.
Dry and store in a clean container.

24. Administering Medications
To ensure proper flow you should give:
Liquid medicines first
Medications that need to be dissolved second
Thick medications last
Pour liquid medications directly into the diluting liquid. Stir well with a spoon.
Liquid preparations should be used whenever possible to avoid obstructing the enteral tube.
Crush pills finely before mixing with warm water.
Shake suspensions vigorously before pouring.
Pour liquids at eye level and with label in the palm of your hand.

25. Do’s and Don'ts Prepare/administer medications separately
Deliver medication slowly & steadily
Flush G-Tube after:
checking placement
feeding/meds
Do not:
Force medication or fluid into the tube
Mix medication with feedings
Give medication either before, after or between feedings.
Flush the tubing with water between giving each medications with 30cc warm water.

26. G – Tube Site Care Cleanse site with mild soap and water
Keep area clean & dry
Observe the site for:
Redness
Swelling
Warmth
Drainage/leakage
Bleeding
Unusual color or odor
Check site for granulation tissue
Cleansing with ½ H2o2 and water done also.
May be cleansed in the bath.
Clean 2x/day using circular motion moving away from the stoma.
Make sure that you gently scrub off all crusted areas on the skin around the tube.
After cleaning, rinse around the area with plain water and pat dry.
Air dry site for 20 minutes to avoid skin irritation.
To prevent tissue breakdown never let a wet dressing stay on the individual’s skin or clothing – stomach acid may cause a chemical burn.
Report any signs of irritation or infection promptly to the nurse
A localized infection at a body opening, such as a stoma, can quickly become a systemic infection and much more difficult to manage.
A systemic infection is caused by bacteria getting into the bloodstream. Sources of bacteria include the stomach and intestines. The same bacteria that contribute to a healthy intestine and digestion can be lethal if introduced into the blood stream.
The tube placement itself may be a sources or site of infection. Movement of the internal tubing can rub the stomach lining and cause an irritation, abrasion, ulcer, abscess, or hole in the stomach cavity or intestine.
The tube may move into the esophagus and create similar difficulties. Bacteria may then invade the unseen injured area enter the blood stream and cause a systemic infection.
It can be normal to have a quarter size area of tan drainage on dressing. Contact nurse if more drainage noted or if the color is yellow or green.
Excessive leakage from the tube insertion site (stoma/hole) in the abdominal wall can often be corrected by adjusting the external bolster properly and maintaining the recommended amount of water in the internal balloon.
To prevent leakage of stomach contents, gently pull on the G-tube so that the tube is snug against the inside stomach wall.
It may need to be repositioned or replaced.
Granulation tissue - Extra red/pink skin/scar growing around the stoma. May have rosebud appearance and bleeding.
Could be secondary to tube/button movement.
Call the doctor.
Stabilize the tube/button.
It may be treated with silver nitrate.
Red, bumpy rash could be a fungal rash – notify nurse
Skin checks are essential secondary to potential lack of adequate nutrition.

27. Mouth Care Maintain oral hygiene Brush teeth after each meal
Lubricate lips as needed
Dental care as directed
These individuals do not take anything by mouth: therefore, oral care is important medically as well for comfort measures.
Infected teeth and poor oral hygiene predisposes individuals to pneumonia following aspiration of contaminated oral secretions.

28. When to Stop the Administration of Feedings &/or Medications
Nausea/vomiting
Coughing/choking
Difficulty breathing
Abdominal or chest pain
Formula observed in mouth
Nausea:
Check for residuals.
Solution may be to cold. Allow to come to room temp.
Feeding may be infusing into stomach to fast – slow rate down!
If continues stop & call the nurse.
Vomiting:
May be caused by the tube moving forward into the stomach and blocking the stomach.
Coughing:
May lead to stomach contents getting into the airway (aspiration) and cause breathing problems or distress. Stop & beep the nurse.
Make sure positioned properly.
Abdominal Pain:
May be caused by the tubes becoming dislodged, having perforated the stomach, or having rubbed and ulcer into the lining.
If c/o abd pain check the external bolster for adjustment (nurse to do), and check the tube’s position. It should be 1/8” above the skin level.
If the tube cannot be rotated easily and move freely in and out of the stoma, it may be imbedded in the gastric wall (potentially causing gastric perforation) or pulled into the peritoneum causing peritoneal infusion of food and liquids. Stop and call the nurse!
Formula noted in the mouth: (Gastro-esophageal Reflux- reflux of the formula from stomach to esophagus):
The formula is coming up the esophagus. One possible reason is that the tube has become dislodged. Stop and call the nurse!

29. Observe/Report the Following Potential Complications:
Abdominal distention
Discomfort/fullness/gas
Constipation
Diarrhea
Fever
Wheezing, gurgling, or whistling
Change in behavior
Cramping or bloating:
Feedings may be to cold or running to fast – adjust accordingly.
May be due to excessive gas or overfeeding – Opening the button by inserting a decompression or feeding tube will allow air to escape and gradually relieve the problem.
Constipation:
May be due to the formula, medications, not enough water and problems with the GI system.
Report hard, dry difficult to pass or bright red bloody stools.
Diarrhea:
May be due to the formula, soap left on the equipment & medications.
May also be a serious bowel infection. Bacteria can get into the formula and feeding equipment. Good hand washing and cleanliness of equipment is essential in safe administering of feeding.
With diarrhea the intestines may not digest and absorb nutrients in the formula. Individuals can become dehydrated within hours because of fluid loss.
Peritonitis: (irritation or infection in the abdomen)
Abdominal pain, fever, vomiting and change in behavior
Ileus: (bowel obstruction)
Vomiting, constipation, abdominal pain, fever and dehydration
Aspiration:
Wheezing, gurgling, or whistling sound / bloating
Nurse to check breath sounds prn
Change in behavior:
May indicate: Silent aspiration pneumonia ( low grade or no temp, glassy or dull eyes, pale, ashen, redder or bluish skin, restlessness, listlessness, malaise and rapid shallow breathing).
Possible discomfort, Eval to rule out GERD.
Electrolyte imbalance.

30. Troubleshooting Potential Complications
Accidental tube removal
cover hole (stoma) with gauze
notify the nursing beeper immediately
Tube/Button clogged
check for kinked tube
flush with warm water
milk tubing
notify nursing if unable to unclog
Migration/Displacement
notify nursing
Accidental tube removal:
Traumatically removed or dislodged causing gastric perforation and leakage of stomach contents into abdominal cavity or onto the abdominal. wall.
Stomach acid can cause the balloon to deteriorate and deflate and tube will fall out.
As it takes one month for gastrostomy tract (the pathway formed from the stomach to the abdomen) to become established, the gastrostomy tube is to replaced by a doctor if it is dislodged before 1 month. After that it can be replaced via a nurse
G- tube tracts begin to close with 1 -2 hours.
Most tubes will last for 3 to 6 months.
Travel with a 14 French Foley catheter, lubrafax, paper towels or better yet, make sure that you always carry a replacement tube (Mic-key button) of the same size.
Tube/ Button Clogged :
May be caused by a buildup of food or medicine in the tube or by body fluids crusted around the opening (maintain a clean button).
Make sure crush pills into a fine powder.
Push/pull method prn.
Migration/Displacement:
Tubes can migrate in and outwards.
If have a large amount of drainage - place individual on left side. If drainage oozes around stoma the tube has probably migrated. With the G –Tube it could migrate inward secondary to gastric motility and block the junction between stomach and intestine. This could result in an obstruction. The Mic-Key can migrate outward due to balloon deflation.