Clinical review
Children in critical care: how parents cope Pam Cox, Birmingham Children’s Hospital, Ladywood Middleway This article examines the parental role in the critical care setting. Parents’ perceptions of stress and stressors are discussed, and the coping strategies developed by families to deal with them are identified. The implications of the findings are discussed in the light of current practice.
Ms Cox is a Clinical Nurse Specialist in Intensive Care at Birmingham Children’s Hospital, Ladywood Middleway, Birmingham
A
JL M k child s requirement for paediatric intensive care is likely to place enormous strain on the way the family functions. The family is the constant factor throughout the child’s life, undertaking the ultimate re sponsibility for emotional, social, develop mental and healthcare needs. Family-centr ed care in the critical setting is not easy when the child requires management that attempts to achieve a fine balance between the effects of technology and caring. Nurses are ideally placed to recognize the coping strategies and methods of adaptation of family members to the child’s illness and disability, and to intervene appropriately (Phillichi, 1989). King and Gregor (1985) state that the level of family stress is high, not only because of the child’s critical state of health, but also because the illness was unexpected and/or the stay in the paediatric intensive care unit (PICU) was prolonged. Associated with the anxiety state are vary ing degrees of depression which may only be relieved by the expression of feelings, according to Weller and Miller (1988).
T a b le 1. M a jo r stre ssors in th e p a e d ia tric in te n s iv e care u n it D ire c tly relating to the child
A ffecting the parental role
Environment of PICU
Personal safety/security within PICU
Concern for the child’s feelings: pain/discomfort/loneliness
Psycholgical/physical — affecting child’s future development
Loss of the parental role
Parental role changes — processes o f involvement/shared care
Concern about the eventual outcome — the loss of the child
Information need/diagnosis, treatment and prognosis
The need to maintain or otherwise a constant presence
Financial concerns/transportation difficulties to and from the hospital
Isolation from other family members
Relationships and support for other siblings Relationships with friends
PICU = paediatric intensive care unit
764
This review examines the predominant stresses and stressors and the subsequent strategies developed by parents to deal with them.
Stress and stressors LaMontagne and Pawlak (1990) examined parents’ perceptions of what was stressful about the PICU experience and the coping behaviours parents used to manage the stress. This study was based on a phenomeno-logical perspective — defined by Lazarus (1966) as a personal experience reflecting a disturbed relationship between the person and the situation and coping, which they defined as the process used to alter this disturbance. The predominant stressors identified were loss of the parenting role, information need and uncertainty over outcome. This was a study of 30 parents, 24 of whom were women and classed as the primary care giver, and results reflected previous find ings by Miles and Carter (1982). Kasper and Nyamathi (1988) suggest that disruption of the parental role is a problem in PICUs. However, a preliminary study of five individual parents by Carnevale (1990) used a similar phenomenological client-centred approach (Rogers, 1951) and obtained very different results. In addition to the environ ment and concern for the child, the author identified parental role conflict, the child’s feelings, relationship with friends and the child’s siblings as being predominant stressors. The parental role conflict referred to relationships with professional staff. There were differences in sample size be tween the two studies. Carnevale (1990) ac knowledged the limitations in his prelimi nary study. Although not truly representa tive and therefore potentially less accurate, it does merit some consideration. In this study, four of the five individual parents were married couples, and two of these were former nurses; this may reflect the broader dimensions and insight into the
Downloaded from magonlinelibrary.com by 130.237.122.245 on January 10, 2019. British Journal of Nursina. 1992, Voi l.N o 15
Children in critical care: how parents cope
perception of the question ‘What is it like to have a child in PICU?’ Significantly, the interviews were conducted in the intensive care environment 24-48 hours after admis sion, when the child’s condition had stabi lized. This would therefore reflect a differ ent perspective and explain why the im mediate needs, relating to parents’ own role, were seen by them as being the pre dominant stressors. Parental role conflict with healthcare staff was identified as the most predomi nant stressor by Carnevale (1990) and in certain instances Carnevale found that as sertiveness by parents only served to alien ate them further. In this respect the findings were similar to those described by Broome (1985) in that feelings of helplessness or jealousy of parents towards staff members closely involved with their loved ones may cause hostile interactions, which are some times seen as demanding or as effective withdrawal. Miles and Carter (1982) and Daley (1984) also rated staff behaviours, e.g. the hustle and bustle of the medical and nursing team and inappropriate responses, as significant sources of stress, together with communication difficulties and lack of care giving other than for critical pro cedures.
C op in g strategies During the critical care experience the fam ily must deal with many stressors (Table /), including role changes, financial con cerns, isolation from other family members, T a b le 2. P a re n ta l co p in g s tra te g ie s Strategy
Action
Abdication of responsibility
Withdrawing from the situation
Information seeking
Respected questioning of professional staff
Intellectualization
Increased interest in physiological aspects of child’s condition
Restructuring
Focusing only on certain aspects o f the child and illness
Exposure of marital relationships
Deepening and strengthening on intermarital conflict and crisis
Utilization of resources
Hospital/community liaison support workers
Religious beliefs
Chaplaincy support/cultural/ ethnic needs
Involvement of extended family
Shared responsibility
Creation of ‘personal space’
Opportunity for reflection and revised strategies
Adapted from: Lewandowski (1980)
British Journal of Nursing, 1992, Voi l.N o 15
transportation problems to and from the hospital, and fear of losing their loved one (Hodovanic et al, 1984). In a study of par ents with children who had undergone open heart surgery (Table 2), Lewandowski (1980) found that parents coped in a variety of ways during this stressful event, includ ing withdrawing from the situation, becom ing extremely interested in the physiologi cal aspects of the child’s condition (intellectualization) and restructuring and focusing only on certain parts of the child and the illness. A child’s hospitalization not only dis rupts family routines and requires the fam ily to make major adjustments, but also places a strain on the ill child, in which the parents grieve the loss of their role of parent to a healthy child and then assume the role of parent to a critically ill child (Freiburg, 1972; Knafl, 1985). In order that parents can take on this revised identity, they have to come to terms with the fact that their child’s life is in the hands of others before they are able to get re-involved in their child’s care (Jay, 1977). This view correlates with that of Lewandowski (1980) who viewed withdrawal from the situation as a coping strategy. Similarly, Broome (1985) felt that withdrawal allowed the family time to assess its strengths and resources. It is not unreasonable to assume that fol lowing an acute period of anxiety, parents feel a genuine desire to relinquish responsi bility and decision making to healthcare staff who have the appropriate skills. In this respect, families can be seen to withdraw to assess the actual and potential difficulties that may confront them. However, the ab dication of responsibility comes at a time when the parents want to demonstrate their love for the child more than ever (Rennick, 1986). Snowden and Gottlieb (1989) looked at the maternal role in the PICU and the hos pital ward and identified six parental roles: vigilant parent, nurturer-comforter, medi cal parent, caregiver, entertainer and pro tector. Although this was a comparative study, non-active roles, i.e. vigilant parent and nurturer-comforter, were observed to be the most predominant, although these responses were altered in the presence of others and during different procedures and settings and were directly related to the child’s condition. Miles (1979) felt that pre vious parental roles and relationships with the child should be assessed to ascertain how the family functioned before the criti cal care experience. A disorganized family
765
Downloaded from magonlinelibrary.com by 130.237.122.245 on January 10, 2019.
Children in critical care: how parents cope
may experience severe disruption as a result of a crisis (Fife, 1985). When the family be comes aware of the disruption, much en ergy is exerted in an attempt to mobilize problem-solving abilities and support sys tems (Broome, 1985). Similarly, in their study of what parents felt to be stressful in the PICU, LaMontagne and Pawlak (1990) found the most commonly used coping strategies were seeking social support (problem focused) and positive reappraisal (emotion focused). This study did not attempt to ad dress the coping strategies of the family as T a b le 3. C a te g o rie s o f co p in g Cognitive — things you think about Interpersonal — actions directed towards other people____________ Social support — drawing on the support of others________________ Direct action — th ings you do Drawing from the environment Source: Carnevale (1990)
T a b le 4. H y p o th e tic a l ta b le s h o w in g assum ed ro le s o f p a re n ts vs n urse s* Parents’ position
Nurse’s role
Diminished parental responsibility
Priority of professional responsibility
Parents assume the secondary caregiver role
Assume the parental role — presume to know how parents feel
Specialist care seen as the priority — creates dependency
Strong power dimension in relationship
Parents not seen as individuals
Parents become easily categorized
The ability to build on life experiences is not acknowledged or recognized
Assume parents will have difficulty in coping
Decision-making process is directed by professionals
The right of advocacy
Lack of respect fo r the special parent/child relationshiop
Independent decision making/ interpreting the needs of the child
Assertiveness leads to alienation
Nurses dictate and disseminate information considered to be relevant
Parental and professional roles do not integrate sufficiently
Nurses assume that technical procedures are not part of the parental role
Parents need to re-establish normal family routines
Nurses assume parents need to be with their child at all times
* This cable was based on the experience of the author in the parental role, and as an experienced nurse in this specialty. It may not therefore be truly representative o f all parents new to this environment.-------------------------------------------------------------------
766
a unit but as an individual parent response, the emphasis being on the primary care giver, i.e. women (as in Snowden and Gottlieb’s (1989) study). The predominance of emotion-focused strategies could reflect some gender bias. Carnevale (1990), however, studied married couples and categorized the coping themes into five groups (Table 3). In addi tion to social support, as identified by pre vious authors, the study showed these to be: cognitive; interpersonal mechanisms; direct action; and drawing from the envi ronment. This study was based on self-re porting data and therefore had some limita tions but it did include strategies that had not been shown before in a similar attempt to measure coping (Miles and Carter, 1982).
Im plications for further research and clinical practice It is evident that the literature reviewed was not totally comprehensive. Although de mographic data were examined, none of the research considered the specific needs and coping mechanisms of different ethnic and cultural groups in terms of the parental and extended family role behaviour. Further re search is necessary to explore this aspect in the psychosocial context to ascertain what role parents would wish to assume in the PICU setting. The literature indicates that there is a need for nurses to facilitate the coping strat egies most commonly used by parents. This would involve social workers, support groups, the chaplaincy, and the extended family members and friends. Further stud ies to identify and evaluate these nursing interventions could form a foundation on which to base effective nursing care. Funda mental to this is the need to review existing practice and behaviour towards families to discuss their roles and the implementation of education programmes to develop skills and knowledge. The nurse-parent-child re lationship plays a major role in the outcome of illness (Hedenkamp, 1980). Table 4 is a hypothetical comparison of the assumed roles of parents and nurses. C onclusion Although the new philosophy of care has emerged in recognition of the integral role of the family in providing comprehensive care (Shelton et al, 1987), current practice does not always achieve or reflect this. While most professionals support the con cept of mutual respect and involvement of the family, in reality it is questionable
Downloaded from magonlinelibrary.com 130.237.122.245 January 10, o2019. British by Journal of Nursing,on 1992, Voi l.N 15
A D V b K l loEIVIEIMT F E A T U R E A fte rc a re o f th e B o w e r PEG T u b e Immediately after a Bower PEG has been insert ed, the aftercare starts. A dry dressing such as a gauze keyhole dressing should be placed over the stoma site for the first 12-24 hours after procedure. The stoma site should be checked twelve hours after the pro cedure. Blood and serous fluid will be present. This is normal. The stoma site or tube should not be touched for the first 8-12 hours after placement. How ever, if the fixation device (Figures 1 and 2) is not flush with the abdomen and the tube is loose, the Endoscopist should be notified in or der to make the necessary adjustments. The Day After the Procedure The site should be treated with povidone iodine for the first 24-48 hours after the procedure. After 48 hours if the stoma site is satisfactory, soap and water may then be used on a daily basis. It is very important that the area around the tube is dried gently but thoroughly. No dressing should be reapplied unless there continues to be leaking around the stoma site. From the first day the Bower PEG should be rotated in a com plete circle during the daily cleaning routine. This enables all areas around the tube to be cleaned thoroughly and also prevents the build up of scar tissue which could potentially adhere to the tube. Report any leakage, swelling, irritation, red ness, skin breakdown or soreness around the stoma site. Do not give the patient an immersion bath until the stoma tract has healed (usually 2-3 weeks after placement). Showering is satisfactory dur ing these first few weeks. After the stoma tract has totally healed, the pa tient is free to take a bath or swim if they are able to do so. NB: Always ensure luer caps on the tube are closed properly. Always dry the tube and exit site thoroughly after immersion in water. Feeding Feeding should only be commenced when bowel sounds are heard. This is normally 8-12 hours after placement. Follow the feeding regimen as prescribed by your Hospital or Dietitian.
25-50ml of water should be flushed through the tube before and after feed. This procedure should also be followed for administration of medicines. Medicines should always be in sus pension presentations. No crushed tablets should be put into gastrostomy tubes. If continuous feeding is utilised, routine flush ing is essential. Elevation of the bed will help prevent reflux and risk of aspiration pneumonia. Do not lie the patient flat for 30 minutes after feeding has finished.
0 To
remove blockage. Initially syringe 25-50ml of lukewarm water. If this fails refer to Hospital Policy for unblocking naso-gastric tubes. For further information contact: Patrick Finn, Product Manager, E Merck Pharmaceuticals, Winchester Road, Four Marks, Alton, Hants GU34 5HB. Tel: (0420) 564011.
Do’s and Dont’s for the long-term care of the Bower PEG • Do not remove the fixation device before stoma formation has taken place — 2-3 weeks after placement. After this time, on a regular basis, you can separate the fixation cover from the base (Figures 1 and Z) to allow fur ther cleaning of this part of the tube. • Do not remove the fixation device unless you have a suitable replacement. 0 Do not re-position the tube. This should only be carried out by the Endoscopist. 0 Never remove the Y-shaped feeding adaptor (Figures 3 and 4) unless you have a replace ment on hand. 0 Bower PEG adaptor repair kits can be order ed from E Merck Pharmaceuticals. 0 Luer caps must be secured by using quarter of a turn. Greater than this may cause damage to the tube. 0 Do not clamp the tube.
Figure 1. 20 French tube fixation device
Q
Figure 2. 12 French tube fixation device
Figure 4. 12 French Feeding Adaptor
MERCK k i‘a
Children in critical care: how parents cope Pam Cox, Birmingham Children’s Hospital, Ladywood Middleway This article examines the parental role in the critical care setting. Parents’ perceptions of stress and stressors are discussed, and the coping strategies developed by families to deal with them are identified. The implications of the findings are discussed in the light of current practice.
Ms Cox is a Clinical Nurse Specialist in Intensive Care at Birmingham Children’s Hospital, Ladywood Middleway, Birmingham
A
JL M k child s requirement for paediatric intensive care is likely to place enormous strain on the way the family functions. The family is the constant factor throughout the child’s life, undertaking the ultimate re sponsibility for emotional, social, develop mental and healthcare needs. Family-centr ed care in the critical setting is not easy when the child requires management that attempts to achieve a fine balance between the effects of technology and caring. Nurses are ideally placed to recognize the coping strategies and methods of adaptation of family members to the child’s illness and disability, and to intervene appropriately (Phillichi, 1989). King and Gregor (1985) state that the level of family stress is high, not only because of the child’s critical state of health, but also because the illness was unexpected and/or the stay in the paediatric intensive care unit (PICU) was prolonged. Associated with the anxiety state are vary ing degrees of depression which may only be relieved by the expression of feelings, according to Weller and Miller (1988).
T a b le 1. M a jo r stre ssors in th e p a e d ia tric in te n s iv e care u n it D ire c tly relating to the child
A ffecting the parental role
Environment of PICU
Personal safety/security within PICU
Concern for the child’s feelings: pain/discomfort/loneliness
Psycholgical/physical — affecting child’s future development
Loss of the parental role
Parental role changes — processes o f involvement/shared care
Concern about the eventual outcome — the loss of the child
Information need/diagnosis, treatment and prognosis
The need to maintain or otherwise a constant presence
Financial concerns/transportation difficulties to and from the hospital
Isolation from other family members
Relationships and support for other siblings Relationships with friends
PICU = paediatric intensive care unit
764
This review examines the predominant stresses and stressors and the subsequent strategies developed by parents to deal with them.
Stress and stressors LaMontagne and Pawlak (1990) examined parents’ perceptions of what was stressful about the PICU experience and the coping behaviours parents used to manage the stress. This study was based on a phenomeno-logical perspective — defined by Lazarus (1966) as a personal experience reflecting a disturbed relationship between the person and the situation and coping, which they defined as the process used to alter this disturbance. The predominant stressors identified were loss of the parenting role, information need and uncertainty over outcome. This was a study of 30 parents, 24 of whom were women and classed as the primary care giver, and results reflected previous find ings by Miles and Carter (1982). Kasper and Nyamathi (1988) suggest that disruption of the parental role is a problem in PICUs. However, a preliminary study of five individual parents by Carnevale (1990) used a similar phenomenological client-centred approach (Rogers, 1951) and obtained very different results. In addition to the environ ment and concern for the child, the author identified parental role conflict, the child’s feelings, relationship with friends and the child’s siblings as being predominant stressors. The parental role conflict referred to relationships with professional staff. There were differences in sample size be tween the two studies. Carnevale (1990) ac knowledged the limitations in his prelimi nary study. Although not truly representa tive and therefore potentially less accurate, it does merit some consideration. In this study, four of the five individual parents were married couples, and two of these were former nurses; this may reflect the broader dimensions and insight into the
Downloaded from magonlinelibrary.com by 130.237.122.245 on January 10, 2019. British Journal of Nursina. 1992, Voi l.N o 15
Children in critical care: how parents cope
perception of the question ‘What is it like to have a child in PICU?’ Significantly, the interviews were conducted in the intensive care environment 24-48 hours after admis sion, when the child’s condition had stabi lized. This would therefore reflect a differ ent perspective and explain why the im mediate needs, relating to parents’ own role, were seen by them as being the pre dominant stressors. Parental role conflict with healthcare staff was identified as the most predomi nant stressor by Carnevale (1990) and in certain instances Carnevale found that as sertiveness by parents only served to alien ate them further. In this respect the findings were similar to those described by Broome (1985) in that feelings of helplessness or jealousy of parents towards staff members closely involved with their loved ones may cause hostile interactions, which are some times seen as demanding or as effective withdrawal. Miles and Carter (1982) and Daley (1984) also rated staff behaviours, e.g. the hustle and bustle of the medical and nursing team and inappropriate responses, as significant sources of stress, together with communication difficulties and lack of care giving other than for critical pro cedures.
C op in g strategies During the critical care experience the fam ily must deal with many stressors (Table /), including role changes, financial con cerns, isolation from other family members, T a b le 2. P a re n ta l co p in g s tra te g ie s Strategy
Action
Abdication of responsibility
Withdrawing from the situation
Information seeking
Respected questioning of professional staff
Intellectualization
Increased interest in physiological aspects of child’s condition
Restructuring
Focusing only on certain aspects o f the child and illness
Exposure of marital relationships
Deepening and strengthening on intermarital conflict and crisis
Utilization of resources
Hospital/community liaison support workers
Religious beliefs
Chaplaincy support/cultural/ ethnic needs
Involvement of extended family
Shared responsibility
Creation of ‘personal space’
Opportunity for reflection and revised strategies
Adapted from: Lewandowski (1980)
British Journal of Nursing, 1992, Voi l.N o 15
transportation problems to and from the hospital, and fear of losing their loved one (Hodovanic et al, 1984). In a study of par ents with children who had undergone open heart surgery (Table 2), Lewandowski (1980) found that parents coped in a variety of ways during this stressful event, includ ing withdrawing from the situation, becom ing extremely interested in the physiologi cal aspects of the child’s condition (intellectualization) and restructuring and focusing only on certain parts of the child and the illness. A child’s hospitalization not only dis rupts family routines and requires the fam ily to make major adjustments, but also places a strain on the ill child, in which the parents grieve the loss of their role of parent to a healthy child and then assume the role of parent to a critically ill child (Freiburg, 1972; Knafl, 1985). In order that parents can take on this revised identity, they have to come to terms with the fact that their child’s life is in the hands of others before they are able to get re-involved in their child’s care (Jay, 1977). This view correlates with that of Lewandowski (1980) who viewed withdrawal from the situation as a coping strategy. Similarly, Broome (1985) felt that withdrawal allowed the family time to assess its strengths and resources. It is not unreasonable to assume that fol lowing an acute period of anxiety, parents feel a genuine desire to relinquish responsi bility and decision making to healthcare staff who have the appropriate skills. In this respect, families can be seen to withdraw to assess the actual and potential difficulties that may confront them. However, the ab dication of responsibility comes at a time when the parents want to demonstrate their love for the child more than ever (Rennick, 1986). Snowden and Gottlieb (1989) looked at the maternal role in the PICU and the hos pital ward and identified six parental roles: vigilant parent, nurturer-comforter, medi cal parent, caregiver, entertainer and pro tector. Although this was a comparative study, non-active roles, i.e. vigilant parent and nurturer-comforter, were observed to be the most predominant, although these responses were altered in the presence of others and during different procedures and settings and were directly related to the child’s condition. Miles (1979) felt that pre vious parental roles and relationships with the child should be assessed to ascertain how the family functioned before the criti cal care experience. A disorganized family
765
Downloaded from magonlinelibrary.com by 130.237.122.245 on January 10, 2019.
Children in critical care: how parents cope
may experience severe disruption as a result of a crisis (Fife, 1985). When the family be comes aware of the disruption, much en ergy is exerted in an attempt to mobilize problem-solving abilities and support sys tems (Broome, 1985). Similarly, in their study of what parents felt to be stressful in the PICU, LaMontagne and Pawlak (1990) found the most commonly used coping strategies were seeking social support (problem focused) and positive reappraisal (emotion focused). This study did not attempt to ad dress the coping strategies of the family as T a b le 3. C a te g o rie s o f co p in g Cognitive — things you think about Interpersonal — actions directed towards other people____________ Social support — drawing on the support of others________________ Direct action — th ings you do Drawing from the environment Source: Carnevale (1990)
T a b le 4. H y p o th e tic a l ta b le s h o w in g assum ed ro le s o f p a re n ts vs n urse s* Parents’ position
Nurse’s role
Diminished parental responsibility
Priority of professional responsibility
Parents assume the secondary caregiver role
Assume the parental role — presume to know how parents feel
Specialist care seen as the priority — creates dependency
Strong power dimension in relationship
Parents not seen as individuals
Parents become easily categorized
The ability to build on life experiences is not acknowledged or recognized
Assume parents will have difficulty in coping
Decision-making process is directed by professionals
The right of advocacy
Lack of respect fo r the special parent/child relationshiop
Independent decision making/ interpreting the needs of the child
Assertiveness leads to alienation
Nurses dictate and disseminate information considered to be relevant
Parental and professional roles do not integrate sufficiently
Nurses assume that technical procedures are not part of the parental role
Parents need to re-establish normal family routines
Nurses assume parents need to be with their child at all times
* This cable was based on the experience of the author in the parental role, and as an experienced nurse in this specialty. It may not therefore be truly representative o f all parents new to this environment.-------------------------------------------------------------------
766
a unit but as an individual parent response, the emphasis being on the primary care giver, i.e. women (as in Snowden and Gottlieb’s (1989) study). The predominance of emotion-focused strategies could reflect some gender bias. Carnevale (1990), however, studied married couples and categorized the coping themes into five groups (Table 3). In addi tion to social support, as identified by pre vious authors, the study showed these to be: cognitive; interpersonal mechanisms; direct action; and drawing from the envi ronment. This study was based on self-re porting data and therefore had some limita tions but it did include strategies that had not been shown before in a similar attempt to measure coping (Miles and Carter, 1982).
Im plications for further research and clinical practice It is evident that the literature reviewed was not totally comprehensive. Although de mographic data were examined, none of the research considered the specific needs and coping mechanisms of different ethnic and cultural groups in terms of the parental and extended family role behaviour. Further re search is necessary to explore this aspect in the psychosocial context to ascertain what role parents would wish to assume in the PICU setting. The literature indicates that there is a need for nurses to facilitate the coping strat egies most commonly used by parents. This would involve social workers, support groups, the chaplaincy, and the extended family members and friends. Further stud ies to identify and evaluate these nursing interventions could form a foundation on which to base effective nursing care. Funda mental to this is the need to review existing practice and behaviour towards families to discuss their roles and the implementation of education programmes to develop skills and knowledge. The nurse-parent-child re lationship plays a major role in the outcome of illness (Hedenkamp, 1980). Table 4 is a hypothetical comparison of the assumed roles of parents and nurses. C onclusion Although the new philosophy of care has emerged in recognition of the integral role of the family in providing comprehensive care (Shelton et al, 1987), current practice does not always achieve or reflect this. While most professionals support the con cept of mutual respect and involvement of the family, in reality it is questionable
Downloaded from magonlinelibrary.com 130.237.122.245 January 10, o2019. British by Journal of Nursing,on 1992, Voi l.N 15
A D V b K l loEIVIEIMT F E A T U R E A fte rc a re o f th e B o w e r PEG T u b e Immediately after a Bower PEG has been insert ed, the aftercare starts. A dry dressing such as a gauze keyhole dressing should be placed over the stoma site for the first 12-24 hours after procedure. The stoma site should be checked twelve hours after the pro cedure. Blood and serous fluid will be present. This is normal. The stoma site or tube should not be touched for the first 8-12 hours after placement. How ever, if the fixation device (Figures 1 and 2) is not flush with the abdomen and the tube is loose, the Endoscopist should be notified in or der to make the necessary adjustments. The Day After the Procedure The site should be treated with povidone iodine for the first 24-48 hours after the procedure. After 48 hours if the stoma site is satisfactory, soap and water may then be used on a daily basis. It is very important that the area around the tube is dried gently but thoroughly. No dressing should be reapplied unless there continues to be leaking around the stoma site. From the first day the Bower PEG should be rotated in a com plete circle during the daily cleaning routine. This enables all areas around the tube to be cleaned thoroughly and also prevents the build up of scar tissue which could potentially adhere to the tube. Report any leakage, swelling, irritation, red ness, skin breakdown or soreness around the stoma site. Do not give the patient an immersion bath until the stoma tract has healed (usually 2-3 weeks after placement). Showering is satisfactory dur ing these first few weeks. After the stoma tract has totally healed, the pa tient is free to take a bath or swim if they are able to do so. NB: Always ensure luer caps on the tube are closed properly. Always dry the tube and exit site thoroughly after immersion in water. Feeding Feeding should only be commenced when bowel sounds are heard. This is normally 8-12 hours after placement. Follow the feeding regimen as prescribed by your Hospital or Dietitian.
25-50ml of water should be flushed through the tube before and after feed. This procedure should also be followed for administration of medicines. Medicines should always be in sus pension presentations. No crushed tablets should be put into gastrostomy tubes. If continuous feeding is utilised, routine flush ing is essential. Elevation of the bed will help prevent reflux and risk of aspiration pneumonia. Do not lie the patient flat for 30 minutes after feeding has finished.
0 To
remove blockage. Initially syringe 25-50ml of lukewarm water. If this fails refer to Hospital Policy for unblocking naso-gastric tubes. For further information contact: Patrick Finn, Product Manager, E Merck Pharmaceuticals, Winchester Road, Four Marks, Alton, Hants GU34 5HB. Tel: (0420) 564011.
Do’s and Dont’s for the long-term care of the Bower PEG • Do not remove the fixation device before stoma formation has taken place — 2-3 weeks after placement. After this time, on a regular basis, you can separate the fixation cover from the base (Figures 1 and Z) to allow fur ther cleaning of this part of the tube. • Do not remove the fixation device unless you have a suitable replacement. 0 Do not re-position the tube. This should only be carried out by the Endoscopist. 0 Never remove the Y-shaped feeding adaptor (Figures 3 and 4) unless you have a replace ment on hand. 0 Bower PEG adaptor repair kits can be order ed from E Merck Pharmaceuticals. 0 Luer caps must be secured by using quarter of a turn. Greater than this may cause damage to the tube. 0 Do not clamp the tube.
Figure 1. 20 French tube fixation device
Q
Figure 2. 12 French tube fixation device
Figure 4. 12 French Feeding Adaptor
MERCK k i‘a
