Educational Materials for Cancer Patients with PEG Feeding for Discharge

Introduction

Maintaining proper nutrition during cancer treatment is crucial. For cancer patients who struggle to ingest adequate nutrients by mouth, enteral nutrition is an option. If an adult patient has a functioning gastrointestinal tract but is unable to ingest adequate nutrients by mouth, enteral nutrition is an option. Enteral nutrition helps patients who are nutritionally depleted or at risk for becoming depleted by delivering important nutrients when they might otherwise be unable or unwilling to consume what they need. Percutaneous Endoscopic Gastrostomy (PEG) tube feeding is a successful and safe procedure for feeding patients with impaired swallowing. PEG provides support for patients with long-term enteral feeding, and advantages over parenteral nutrition. This article provides educational materials for cancer patients with PEG feeding, focusing on what nurses should teach patients about PEG tube home care.

Why Enteral Nutrition?

Enteral nutrition is preferred over parenteral nutrition since it helps preserve GI function, allowing normal absorption of nutrients in the digestive tract. There are many clinical reasons in which enteral nutrition may be warranted, including:

Feeding and swallowing disorders
Food allergies
Cancer
Gastrointestinal issues such as an obstructed bowel, short bowel syndrome, or Crohn’s disease
Excessive nutrient losses through diarrhea, vomiting or fistulae
Gastroesophageal reflux disease (GERD) or esophagitis
Neurological disorders including paralysis
Recovery from surgery or trauma
Critical illnesses requiring mechanical ventilation

Types of Enteral Access

Enteral nutrition may be administered through the nose or directly into the GI tract. The type varies based on the patient’s clinical condition as well as the approximate duration of enteral nutrition as nutrition therapy. For example:

Nasoenteral Tubes: These enteral feeding tubes are placed in the nose and empty either into the stomach [nasogastric (NG)] or intestines [nasoduodenal (ND)/nasojejunal (NJ)]. These enteral nutrition routes are often used when nutrition support is meant to be for a shorter duration, such as 4-6 weeks or less. Patients with an NG-tube or NJ-tube may feel some irritation in their nose where the tube is inserted.
Gastrostomy Tubes: This is a procedure in which the feeding tube (i.e., G-tube or PEG, for percutaneous endoscopic gastrostomy) is placed directly into the stomach. Patients with a gastrostomy tube often need it for a longer period of time. This tube is inserted through the belly and brings food directly to the stomach. It can be placed during an outpatient procedure and does not require an overnight stay. This tube is often used when patients will need a feeding tube for three to four months or longer.
Jejunostomy Tubes: This is when the tube (i.e., J-tube) is placed directly into the jejunum of the small intestine. A J-tube is a soft, plastic tube placed through the skin of the belly into the midsection of the small intestine. It can be placed during an inpatient or outpatient procedure. The tube delivers food and medicine until the person is healthy enough to eat by mouth. It bypasses the stomach completely and is often used when the patient cannot digest food in the stomach, like in some cases of esophageal cancer or stomach cancer.

Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement

The pull method is commonly used to place a PEG tube into the left upper quadrant of the abdomen via the use of an endoscope. The endoscope is placed into the mouth and advanced into the stomach. The light on the tip of the endoscope transilluminates the abdominal wall to identify a safe location for placement. A needle is then placed through the patient's skin into the stomach and visualized within the cavity of the stomach to verify the identified placement site. The needle is removed, and an incision is made. A plastic sheath with a needle called a trocar is inserted into the incision. The needle is removed, and a guidewire is passed through the trocar. The guidewire is grasped with forceps. Using the pull method, the endoscope is removed from the mouth, which allows the guidewire to exit the mouth. The guidewire is then attached to a loop at the tapered end of the PEG tube and slowly advanced through the mouth and esophagus, into the stomach, and out of the incision until it hits the internal bumper (also called a bolster). This bumper holds the PEG tube in place inside the stomach. The external bumper is attached to the outside of the PEG tube, approximately 1 to 2 cm between the external bumper and the abdomen. This allows for free movement of the PEG tube and decreases the incidence of buried bumper syndrome, skin breakdown, and tissue necrosis. The tissue edema and secretions from the PEG tube insertion create an early gastrostomy tract, which prevents peritoneal leakage.

Nutrition and Formula Needs

When it comes to determining the nutrition and formula needs for patients receiving enteral nutrition, there are a number of considerations. A general guideline is to provide a patient with 12-25 calories per kilogram of body weight per day (12-25 kcal/kg/day) using a standard feeding formula. The dietitian and healthcare team will determine the right combination of nutrients, calories, and fluid amounts that are appropriate for the individual patient. The only foods that should go into the feeding tube are commercial formulas specially made for feeding tubes.

Types of Tube Feeding Formulas

There are several types of tube feeding formulas available to meet the needs of adults requiring enteral nutrition.

Standard Formulas: A standard tube-feeding formula is for adults who have normal digestion and absorption. Standard formulas include all of the nutrients required to maintain health. Some standard formulas can be used for both enteral nutrition and as an oral supplement.
Peptide-Based Formulas: Peptide-based formulas differ from standard formulas in that the protein source is hydrolyzed, or broken down into smaller components or peptides.
Real Food Ingredient Formulas: Enteral nutrition formulas with real food ingredients or pureed foods are made from a blend of ingredients such as chicken, grains, vegetables, and fruit. They may be suitable for people who have difficulty digesting or tolerating a standard formula, or for those who require enteral nutrition for a long period of time.

Patient Education for Home Care

The nurse must provide PEG tube education to the patient and caregiver to help mitigate complications. This education should be initiated prior to PEG tube placement, during the planning and preoperative stages. This allows the patient and caregiver to process the information and identify any questions or concerns. Patient teaching should continue postprocedure when the nurse can demonstrate PEG tube care with a return demonstration from the patient and caregiver. The nurse should encourage the patient and caregiver to contact their healthcare team if they have any questions while taking care of the PEG tube at home.

Preventing Dislodgement

A daily assessment, more frequent if needed, of the PEG tube and insertion site is essential to prevent complications. It is important to note that the peri-insertion area may feel "hard or firm" immediately under the skin. This is likely from palpation of the internal bumper. Nurses should teach the patient and caregiver to keep the PEG tube securely attached to the abdomen by using tape or a fixation device. This prevents accidental dislodgement.

Daily Use and Care

Nurses should provide education on the importance of gently rotating the bumper to prevent ulcer formation between the external bumper and abdominal wall. The PEG tube may need to be cleaned up to three times per day until the PEG insertion site has healed. Once the site has healed, the PEG insertion site will need to be cleaned daily and as needed with soap and water or sterile saline. The patient and caregiver should be instructed to avoid harsh soaps and chemical agents at the peri-insertion area. This can cause skin irritation. The nurse should inform the patient and caregiver to pat dry the area with a towel or gauze to prevent infection and skin breakdown. Nurses should inform the patient and caregivers that some leakage from around the PEG tube insertion site is normal for the first 2 to 4 weeks after insertion. The clinician may instruct the patient to apply a gauze dressing over the insertion site and the external bumper until the leakage has subsided. After the oozing has stopped, there is no need for a gauze dressing around the PEG tube insertion site, and it does not need to be covered while showering. Swimming is permitted in clean water once the tract is mature and healed. Nurses should teach patients and caregivers to be cognizant of where the PEG tube exits the stoma by noting the centimeter marking or guide number on the tube. This helps for early recognition of tube migration or dislodgement. You may have a feeding tube with a legacy connector or an ENFit connector.

Flushing the Tube

The PEG tube should be flushed with 30-50 mL of water every 4 to 6 hours to prevent the tube from becoming obstructed if it is not being utilized. Nurses should emphasize the importance of flushing the PEG tube with 15 to 30 mL before and after administering bolus feedings and medications. When administering medications, the liquid form should be used. If this is not feasible, tablets should be crushed and completely dissolved in 10-15 mL of water. Enteric-coated and extended-release capsules cannot be crushed. The head of the bed should remain elevated, 30 to 45 degrees, while administering liquid through the PEG tube to prevent aspiration.

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Complications and Management

Dislodgement

Once the PEG tube is inserted, it must remain in place until the tract has matured for at least 4 weeks. It can take as long as 6 to 8 weeks for the tract to mature if the patient has delayed wound healing. If the PEG tube is removed prior to tract maturation, gastric contents could spill through the immature tract into the peritoneal cavity. This could ultimately result in peritonitis. If the PEG tube is inadvertently removed after tract maturation, the tract will close spontaneously within approximately 4 hours if the PEG tube is not replaced. If the PEG tube tract closes and is still needed, the patient must undergo an esophagogastroduodenoscopy to have the PEG tube reinserted. If the tube comes out all the way in the first few weeks after placement, don’t put it back in. Call your healthcare provider right away. Don’t wait until the next day. After the first few weeks, if the tube comes out, ask your provider what to do next. In some cases, you may be told to replace the tube at home. Or you may need to see your provider to replace it.

Infection

The site should be closely monitored for any signs and symptoms of infection, including increased redness, tenderness, and purulent discharge. If the peristomal area remains moist, a yeast infection may develop, requiring an antifungal agent. A bacterial infection will likely require an antibiotic. Therefore, the site must remain clean.

Buried Bumper Syndrome

This occurs as a long-term result of the external bumper being placed taunt to the skin. The internal bumper eventually embeds itself into the abdominal wall, which can cause pain, infection, and peritonitis. Pressure necrosis can also occur secondary to the impediment of blood flow. It is important to allow slack or space between the external bumper and the skin. The external bumper is easily adjusted with the appropriate training.

Hypergranulation Tissue

There may be issues with excessive granulation tissue leading to a buildup of pink or red tissue around the PEG tube insertion site resulting in discomfort. This can be treated by using silver nitrate to cauterize that area. The granulation tissue will turn a grayish/white color and will slough off without additional intervention.

Obstruction

If the PEG tube becomes clogged, connect a 60 mL syringe to the PEG tube with the plunger pulled back to attempt to dislodge the obstruction. If this is unsuccessful, flush warm water through the tube in a pulsating manner. If this is also unsuccessful, clamp the tube and allow the warm water to sit for up to 60 minutes. If all these measures are unsuccessful, contact a clinician for an order for pancreatic enzymes or an enzyme declogging kit.

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Low-Profile PEG Tube

Some patients may opt for a low-profile PEG tube to avoid having a lengthy PEG tube once the tract has matured. A low-profile tube is also an option if the original PEG tube needs to be replaced. The low-profile PEG tube lays flush against the abdomen. When the patient needs to utilize the PEG tube, an extension tube is inserted in the gastric port. After use, the extension set is disconnected, and the gastric port is closed. If the patient has a low-profile PEG tube, it is recommended that the tube is routinely exchanged approximately every 3 to 4 months per the manufacturer's guidelines. The internal balloon on the end of the low-profile gastrostomy tube should always be filled with water to prevent dislodgment. The amount of water depends on the manufacturer, usually between 5 and 10 mL.

PEG Tube Removal

Due to the nature of the varying types of gastrostomy tubes, there are different methods for removal. You have been discharged with a gastrostomy tube, or G-tube. It is also called a gastrostomy feeding tube, stomach tube, or PEG tube. The G-tube was inserted through your belly (abdominal) wall and into your stomach. The tube will provide you with food, fluids, and medicine. Your G-tube may move in and out slightly.

Feeding Methods

Gravity Method

This information explains how to use the gravity method to feed yourself through your feeding tube. The gravity method is a way to send formula from your feeding bag and into your feeding tube by the force of gravity.

How to use the gravity method during your tube feeding:

Wash your hands thoroughly with soap and clean, running water before starting your feeding. If you’re washing your hands with soap and water, wet your hands, apply soap, rub them together thoroughly for at least 20 seconds, then rinse. Dry your hands with a towel. If you’re using an alcohol-based hand sanitizer, cover your hands with it.
Gather your supplies in a clean and comfortable place. Do not set up or do your tube feeding in the bathroom.
Wipe the top of the formula can with a clean cloth or paper towel.
Hang the feeding bag 2 to 3 feet (.6 to .9 meters) above you on either an IV pole or hook. The bag will only hold 1,000 mL (4 cans) at a time. If you run the feeding throughout the day or night, pour in 6 to 8 hours worth of formula per feeding at a time. For example, if your tube feeding rate is 120 mL per hour, then pour 1 can every 2 hours.
Hold the end of the feeding bag tube over a cup. Slowly open the roller clamp on the feeding bag tube. Let the formula run through the tubing, then close the clamp.
Open the plug at the end of your feeding tube. Fill the syringe with the amount of water recommended by your healthcare provider.
Unclamp your feeding tube. Reclamp your feeding tube.
Connect the end of the feeding bag tubing to your feeding tube or button adapter. Make sure that the end of the tube is placed firmly.
Unclamp your feeding tube and slowly open the roller clamp on the feeding bag tubing. Check the bag every 5 to 10 minutes. You can also lower or raise the bag to change the flow of the formula.
When the feeding bag is empty, close the roller clamp on the feeding bag tubing. Close the clamp on your feeding tube. Fill the syringe with the amount of water recommended by your healthcare provider. Place the syringe into the end of your feeding tube or button adapter. When you’re done, rinse the feeding bag. Pull the pieces of the syringe apart and rinse each part with warm water.

To connect, follow the arrow on the adapter by turning it clockwise (to the right) until it locks in place. Do not turn the connector past the lock place. To disconnect, follow the arrow on the adapter by turning it counterclockwise (to the left) until the black lines line up. If you’re not using your feeding tube daily, flush it with 60 mL of water at least once a day.

Other Feeding Instructions

Wash your hands thoroughly with soap and clean, running water before starting your feeding. During the feeding and for 1 hour after, sit in a chair or sit up in bed. Before feeding begins, your healthcare provider may have you check to see that your stomach is empty. Follow your healthcare team's specific instructions if you are advised to check residuals. Put the tip of an empty syringe into the end of the G-tube. Pull back on the syringe to withdraw your stomach contents. In some cases, your provider will ask you to check how much feeding remains from the previous time. If so, your provider will tell you how much fluid is safe to have in your stomach before you start your feeding. Clean the area around the tube with mild soap and water. Pat the area dry after bathing and as needed. Clean the area more often if it gets wet. Or if it's leaking some discharge (weeping). Keep the disk (flange) a few millimeters off the skin. This should leave just enough room for a gauze sponge if your provider advises keeping gauze on the site. Pulling the flange too tightly can damage the skin. But leaving the flange too loose leads to leaking around the G-tube. Your healthcare team will go over these guidelines before you leave the hospital. Flush the tube with 15 to 30 mL of warm water, or the amount recommended by your provider, after every feeding or dose of medicine. This helps keep the tube clean and prevents clogging. Do not apply any creams or lotions around the G-tube unless advised by your provider. Give medicines through the G-tube as advised by your provider. Liquid medicines can be given directly. Pills may need to be crushed and mixed with enough water before taking them through the tube. Capsules may also need to be opened to remove the powder. The powder may be dissolved in water beforehand. Fill the feeding bag with the prescribed amount of formula. Run the fluid to the end of the tube to clear out any air. Clamp the tube. Connect the end of the feeding bag tubing to the G-tube. Hang the bag at least 18 inches above the level of your G-tube. Open the clamp and allow the formula to flow into the G-tube. Follow with the prescribed amount of water. Follow your healthcare team's instructions on when to clean your bag and tubing and when to use a new bag and tubing. Set the pump rate of flow to the prescribed rate per hour. Open the clamp on the tubing. Press the start button on your pump. When feeding is done, disconnect the feeding set. Connect the tip of an empty syringe to the feeding tube. Slowly push in the prescribed amount of water. Remove the plunger from a syringe and connect the syringe to the G-tube. Hold the syringe upright and pour the formula into the syringe. Refill the syringe as the formula reaches the bottom of the syringe. Repeat the process until the prescribed amount of formula is given. Follow the feeding with the prescribed amount of water. Follow your healthcare team's instructions on when to clean your syringe and tubing and when to use a new syringe and tubing. Follow your healthcare provider's specific instructions on what to do if the tube comes out by accident. Ask for these instructions in writing so you or a family member know exactly what to do. It's important to clean the wound area as directed by your provider. Ask for written instructions on what to use and how to clean the area. When you clean the site, inspect the tube for any changes. If there is any tube damage, it will need to be replaced. Otherwise, follow up with your provider, or as advised. If your tube is scheduled to be removed, your provider will tell you when this needs to happen and what you need to do.

Managing Tube Feeding at Home After Esophageal Cancer Surgery

Esophageal cancer (EC) is an aggressive malignancy with low survival. Nutritional problems are present throughout the perioperative period and are key to prognosis. Home enteral nutrition appears to improve the nutritional status of patients with EC. However, various complications, including gastrointestinal, mechanical, and metabolic issues, can arise during management, imposing significant physical and psychological burdens on patients. Causal analysis reveals that 80% of tube-fed patients may experience a range of mechanical complications due to inadequate self-management practices, severely impacting their quality of life and well-being.

Challenges Faced by Patients

More than half of patients said that although medical staff provided them with discharge instructions when they were discharged from hospital, the form of teaching was centralized and uniform, the instruction time was short, and the level of patient education was not taken into account. As a consequence, the understanding of some patients was incomplete. After returning home, the patients were challenged by constantly changing problems of feeding tube self-management, inadequate operational skills and a lack of access to information.

Lack of Motivation: 44.4% patients felt that the feeding tube was unnecessary and they did not want to use it. These feelings hinder self-management of the feeding tube, and thus the effectiveness of self-management. They could not judge the authenticity of the information, which prevented their self-management of the problem.
Lack of Behavioral Skills: 61.1% patients stating that administering nutrients through a feeding tube at home has always been poorly done, with frequent malfunctions, placing a burden on themselves and their family members.
Lack of Awareness: 44.4% patients stated that they were often influenced by their own inherent cognition in the process of using and maintaining feeding tubes. Believing that their condition had been cured, they often felt that the tubes were unwanted or not needed. Thus, their motivation for feeding tube self-management at home was low.

Improving Self-Management

Patients expressed the hope that hospitals would provide an authoritative and reliable platform to access trusted information. For example, patients have suggested a WeChat public number that includes knowledge and care videos on prevention, detection and management of complications, along with the phone number of the video producer and the person in charge.

Ordering Supplies

Your case manager will check with your insurance company about your insurance coverage. If your insurance covers tube feedings, we will refer you to a home care provider who’ll give you formula and equipment. Always reorder formula and equipment when you have at least 10 days of supplies at home. This will help you make sure you never run out of formula. If your insurance does not cover your formula or supplies, you can buy that brand or a generic version at your local pharmacy, grocery store, or online. Talk with your healthcare provider about what generic version is right for you. If you’re no longer using a feeding tube, you can donate your leftover supplies. Check the expiration date of your formula. Cover open cans of formula and store them in the refrigerator between feedings.

When to Seek Professional Help

It’s important to follow your care team's instructions for cleaning the feeding tube and the area surrounding it. If the feeding tube isn't cleaned properly, that puts the patient at risk of infection. Contact your healthcare provider if you experience any of the following:

Increased redness, tenderness, or purulent discharge at the insertion site
Signs of buried bumper syndrome, such as pain or pressure around the tube
Persistent obstruction of the tube
Accidental dislodgement of the tube
Any concerns about the tube's function or your nutritional status

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