A nurse is caring for a 14-year-old with a gastrostomy tube. The girl has skin breakdown and irritation at the insertion site. Which would be the most appropriate method to clean and secure the gastrostomy tube?
A) Make sure the tube cannot be moved in and out of the child's stomach.
B) Use adhesive tape to tape the tube in place and prevent movement.
C) Place a transparent dressing over the site whether there is drainage or not.
D) If any drainage is present, use a presplit 2 × 2 and place it loosely around the site.
Ans: D
Skin around the gastrostomy or jejunostomy insertion site may become irritated from movement of the tube, moisture, leakage of stomach or intestinal contents, or the adhesive device holding the tube in place. Keeping the skin clean and dry is important and will help prevent most of these problems. If any drainage is present, a presplit 2 × 2 can be placed loosely around the site and changed when soiled. If no drainage is present, the nurse should not place a dressing as it can cause undue pressure and trap moisture, leading to skin irritation. Preventing movement of the tube helps reduce skin irritation; however, the tube should be able to move slightly in and out of the child's stomach.
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