Percutaneous Endoscopic Gastrostomy (PEG) tube feeding is characterized by a successful and safe procedure for feeding patients with impaired swallowing [1]. The PEG is used for deteriorating neuromuscular disorders, and the advantages of PEG tubes are improving the body’s status by nutritional support in oncologic and pediatric patients [2, 3].

PEG provides support for patients with long-term enteral feeding, and advantages over parenteral nutrition [4]. With the advancement in the field, PEG tube placement is performed by endoscopic procedures worldwide and estimated 100000-125000 procedures are performed annually in the United States [5].

The most important function (PEG) is to provide a route for enteral feeding and hydration and drug administration for patients. A gastrostomy tube placed endoscopically is usually a better choice than surgical placement [6].

From minor complications such as peristomal wound infection and tube leakage into the abdominal cavity causing peritonitis, stoma leakage, inadvertent PEG removal, tube blockage, pneumoperitoneum, and gastric outlet obstruction, other complications, such as hemorrhage, necrotizing fasciitis, bumper syndrome, aspiration pneumonia, perforated viscus, colonic fistula, and metastatic seeding may occur which are considered major problems [7].

Pre-insertion, the nurse discussed the goals and diagnosis to obtain informed consent from the patient and family. In some conditions, through PEG, patient's survival and nutritional conditions improved along with their quality of life [4].

Awareness of these complications and the use of preventive strategies can allow the endoscopist to maximize outcomes and to identify complications at an earlier stage. As with any invasive technique, a thorough knowledge of purpose, indications, and fundamental procedural steps constitutes the most important safety factor [8, 9].

The patient and caregiver should be aware of and meet with all members of the Health Professional team involved in the process of gastrostomy insertion as the ongoing care is an important part of the management of many patients and caregivers [10]. Quality of PEG tubes care begins at pre-insertion assessment and during post-insertion aftercare. The prevention of complications and proper management is critical to ensure a successful outcome [4].

Nurses are mainly providing care to patients with PEG tubes. It is important that health professionals’ team have the knowledge and skills to provide information to the patients and their families to provide the best possible care for patients with a PEG [11]. Also, the patient/ caregivers should be instructed and provided with written information on safe and effective gastrostomy tube care and feeding. The risk predictors for increased adverse events are related to PEG feeding, as well as a consequently extended hospital stay due to the patient’s physical and nutritional status [12].

The purpose of this study was to evaluate the effect of nursing-based guidelines on the caregivers’ knowledge and practices regarding adult patients with PEG.

The present study shows that more than two-thirds of studied patients were male with a lower financial status. This result was in accordance with the studies [19] [20], which reported that more than half of the studied group were male.

The finding of the study reported that less than half of the studied patients were illiterate and one-fifth of them obtained a primary level of education and their age was from 33-75 years. This result agrees with the reported study, which claimed that the highest number of patients who required a feeding tube placement belonged to the age group of 51-60 years [21]. Also, it is reported that the median age was 68 years [20].

Regarding the socio-demographic characteristics of the studied caregivers, the present study results showed that two-fifths of the studied caregivers were female and their age was from 20 to 29 years, while more than half of them were in high school. Also, less than half of the caregivers were sons or daughters, and less than one-quarter of them were spouses, which agreed with another study [21] that reported that 80% of caregivers were 31–64 years of age. Also, it was reported [22] that nutrition by PEG was dependant on the activity of patients and their careers. So the patients' experiences and satisfaction of living with a PEG are dependent on the educational state, age, gender, and medical diagnosis. The main caregivers for PEG patients at home were spouses.

The current study reflects the physical health and nutritional assessment of the studied patients with PEG, the majority of them were suffering from oncologic disorder. This result was not in agreement with another report [23] which claimed that the most studied patients were inserted with PEG, from the neurologic group, followed by the oncologic disorder, another diagnosis and trauma.

The present study shows that the majority of studied patients performed oral hygiene and less than two-thirds of them were taking prescribed chemotherapy treatment. This result corresponded with another study [24], which reported that tube feeding by percutaneous routes appeared to be comparably effective during chemo/radiotherapy. Also, it was reported that prophylactic PEG not only decreases adverse effects but also may potentially improve oncological outcome of the patients with oropharyngeal cancer [26].However, a report showed that patients who had chemotherapy or radiotherapy before PEG placement had a higher incidence of peristomal infections [27].

The present study shows that half of the studied patients were inserted PEG recently; this correlated with another study [25], which claimed that there is a progressive increase in the use of PEG with the meantime of treatment longer than one year.

The current study results revealed that more than two-thirds of studied patients had no problems in the pre-gastrostomy insertion site and had a clean surgical wound site and more than half of studied patients were under feeding plan. This result disagrees with another reported study [26], which claims that peristomal infection remains the most common complication following PEG tube placement, but another study states that the quality of life improves after PEG in both patients and caregivers in this series [28].

The findings of the present study showed highly statistically significant differences between pre/post and follow-up intervention regarding the caregiver’s knowledge about PEG; this finding disagrees with another study [27], which reported a barrier to gastrostomy feeding existing among Asian clinicians and their caregivers due to negative perceptions about complications and no differences in nutrition outcomes were observed between NG and gastrostomy feeding at 4 months. While agreeing with the result of another study [28], which reported that PEG is a simply invasive PEG procedure with low morbidity and mortality rates, and is easy to follow-up and replace when a blockage occurs; another study [29] reported improved understanding of the caregivers' perspectives and concerns in adults who already had or will have PEG in the future. Also, updated knowledge relating to PEG tube indications, placement, management, and care, reinforces PEG feeding as the most valuable access for patients [1].

Regarding caregivers’ practice related to nutritional management and care of PEG in follow-up, the present study showed that the majority of them had better levels. This finding disagrees with the fact that the number of patients undergoing PEG has increased, so the guidelines may help in the improvement of PEG-related care, nutritional management, and relocation of medical resources [32].

The findings of the present study showed that there were highly statistically significant differences between caregivers’ practice about PEG care pre/post- and follow up guidelines’ intervention. These results are in conformity with the reported study [22], which showed that comprehensive and practical discharge training, and home care and counseling services should be provided to effectively address the challenges faced by caregivers of patients with PEG. So, to avoid complications of PEG, the caregivers must be careful with their experiences and practices.

The present study showed that the general patient outcome concerning physical, nutritional and patient/caregiver experience in post and follow-up guidelines improved. This finding agrees with another study [1], which reported that health education provides safety of PEG feeding after placement, thus resulting in lower costs and appropriate nursing care by healthcare professionals, and patients/caregivers to prevent complications. Another study [30] claimed that according to the patients/caregivers who reflected their experiences of PEG tube feeding, including constructive cognitive appraisal, they focused on positive adaptation and acceptance of PEG feeding.

The present study shows patients’ progressive outcomes concerning physical and nutritional state post and follow-up intervention about gastrointestinal symptoms. The result shows that less than one-third of the patients had no problem while one quarter of patients were suffering from nausea and anorexia at follow up. These results are in agreement with another study [31], which confirms that long-term enteral feeding via PEG is a safe, functional, easy-to-apply, and highly suitable method with excellent long-term outcomes and minimal troubles.

The current study shows that there were no statistically significant differences between post and follow-up intervention of nursing-based guidelines regarding tube troubleshooting for patients with a PEG; these results are in agreement with another study [32], which reported the development of many complications such as dislodgement, outflow, and infection. An infected stoma is an important complication and PEG stoma infection can compromise patients’ quality of life and impact morbidity. It is important that the patient is monitored adequately to assess for early signs of potential complications to ensure timely medical attention and good clinical outcomes.

The findings of the present study highlight the importance of regular nutrition by mini nutrition assessment. The two-thirds of the studied patients had normal nutritional status and half of them had average weight at follow-up. This result agrees with the reported study that the patients’ nutritional status and conditions should be screened to minimize malnutrition in hospitalized patients to decrease complications after PEG tube placement, including undernourishment and many organic disorders [1].

The finding of this study shows that there is a highly statistically significant difference between post and follow-up intervention regarding patients’ outcomes concerning the physical and nutritional state. Another study [33] reported that the complications of PEG are few but produce side effects in these elderly patients with multiple co-morbidities, as such, patients considered for PEG feeding should have reasonable prognosis and the procedure is inappropriate for patients with worst health condition.

The current study results revealed that the majority of the studied patients were overall satisfactory and more than half of the caregivers were had difficulty coping with the care of PEG and during follow-up, there was a statistically significant number of caregivers coping with the care of PEG with overall patient satisfaction between post and follow-up intervention. This finding agrees with the study [13], where the majority of caregivers and patients felt that PEG-tube helped in feeding and prolonging survival. Also, it was reported that the primary outcome is based on the caregiver’s self-efficacy for improving the patient management.

It is the opinion of the researcher that one of the responsibilities of nurses toward patient/ family care is to educate them through program, guidelines, purchases, or patient/family classes to increase the quality of patient care especially oncology patients [34]. Additional research is needed to safely guide PEG monitoring, management, and patient/family education. Nurses administering PEG play a critical role in the early identification and management reactions; and the management programs are important to ensure consistent delivery of best-practice education and care [35]. The nurses play an essential role in providing patient-focused health information to the family. Also, according to a study [36], the reason behind inappropriate care towards PEG feeding is explained by the lack of education, knowledge, teamwork, communication, and financial support.

The general patient outcomes concerning physical, nutritional state and patient/caregiver experience of post and follow-up guidelines intervention improved. The findings of the present study showed that there were highly statistically significant differences between the caregiver’s knowledge and practice about PEG care pre/post and follow up guidelines intervention,

Health care professionals should be aware that caregiver education is an integral part of patient care with PEG. Continuous training and educational programs must be designed for caregivers to get updated knowledge about practices regarding the care of patients with PEG. Using research findings, the policies, procedures, and practical guidelines for the patients’ caregivers should be developed.

Official permission was obtained from the Director of the intended hospital in which the study was conducted and the heads of the departments. Meeting and discussions were held between the researchers and nursing administrative personnel to make them aware of the aims of the study. The aim of the research was also clarified to the participants. Verbal consent was obtained from each patient and caregivers to participate in the study, after clarifying the procedures of the study. Participants were informed about their right to refuse participation and withdraw at any time without any significance. The privacy of data was ensured.