The Management of an Individual

with a Percutaneous Endoscopic

Gastrostomy

Mike Lawrence
Clinical Nurse Manager
Bro Morgannwg NHS Trust
Learning Disabilities Directorate
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.
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)
 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)
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.
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.
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.
These indications can occur in a
number of conditions:

Cerebral Palsy

CVA

Motor Neurone Disease

Cancer

Trauma

Parkinson’s Disease
PEG Management

Management of the PEG Site

Tube Management
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
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
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
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.
Frequency of tablet crushing or
capsule opening (n = 540)

Every drug round

29% Every day
40%
Never
5% Weekly
19% 7%
Twice a week

(Nursing Standard - July 3rd 2002)

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.
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)
Nursing & Midwifery
Council
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
 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.
 Flowchart for
administration
No Is there a liquid alternative? Yes

Is there a non oral alternative Yes Prescriber willing to

route or a ‘special’ available? prescribe?

No Yes
No

Can the medicine be

safely crushed or
opened?
Yes Licenced action get
prescription changed
No Unlicenced action always obtain and record the
written authorisation from the reason.
prescriber in conjunction with
Ask prescriber to the pharmacist
reconsider therapy Adapted from
Wright, 2002
Advice on the Administration of
Liquid Medications

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.
Complications

Tube Blockage
Leakage
Oesophageal Reflux
Diarrhoea
Constipation
Oral Hygiene
Taste
 Monitoring

Clinical Physical
Weight Swallow Assessment
Fluid Balance PEG Site
Blood Biochemistry Tube Care
Urine Biochemistry Nutritional
Intake assessed
against individual
calculated
requirements

Important to monitor an individual’s independent

abilities (PEG Clinic)
Ethical Concerns

PEG Feeding The taste & sensation

of food & drink