Tell me more about g-tubes and J-tubes

leslie :-D · Oct 28, 2007

When inserting a foley cath, how far in do you go....and how do you know when to stop? Seem like it could coil without the nurse realizing it. Is there resistance?
And sorry to sound so dumb, but I realize that the g-tube is kept in place by the baloon; should the nurse inflate the foley when it is in the stoma? How many cc?

insert the foley 2-3 inches.

cut off desired length of other end of catheter.

check placement as you would w/g-tube.

balloon only needs 5-6cc .

keep in mind, some nurses don't even inflate balloon, but continual monitoring is indicated.

also, this is a very temporary measure and should not be replaced for the g-tube.

the main purpose of inserting the catheter, is to keep stoma open.

a foley catheter, breaks down very quickly in the stomach.

leslie

AmericanChai · Oct 28, 2007

So if somone pulls out their G-tube.......what should the nurse do?
And a peg tube and J-tube, if pulled out, can not be reinserted by the nurse, correct? But a G-tube can?

There are different types of gtubes. There are long tubes and short "buttons". Some have a balloon device to hold it in place and others have a silocone mushroom-shaped device. The balloon ones are easy to re-insert if you do it quickly after it has been pulled out. If you wait too long the stoma will close (like within minutes for some people). If the mushroom one is pulled out, insert a foley catheter and tape it into place until a new tube can be reinserted. It helps to use lubricating jelly to insert or remove a tube for changing it.

Here's a link to a balloon type button. These can be easily changed at home. The balloon is filled with water after being inserted. There's a special valve on the side of the button that allows it to be inflated/deflated. It should also be checked weekly to make sure it is holding the proper amount of water, otherwise it can leak and fall out.

http://www.appliedmedical.net/amtminibut.htm

Here's a link to a non-balloon tube

(see bottom photo)

http://www.appliedmedical.net/amtcapsmonarch.htm

Here's a non-balloon button

http://www.noahslifewithhydrocephalus.com/mediac/400_0/media/Gastrostomy_bardButton.jpg

J-tubes have to be placed using x-ray to confirm the proper placement. If they come out, it requires another xray and surgeon to put them back in. They can become dislodged and end up feeding into the stomach instead. They can be very touchy with patients who like to pull on their tubes. Some people choose to get a jtube placed directly into the jejunum rather than going through the stomach. This is true especially for very long term use or if the patient keeps pulling it out. Oftentimes these patients will have one jtube and a gtube that is used strictly for venting gas or stomach secretions. A farrell bag might be used for this purpose.

I am not a nurse (yet) but I'm the proud mom of a g-tube fed child who has had her tube for 3 years. :) I have learned a lot about tubes on some tube-feeding support boards. I have placed her NG tube and changed her gtube. If you want to see lots of pics of gtubes and get some tips on care and securing it so it has less chance of being pulled see my daughter's website: www.reflux.darshani.com

p_hawk · Oct 28, 2007

... I am not a nurse (yet) but I'm the proud mom of a g-tube fed child who has had her tube for 3 years. :) I have learned a lot about tubes on some tube-feeding support boards. I have placed her NG tube and changed her gtube. If you want to see lots of pics of gtubes and get some tips on care and securing it so it has less chance of being pulled see my daughter's website: www.reflux.darshani.com

I had a son that was tube fed, the small, balloon held-in type. (like my technical jargon?! :lol2: ) He'd get his thumb hooked on it sometimes when he'd seize and pop it out. It seemed we were forever putting another in. His gastroenterologist (...spelling...) even sent us home with 'replacements' so we wouldn't have to make the long drive (it was almost 2 hours) to his office just for something small like that. I had a small dog that felt as if my son was one of her puppies. I had to watch her because she'd untuck his shirt, pull it up and 'clean' his button.. eww. She even chewed one nearly to pieces once... when we were out of replacements... That was such a fun phone call to make to the dr's office. "Uh hello... yeah um.. could you let Dr. G know that our dog ate the kid's button? Ate it. Right. Yes, I'll hold... Hi, Dr.. what? uh.. the dog. Seriously. No, I'm not kidding!" LOL! Thankfully our Dr. had a great sense of humor!:chuckle Although I did get several people asking me if we were the ones with "the dog" the next time we were at the hospital...

My son ended up with a j-tube eventually.

AmericanChai · Oct 28, 2007

IngyRN,
See reply of ktwlpn. N/G tube is typically used to keep stomach empty and is usually set to suction. It is used on a short term basis and not usually for nourishment. G-tubes and PEGS are placed in the stomach through endoscopic or radiologic methods and are designed for long-term use.
ebear

This is not quite true. NG's are used for nourishment, too. Although they are not meant for long-term use, a lot of doctors will use them for months for nourshment to see if the person will start to gain and grow with increased nourishment, or if there might be something else going on like malaborption or disease causing them to not gain weight. Some people who are not expected to need a feeding tube long term will have an NG short term. Also people who are too medically fragile to do the surgery on.

My daughter had an NG for four long months before I finally convinced the doctor she needed a g-tube. It was really awful to have to keep putting her tube back in after she repeatedly pulled it out day after day. The doctor did not know if she would overcome her feeding problems on her own or not so she resisted getting a gtube placed. I now know that NG tubes can actually contribute to feeding aversions especially in babies and children, and can make reflux worse and are generally not a good thing. After she got her NG tube her consumption went from 50% of what she needed for growth, to zero consumption of bottles, thus earning her a gtube. On the plus side she started to grow immediately after the placement of the NG tube and I am thankful for it because it really turned her health around. I am part of a tube-feeding support community and it is not unheard of for children to have NG tubes for a year or more before finally getting a gtube.

AmericanChai · Oct 28, 2007

I had a son that was tube fed, the small, balloon held-in type. (like my technical jargon?!) He'd get his thumb hooked on it sometimes when he'd seize and pop it out. It seemed we were forever putting another in. His gastroenterologist (...spelling...) even sent us home with 'replacements' so we wouldn't have to make the long drive (it was almost 2 hours) to his office just for something small like that. I had a small dog that felt as if my son was one of her puppies. I had to watch her because she'd untuck his shirt, pull it up and 'clean' his button.. eww. She even chewed one nearly to pieces once... when we were out of replacements... That was such a fun phone call to make to the dr's office. "Uh hello... yeah um.. could you let Dr. G know that our dog ate the kid's button? Ate it. Right. Yes, I'll hold... Hi, Dr.. what? uh.. the dog. Seriously. No, I'm not kidding!" LOL! Thankfully our Dr. had a great sense of humor!:chuckle Although I did get several people asking me if we were the ones with "the dog" the next time we were at the hospital...
My son ended up with a j-tube eventually.

What a funny story!! :lol2: What is it with dogs? My daughter was a big projectile vomiter. Whenever she'd vomit our old dog would come running to clean it up. :barf02: It was still pretty fresh formula because she would vomit within minutes of being fed.

Marie_LPN, RN, LPN, RN · Oct 28, 2007

So if somone pulls out their G-tube.......what should the nurse do?
And a peg tube and J-tube, if pulled out, can not be reinserted by the nurse, correct? But a G-tube can?

Always call the doc, to see what to do next. Sometimes they'll want you to put it back in, sometimes not.

ebear, BSN, RN · Oct 28, 2007

As I said, "Not usually". Exception would be NICU/PICU on a short term basis.

core0 · Oct 28, 2007

So if somone pulls out their G-tube.......what should the nurse do?
And a peg tube and J-tube, if pulled out, can not be reinserted by the nurse, correct? But a G-tube can?

All of these should have something placed in the tract if possible to keep the tract open.

A G-tube and a PEG are the same thing. A PEG is placed endoscopically, but is frequently used when IR places it. Typically a G-tube refers to surgical placement. All of these go through the abdominal wall into the stomach.

PEGs placed by IR and GI use either a scope or a guidewire through the mouth. The stomach is insufflated which pushes the stomach against the abdominal wall. A needle is put through wall. In the case of GI a wire is passed through the needle and pulled out through the mouth by the scope. In the case of IR the wire is grasped through the needle and pulled out. The end result is the same. The wire passes through the mouth, through the stomach and out through the skin. The tube is then passed over the wire and out through the skin. At the end of the tube is a bumper (looks like a flat disk). This is pulled tight and pulls the stomach against the abdominal wall. Usually IR sutures in their PEGs but GI doesn't (the kits have a flat outer bumper). Your mileage may vary.

Surgical G-tubes involve making a small incision, grasping the stomach and making an ostomy in the stomach. The stomach is sewn to the abdominal wall. A tube is placed inside and the balloon on the end is inflated to seal it.

J tube can be either percutaneously placed like PEGs or surgical placed like J tubes. In the case of surgery a loop of Jejunum is lifted up and an ostomy is matured. In the percutaneous model, it is similar to a PEG but a long jejunal tail is put into the jejunum. Most percutaneous j-tubes are actually G-J tubes with a jejunal opening and a gastric opening. This allows you to feed jejunally while decompressing gastrically for example. The ports are usually labeled with the appropriate letters.

A PEG or a G-tube cannot really migrate. Although I have seen them migrate into the abdominal wall. The G-J tubes that IR or GI put in can migrate. What usually happens is that the J portion flips up into and is coiled in the stomach. This can easily be seen on a KUB. If this happens it has to be put back in by GI or IR.

Any tube that comes out can be replaced by a foley. The key is to keep the tract open. Make sure you know what the physician wants and what the hospital policy is. Usually use a foley slightly smaller than the G-tube. Put it in, inflate the balloon and pull back until you feel tension. With a fresh G-tube this will hold it against the abdominal wall. The major danger with a fresh PEG is that the abdominal wall will fall away. If you get resistance stop and inform the physician.

Just to make things more confusing after the PEG has been in a while the silicone starts to corrode and usually the appliance is replaced with a button (the same that is used for G-tubes). At this point they are functionally identical.

Hope this helps

David Carpenter, PA-C

IngyRN · Oct 29, 2007

All of these should have something placed in the tract if possible to keep the tract open.
A G-tube and a PEG are the same thing. A PEG is placed endoscopically, but is frequently used when IR places it. Typically a G-tube refers to surgical placement. All of these go through the abdominal wall into the stomach.
PEGs placed by IR and GI use either a scope or a guidewire through the mouth. The stomach is insufflated which pushes the stomach against the abdominal wall. A needle is put through wall. In the case of GI a wire is passed through the needle and pulled out through the mouth by the scope. In the case of IR the wire is grasped through the needle and pulled out. The end result is the same. The wire passes through the mouth, through the stomach and out through the skin. The tube is then passed over the wire and out through the skin. At the end of the tube is a bumper (looks like a flat disk). This is pulled tight and pulls the stomach against the abdominal wall. Usually IR sutures in their PEGs but GI doesn't (the kits have a flat outer bumper). Your mileage may vary.
Surgical G-tubes involve making a small incision, grasping the stomach and making an ostomy in the stomach. The stomach is sewn to the abdominal wall. A tube is placed inside and the balloon on the end is inflated to seal it.
J tube can be either percutaneously placed like PEGs or surgical placed like J tubes. In the case of surgery a loop of Jejunum is lifted up and an ostomy is matured. In the percutaneous model, it is similar to a PEG but a long jejunal tail is put into the jejunum. Most percutaneous j-tubes are actually G-J tubes with a jejunal opening and a gastric opening. This allows you to feed jejunally while decompressing gastrically for example. The ports are usually labeled with the appropriate letters.
A PEG or a G-tube cannot really migrate. Although I have seen them migrate into the abdominal wall. The G-J tubes that IR or GI put in can migrate. What usually happens is that the J portion flips up into and is coiled in the stomach. This can easily be seen on a KUB. If this happens it has to be put back in by GI or IR.
Any tube that comes out can be replaced by a foley. The key is to keep the tract open. Make sure you know what the physician wants and what the hospital policy is. Usually use a foley slightly smaller than the G-tube. Put it in, inflate the balloon and pull back until you feel tension. With a fresh G-tube this will hold it against the abdominal wall. The major danger with a fresh PEG is that the abdominal wall will fall away. If you get resistance stop and inform the physician.
Just to make things more confusing after the PEG has been in a while the silicone starts to corrode and usually the appliance is replaced with a button (the same that is used for G-tubes). At this point they are functionally identical.
Hope this helps
David Carpenter, PA-C

THANK YOU sooo much. This was the BEST explanation. Exactly what I was looking for!!

aubie · Dec 12, 2007

Another question:

How is it possible, with continuous infusion of feeding solution for shift, after shift of nurses document 0 for residual?

Shouldn't there be something there, at least sometimes?

Thanks,

core0 · Dec 12, 2007

Another question:
How is it possible, with continuous infusion of feeding solution for shift, after shift of nurses document 0 for residual?
Shouldn't there be something there, at least sometimes?
Thanks,

It depends on the type of feed and the type of tube. In a j-tube it would be very common for there to be no residuals. If you think about this you have a hollow tube so any feeds go right into the tube. There is no place for there to be a residual. I don't think that we check residuals in J-tubes. Not sure thought. If there is a problem abdominal distension would be a better indicator than residuals.

In a G-tube it would be more unusual. Usually the stomach collects food and boluses it. If there is an incompetent (or no) pylorus then the food may immediately dump. When I did peds GI we had a kiddo with dumping syndrome. When we scoped him the G-tube was pointed right at the pylorus. When he was bolus fed the feeds jetted directly into the small bowel and he was unable to absorb the feeds. By changing him to drip feeds the dumping syndrome was solved. So if you have abnormal anatomy you may not have residuals. Also if you have a high G-tube with a large dependent volume you may not get a residual.

David Carpenter, PA-C

ebear, BSN, RN · Dec 12, 2007

CoreO! You are so bloomin smart!!! I'm very serious.