Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [126], C).
2. 2.Show
   Wash hands with soap and water or an alcohol‐based handrub, and assemble the equipment required. Apply apron and clean gloves.
   Hands must be cleansed before and after patient contact to minimize cross‐infections ([115], C).

Procedure

1. 3.Show
   Remove the existing dressing. Observe the peristomal skin and stoma site for signs of infection, erythema, irritation or excoriation. Observe the tube and consider how it is being kept in place, and note the presence of any sutures, external fixation plates, clamps or balloon ports.
   To gain access to the stoma site. To detect complications early and instigate appropriate treatment (NNNG [129], R). To minimize the risk of accidental displacement of the tube. E
2. 4.Show
   Note the number of the measuring guide on the tube closest to the end of the external fixation device. If the stoma tract has formed (14 days post‐insertion), loosen the tube from the fixation device and ease the device away from the abdomen. The external fixation plate should be subjected to very low traction, without tension, to maintain contact of the stomach with the abdominal wall. If the tube is less than 14 days post‐insertion then do not loosen the fixation device.
   To ensure the gastrostomy tube is reattached to the fixation device in the correct position (Loser et al. [90], C).
3. 5.Show
   Clean the stoma site with a sterile solution, such as 0.9% sodium chloride, using a circular outward motion. Use low‐linting gauze to dry the area thoroughly.
   To minimize the risk of cross‐infection and ensure the stoma site is thoroughly cleaned (Fraise and Bradley [54], E; Lynch and Fang [92], R).
4. 6.Show
   If the stoma tract has formed (14 days post‐insertion), rotate the gastrostomy tube 360°. If the tube is less than 14 days post‐insertion then do not rotate the tube.
   To prevent the tube adhering to the sides of the stoma tract (NNNG [129], R).
5. 7.Show
   Gently push the external fixation device against the abdomen, checking the measurement guide.
   To enable the gastrostomy tube to be reattached to the fixation device. E
6. 8.Show
   Gently but firmly pull the gastrostomy tube and attach it to the fixation device. Consult the patient's medical and nursing notes for the correct numbered position mark at the gastrostomy exit site. The fixation device should remain at the same length, so that gentle traction on the tube allows 0.5 cm give but no more for the first 14 days.
   To ensure that the tube is correctly secured. E
7. 9.Show
   Ensure the correct point on the measuring guide on the tube is placed closest to the end of the fixation device.
   To ensure that the tube is correctly secured. If the patient gains weight, the external fixation device should be released slightly to prevent pressure necrosis of the stoma site (Loser et al. [90], C).

Post‐procedure

1. 10.Show
   The dry dressing should be replaced daily using aseptic technique until the stoma site has no erythema or exudates or any other signs of infection. Most forms of infection can be readily treated by means of antiseptic measures and daily change of dressing using an aseptic technique (Loser et al. [90]). Do not replace the dressing with an occlusive type. Do not use bulky dressings, particularly under the external fixation device.
   To encourage wound healing. E

   To prevent air getting to the stoma as this may cause infection (Lynch and Fang [92], R) or abdominal discomfort.

   Using non‐bulky dressings avoids increasing the pressure on the internal retention disc or retention balloon and increasing the risk of tissue necrosis and ulceration occurring in the stomach (Cappell et al. [28], E).
2. 11.Show
   Make the patient aware of and monitor them for red flag symptoms. In the immediate recovery period, ensure regular observations of temperature, blood pressure, pulse respirations and pain score. Red flag symptoms include pain on feeding, prolonged or severe pain, and external leakage of gastric contents. If the patient complains of pain or discomfort, administer analgesia. If this is persistent, liaise with the medical team and/or request a gastroenterology review (Healey et al. [66]).
   To monitor for signs of peritonitis or potential complications following insertion of the gastrostomy tube (NNNG [129], C).
3. 12.Show
   Remove and dispose of any equipment.
   To reduce the risk of cross‐infection. E
4. 13.Show
   Record the procedure in the patient's notes.
   To maintain accurate records (NMC [126], C).