Archive for category Procedures

Helpful Interventions

Posted by on Saturday, 3 April, 2010

Interventions to decrease stress in the drug exposed medically fragile infant

  • Decrease lights and noise in room, including TV/radio.
  • Wrap the baby snugly with hands mid-line.  This helps to overcome extensor tone.
  • Always place baby on back or side to sleep—never on tummy.
  • Hold the baby’s hands mid-line over the baby’s chest with one of your hands, exerting a secure feeling.
  • Try rocking with baby held vertically. This is often more successful than horizontal rocking.
  • Frequent warm water baths help calm them.
  • If baby is gaze averting seemingly over stimulated by simple eye contact with you, sit the baby on your lap, snugly wrapped, facing away from you.
  • Do not use walkers with these infants. Walkers increase predisposition to weight bear on toes.
  • Protect the baby’s knees from irritation during periods of frantic fussiness.
  • Use a pacifier to help with their non-nutritive sucking needs.

Gastrostomy Feedings

Posted by on Saturday, 3 April, 2010

Children who are unable to take nourishment by mouth because of conditions such as anomalies of the throat, esophagus, or bowel, impaired swallowing capacity, severe debilitation, respiratory distress, or unconsciousness are frequently fed by way of a tube. This tube is inserted directly into the stomach (gastrostomy) or jejunum (jejunostomy) or nasally to the stomach (gastric gavage). Such feedings may be intermittent or by continuous drip. Placement of a gastrostomy tube is performed under general anesthesia and the tube is held in place by a balloon filled with fluid. Postoperative care of the wound site is directed toward prevention of infection and irritation. The area is cleansed and covered with a sterile dressing daily or as often as needed to keep the area dry. After healing takes place meticulous care is needed to keep the area surrounding the tube clean and dry to prevent excoriation and infection. Daily applications of antibiotic ointment or other preparations may be prescribed to aid in healing and prevention of irritation. Care is exercised to prevent excessive pull on the tube that might cause widening of the opening and subsequent leakage of highly irritating gastric juices.

Bolus feeding using a syringe. The feeding syringe is connected to the extension tubing.
Infants and children can be fed simply and safely by a tube passed into the stomach through either the nares or the mouth. The tube can be inserted and removed with each feeding (short-term only) or taped securely in place between feedings (also, short-term only). When this alternative is used, the tube should be removed and replaced with a new tube according to specific orders, and the type of tube used. Meticulous hand washing should be practiced during the procedure to prevent bacterial contamination of the feeding, especially during continuous drip feedings.

GI tube

The schedule of tube feedings is planned to meet the infant’s/child’s nutritional, fluid and electrolyte needs. A Physician must order tube feedings. The order should include formula, rate, route, and frequency. Some tube feedings are ordered as continuous drip over 24 hours while others are ordered for a specified amount given at intermittent intervals.

Preparation for gavage/gastrostomy feedings:

  • A suitable tube selected according to the size of the child/infant and the viscosity of the solution being fed.
  • A receptacle for the fluid; gavage bag, syringe barrel or asepto syringe are satisfactory.
  • A syringe to aspirate stomach contents and/or to inject air after the tube has been placed (gavage).
  • Water or water-soluble lubricate to lubricate the tube; sterile water is used for infants (gavage).
  • Tape to mark the tube and to attach the tube to the infants neck (gavage).
  • A stethoscope to determine the correct placement in the stomach (gavage).
  • The solution for feeding.
  • Infusion pump for continuous feedings.

Procedure for gastrostomy feedings: bolus method

  1. Check placement or gastric tube (gavage feedings only), always prior to feeding via oral GT.
  2. Elevate head of bed to 30 degree during the feeding and one hour after to help prevent aspiration.
  3. You will need a syringe to aspirate stomach contents. This is done when the infant is first started on feedings. The residual is the contents of the last feeding remaining in the stomach just before the next feeding is to be given. If more than ½ of the last feeding remains in the stomach as residual, hold feeding for 1 hour, then check residual again. If the infant continues to have large amounts of residual, hold feedings and contact the doctor.
  4. Record gastric residual if ordered and return the residual into the stomach.
  5. Slowly pour the formula into the syringe and unclamp the tubing. Keep the syringe filled to prevent air from entering the stomach. Adjust the flow rate by raising or lowering the syringe. The feeding should finish in 5-10 minutes for bolus feedings.
  6. When the syringe is nearly empty, add the prescribed amount of water to the syringe. Administration of water with gastric feedings also maintains fluid and electrolyte balance.

Continuous drip method:

  1. Hang gavage bag on IV pole.
  2. Connect administration set to end of gastrostomy or nasogastric tube.
  3. Connect to infusion pump and set pump.
  4. Advance tube feedings (as ordered). Should be advanced gradually to prevent diarrhea and gastric intolerance of formula.
  5. Provide free water as ordered.

Complications

Tube feedings provide an excellent environment for bacterial growth, which may lead to gastrointestinal infection. The tubing and the feeding bag should be changed every 24 hours. The infant/child must receive adequate fluid in order for the waste products or protein metabolism to be excreted in the urine. Fluid intake/output must be recorded carefully. The tube should be flushed regularly with water to prevent clogging of the tube. A guidewire or stylet is never used to unclog feeding tubes.

Gastrointestinal problems are the most common problem associated with tube feedings. Delayed emptying of the stomach is common. Medication that speeds movement in the stomach may be prescribed. Diarrhea is another common complication. The treatment depends on the cause. In many cases, the diarrheas can be treated by changes in the tube feeding, such as diluting the formula or changing the type of formula. Aspiration is a serious complication. Pneumonia can develop if some of the stomach contents enter the lungs. Elevation of the head of the bed to 30 degrees, and periodically measuring gastric residual (so that excessive amounts do not accumulate) are ways of preventing aspiration.

Metabolic complications such as fluid and electrolyte imbalance are easily corrected if the infant/child is carefully monitored. Mechanical problems can result from irritation of the gastrointestinal tract by the tube itself or from clogging of the tube.

A nutrition support team in collaboration with the physician will monitor the infant/child carefully to see that nutritional goals are being met and to treat complications, if they develop. The infant will be weighted regularly. Fluid and electrolytes are checked, as are other indicators of nutritional status such as serum albumin and transferrin levels, total lymphocyte count, skinfold thickness, and normal rate of growth in children.

Records should be maintained to record amount and type of feeding, the infant’s response to tube feeding, patency of tube, and any adverse effects.