The Management of an Individual with a Percutaneous Endoscopic Gastrostomy

Peg

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. 29%
5%
7%
19%
40% 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. Nursing & Midwifery
Council
1.3 You are accountable for
your practice, regardless of
directions from another
professional.
1.4 You have a duty of care to
your patients
8.1 You 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
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