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Percutaneous Tubes and Drains

Martin, Melayne; Kingan, Michael J.

Journal of Wound Ostomy & Continence Nursing: November/December 2018 - Volume 45 - Issue 6 - p 543–544
doi: 10.1097/WON.0000000000000482
Getting Ready for Certification
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Melayne Martin, BSN, RN, CWOCN, Parkland Health & Hospital System, Dallas, Texas.

Michael J. Kingan, DNP, AGPNP-BC, CWOCN, MedStar House Call Program, MedStar Health, Baltimore, Maryland.

Correspondence: WOCNCB, 555 East Wells Street Suite 1100, Milwaukee, WI 53202-3823 (info@wocncb.org).

The authors declare no conflicts of interest.

An important aspect of the WOC nurse role is to manage percutaneous tubes and skin problems associated with these tubes. Tubes and drains are placed to facilitate drainage, to administer fluids or medications, and/or to provide nutritional support.1

Commonly encountered percutaneous tubes include gastrostomy, jejunostomy, nephrostomy, and biliary drains.1,2 The WOCNCB Ostomy certification examination includes questions related to percutaneous tubes. When preparing for the examination, it is important to have a clear understanding of the location and purpose of percutaneous tubes1 as well as management of tube-related complications.

1. Fellows J, Rice M. Nursing management of the patient with percutaneous tubes. In: Doughty D, McNichol L, eds. Wound Ostomy and Continence Nurses Society Core Curriculum Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:723–733.

2. Singh C. Use of a moisture wicking fabric for prevention of skin damage around drains and parenteral access lines. J Wound Ostomy Continence Nurs. 2016;43(5):551–553.

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PRACTICE QUESTIONS

1. A daughter arrives for discharge teaching about her mother's percutaneous gastrostomy tube (PEG). She will be the primary caregiver in the home. What supplies will be needed when teaching about basic PEG tube care?

  1. Sterile gloves, sterile gauze, and hydrogen peroxide
  2. Sterile gloves, sterile cotton tip applicators, and bacitracin
  3. Clean gloves, silver nitrate, and hydrogen peroxide
  4. Clean gloves, nonsterile 4 × 4 gauze pads, and mild soap and water

Outline Location: 020904

Cognitive Level: Application

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ANSWER D:

The supplies needed for basic PEG tube care would include nonsterile 4 × 4 gauze pads, gloves, and mild soap. Cleansing around an established PEG tube where there are no complications is accomplished using mild soap and water and use of a disposable cloth that has low risk of leaving fibers at the site that could cause a prolonged inflammatory response. The PEG tube and the surrounding skin are not sterile and do not require a sterile procedure, thus sterile gloves and other supplies are not needed. Full-strength hydrogen peroxide is contraindicated due to the risk of hypergranulation tissue development. Bacitracin should not be included in basic PEG tube care. Peritubular infection would require a systemic antibiotic. The question stem does not include information that would indicate that an infection is present. Silver nitrate is not part of basic PEG tube care and is used when hypergranulation tissue is present and causing bleeding or pain. The question stem does not indicate hypergranulation tissue was present.

Fellows J, Rice M. Nursing management of the patient with percutaneous tubes. In: Doughty D, McNichol L, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:723–733.

Warriner L, Spruce P. Managing over granulation tissue around gastrostomy sites. Brit J Nur. 2012;21(5):S20–S25.

2. The WOC nurse is evaluating a patient with hypergranulation tissue around a percutaneous endoscopic gastrostomy (PEG) tube who is experiencing minor bleeding with cleansing and occasional leakage of the feeding. The external tube stabilizer (bumper) is assessed to be about an inch from the opening in the skin. When planning care for this patient, what factors need to be addressed?

  1. Infection and swelling
  2. Pressure and ischemia
  3. Friction and moisture
  4. Distension and fever

Outline Location: 020903

Cognitive Level: Application

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ANSWER C:

Friction and moisture are 2 common causes of hypergranulation tissue formation around a percutaneous endoscopic gastrostomy. Migration of the tube causes increased leakage of gastric contents on surrounding skin, enlargement of the tract, and erosion around the tract. The friction caused by the tube migration and the added moisture create inflammation both in the tract and at the site. Infection and swelling are relatively rare unless the tube has been traumatically removed or after surgical placement. Signs of infection at the site include pain, erythema, or induration in the surrounding skin and in rare cases, signs of systemic infection. Pressure and ischemia are symptoms of the internal and external stabilizers being too tight and can be seen with buried bumper syndrome. These wounds progress like a pressure injury, with erythema and pain being the first symptoms. Distension and fever indicate obstruction, perforation, or infection. They are independent of hypergranulation tissue formation, though the nurse would want to notify a provider for these assessment findings.

Fellows J, Rice M. Nursing management of the patient with percutaneous tubes. In: Doughty D, McNichol L, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:723–733.

Haywood S. PEG feeding tube placement and aftercare. Nursing Times. 2012;108(42):20–22.

Roveron R, Antonini M, Barbierato M, Calandrino V, Canese G, Chiurazzi LF, et al Clinical practice guidelines for the nursing management of percutaenous endoscopic gastrostomy and jejunostomy (PEG/PEJ) tubes in adult patients: An executive summary. J Wound Ostomy Continence Nurs. 2018;45(4):326–334.

Warriner L, Spruce P. Managing over granulation tissue around gastrostomy sites. Br J Nurs. 2012;21(5):S20–S25.

3. The WOC nurse is evaluating a patient with severe gastroparesis with an obstructed gastrojejunostomy tube. Attempts to clear the tube have failed. What is the next step for this patient?

  1. Remove the blocked tube and place a new tube.
  2. Remove the blocked tube and place a larger tube.
  3. Call the provider and request surgical tube change.
  4. Call the provider and request radiology tube change.

Outline Location: 020901

Cognitive Level: Application

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ANSWER: D

The nurse would notify the provider about the need for tube replacement in radiology. Patients with severe gastroparesis may require a gastrojejunostomy tube. This tube type allows for decompression of the stomach and for postpyloric feeding. When obstructed, the tube must be replaced using radiology to ensure placement into the jejunum. The nurse would not remove this tube at the bedside and replace a new or larger tube. Surgical replacement of the tube is not needed because this type of tube can be changed with radiologic guidance.

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REFERENCES

Fellows J, Rice M. Nursing management of the patient with percutaneous tubes. In: Doughty D, McNichol L, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:723–733.
    Roveron R, Antonini M, Barbierato M, Calandrino V, Canese G, Chiurazzi LF, et al Clinical practice guidelines for the nursing management of percutaenous endoscopi gastrostomy and jejunostomy (PEG/PEJ) tubes in adult patients: An executive summary. J Wound Ostomy Continence Nurs. 2018;45(4):326–334.
    © 2018 by the Wound, Ostomy and Continence Nurses Society.