Information
You are the medical SHO on the stroke unit. You have been
asked to see the daughter of one of your patients Mr. X who has been admitted
with a stroke
Mr. X is
a 75-year-old gentleman who was previously fit and well. He has been admitted
to your unit with a right-sided weakness and associated sensory aphasia. He
has been unable to swallow and has been aspirating. A naso-gastric tube was
inserted but this appeared to cause discomfort and he keeps pulling it out.
The decision has been made to refer the patient
for insertion of a PEG tube. The patient’s daughter Mrs.Y wishes to speak to
the doctors about this.
Plan (ACES
for PACES Page 574)
Objectives
The objectives of management in this case are:
♥
Support
Provide nutritional support
with enteral nutrition via PEG feeding
ª
Prevention
Prevent aspiration pneumonia
Methods
§
Surgery
Insertion of PEG tube
♥
Staff
Trained nursing staff and
dieticians to help care for the PEG tube after insertion and manage
nutritional support
ª
Equipment
Equipment required for
managing PEG feeding
¨
Residence
If the patient is discharged
support will be necesary to manage the PEG tube
Risks and Benefits
PEG insertion is associated with risks (sedation,
aspiration, perforation, haemorrhage, infection) but the benefits of
nutritional support and prevention of aspiration by persisting with oral
nutrition outweigh the risks. Without adequate nutrition the chances of
successful rehabilitation would be compromised.
Introduce /Identify
Listen (ACES for PACES Page
581)
Thoughts (Views)
♥
Thinks her father is undergoing a great deal of suffering
Knowledge
ª
Is aware her father has a stroke and cannot swallow on account
of this .She is aware that this is compromising his nutritional state and will
interfere with rehabilitation
Expectations
¨
Expects an alternative means of nutritional support for her
father but is afraid that PEG insertion may be a traumatic experience
Effects
§
She is worried that the PEG tube may cause further distress to
her father
Survival
♥
She is worried that PEG insertion is a major procedure and her
father may not survive the procedure
Modify
(ACES for PACES Page 582)
ª
The main concern of the daughter is that the procedure may cause
further distress and may harm her father. The explanation must address these
concerns
Convey (Deliver) (ACES for
PACES Page 580)
♥
Agree that there are risks associated with insertion of a PEG
tube but that every attempt would be made to keep these risks to a minimum
ª
Point out the benefits of PEG insertion
¨
Discuss the risks and benefits and point out that in this type
of situation it is the balance of risk and benefit that must be taken into
account and in her father’s case the opinion is that the benefits of inserting
a PEG tube outweigh the risks
§
Assure the patient that competent individuals who would ensure
that risk is kept to a minimum would carry out the procedure
§
Assure the patient that likewise every attempt would be made to
keep the patient as comfortable as possible during the procedure
