Managing nasogastric tube feeding and maintaining nutrition

Health is defined by WORLD HEALTH ORGANIZATION(WHO) as a “state of complete physical, mental and social well being and not merely the absence of any disease or infirmity”. Health is a positive quality which emphasizing physical, social, intellectual, emotional and spiritual well-being.

Maslow’s hierarchy theory states that basic human needs are necessary for human survival and health. The most basic or first level include physiological needs such as air, water and food. According to Maslow, the extent to which basic needs are met is a major factor determining persons level of health.

Food is anything that can be used by the body to sustain growth and bodily processes and provides energy. Each individual food has its own unique set of nutrients that meet the varying requirements of the human body. This is why it is so important to eat a wide variety of food to ensure that the body gets all the diverse and essential nutrients.

Nutrients are the components of food that help to nourish the body. The basic classes of nutrients are carbohydrates, lipids(fat),protein, vitamins, minerals and water. All nutrients, both in kind and amount ,are the cornerstone of good health and provides the cutting edge for prevention of diseases.

These nutrients are supplied to the body cells by gastro intestinal system. This is accomplished through the process of ingestion(taking food),digestion(breakdown of food),absorption(transfer of food product into circulation).

Good nutritional status refers to the intake of a well balanced diet that supplies all the essential nutrients in right proportion to meet the requirements of the body. Such a person may be said to be receiving optimum nutrition.

Optimum nutritional status can be affected by many factors such as inadequate intake of food or consuming food which contains less nutrients, food habits and economic insufficiencies etc.

In sickness the ability to eat and drink adequately can get altered. The disease affecting central nervous system, gastrointestinal system and some surgical conditions can alter the patients ability to take the food through the mouth. In these conditions patients are at high risk of under nourishment.

There are artificial feeding methods available to keep the risk patients free from under nutrition through enteral and parenteral feeding. When gastro intestinal tract cannot be used for the ingestion, digestion and absorption of nutrients parenteral nutrition may be substituted. Parenteral nutrition refers to the administration of nutrients by a route other than the GI tract(Blood stream).

When the gastro intestinal tract is functional but patient cannot be provided with high calorie supplements orally, tube feeding can be provided with nasogastric tube, nasointestinal tube, gastrostomy and jejunostomy.

A nasogastric tube is commonly used for short term feeding problems, usually ordered for a patient who has a functional GI tract but unable to take any or enough oral nourishment. Nasogastric tube feeding is a technique of giving food in patients, who are not able to swallow the food through mouth, with the help of a long soft plastic tube which is inserted through the nose via throat directly into the stomach.

The history of enteral feeding goes back about 3500 years back to the ancient Greeks & Egyptians, who infused nutrient requirement solutions into the rectum to treat various bowel disorders. The ancient Egyptians used reeds and animal bladders to supply patients with a mix of wine, chicken broth and raw eggs. In 1793, an early healer delivered jelly, eggs, milk, sugar and wine to a patient through a hollow whale bone covered with eel skin, which was pushed down the throat to the stomach. In 1800, Philip Phisik, a surgeon from Philadelphia, introduced the use of a stomach tube as a form of stomach pump (Paine, 1934). This was used for poisoned patients for the purpose of washing out their stomach.

In the 1930s, nurses training in Australia and the United Kingdom utilized a text entitled Modern Professional Nursing (Scott, c1930). It included discussion of using a tube inserted via the nose into the stomach, apparently for the sole occasional purpose of administering bolus artificial feeding. In addition to nutrition delivery in the 1930s, nasogatric tubes also were used to relieve pressure in the stomach caused by gas and gastrointestinal secretions (decompression).

Today nasogastric tube feeding is a very common procedure seen in the medical and surgical units of the hospitals. The tube is made of superior plastics like polyethylene, polyvinyl or polyurethane (Clevenger & Rodriguez, 1995).This tube is inserted through the nose or mouth and placed directly into the stomach. The need of tube feeding includes delivery of nutrition, administration of medicines, gastric irrigation, and gastric decompression before and after surgery or intestinal obstruction . Patients with nasogastric tubes currently receive care in a wide variety of settings, such as intensive medical and surgical care units, emergency rooms, , general and specialized acute and chronic care areas, extended health care facilities, and home care settings(Susan C Dewit,2006).

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The feed provided through the nasogastric tube should be in liquid or semi-liquid form and given in room or body temperature. Blenderized foods from a normal diet or commercial formulas are usually provided. Feedings are administered by gravity drip method or by feeding pump or by intermittent feeding. A maximum amount of 300-400 ml of feed can be provided at a time delivered at an interval of 2-3 hrs depending upon the patients tolerance and physicians advice..A variety of feeds should be provided though nasogastric tube in order to ensure the optimum nutritional status.

Caring of the patients receiving nasogastric tube feeding is a major nursing responsibility that entails a number of interventions like delivering feeds, assessing correct placement of the tube, maintaining the tube’s patency, ensuring adequate nutrition, securing the tube in place, and meeting patient comfort and other basic needs. The weight of the patient should be checked daily and maintain an accurate intake and output record. Blood glucose level also should monitored at definite intervals. When the patient is in a long term feeding maintaining the nutrition and general health is an important and nurse’s responsibility. In order to maintain the nutritional status the nurse should calculate patients requirements and select diet accordingly.

Emma L(1983) points out enteral feeding is associated with greater risk of complications, around 11.7%.Her study reveals that tube-related complications are common in patients receiving long-term home enteral nutrition. Even though different feeding modalities are available, unfortunately no method of enteral feeding is risk free. aspiration pneumonia, high gastric residuals ,constipation ,diarrhea, abdominal distention, vomiting, regurgitation, erosion of esophageal, nasal and oropharyngeal mucosa and infection are the complications of tube feeding.

Initially only nurses were carried out this procedure .However, over years caregivers of the patient are also involved in feeding the patient through the tube. Now the responsibility of feeding the patient through the tube is shared by the caregivers both in hospital and home settings. Since the family members are also involved in feeding patients they should be instructed about feeding, importance of nutritious diet, signs and symptoms and importance of reporting them to the doctor or nurse.

Ellet.M L, A. States enteral feeding is desirable because it allows better use of nutrients, is safer, and more cost effective than parenteral nutrition. Tube feeding permits maintenance of tissue metabolism even though patient cannot ingest anything through mouth. The potential advantage of tube feeding includes providing nourishment to the patient prolonging life and enhancing comfort and quality of life(WONG 2002).Current scenario shows enteral tube feeding is a common medical procedure in many of the hospital, long term and home care setting.

NEED OF THE STUDY

. Managing nasogastric tube feeding and maintaining the nutrition are a nurse’s responsibility. Initially only nurses were carried out this procedure but over years caregivers of the patient also shared the responsibility of feeding the patient through the tube .Now Family members are participating in feeding the patient through N.G Tube both hospital and home settings. Caregivers involving in feeding is a good aspect of patient care but when they are involved they should be properly trained and educated. But in many settings the caregivers are feeding the patient without proper understanding about it. Researcher also observed the faulty feeding techniques of the caregivers while he was working in the medical and surgical departments. Even though no complications were reported so far, the patients are at high risk of getting complications.

STATEMENT

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING ON KNOWLEDGE AND TECHNIQUES OF NASOGASTRIC TUBE FEEDING BY THE CAREGIVERS OF PATIENTS RECEIVING TUBE FEEDING IN A SELECTED HOSPITAL AT ALAPPUZHA,KERALA

SPECIFIC OBJECTIVE

1)To assess and compare the level of knowledge regarding nasogastric feeding, between control and experimental group before and after intervention.

.2)Assess and compare the degree of technique of nasogastric tube feeding between control and experimental group before and after intervention.

3)To associate the selected demographic variables(age, education, occupation and source of instruction) with knowledge and techniques of feeding among experimental group.

AIM OF THE STUDY

The aim of the study is to evaluate whether structured teaching about NG tube feeding made any difference in the knowledge and techniques of caregivers in feeding patients through nasogastric tube compared to those who did not receive the structured teaching.

HYPOTHESIS

There will be a significant difference between experimental and control group of caregivers with regard to the knowledge and technique of nasogastric tube feeding.

SUB HYPOTHESIS

H1-There will be a significant difference in the mean knowledge score on tube feeding among caregivers of the experimental and control group after the intervention and no significant difference before intervention.

H2- There will be a significant difference in the scores of techniques of feeding between the control and experimental group after intervention and no difference before intervention.

OPERATIONAL DEFINITION

EFFECTIVENESS : In this study effectiveness refers to the knowledge gained by the caregiver as a result of selected aspect of nasogastric tube feeding and the ability to carry out the tube feeding with correct technique.

KNOWLEDGE : knowledge refers to ideas, information, factual knowledge held by a person from various sources. In this study knowledge refers to the factual information gained by the participants regarding naogastric tube feeding through the teaching learning experience which is assessed by using structured interview schedule.

TECHNIQUE

Technique is the way of carrying out an activity step by step and systematically .In this study technique refers to the correct method of carrying out N.G Tube feeding with the proper application of scientific principles of tube feeding

STRUCTURED TEACHING

Structured teaching refers to planned events, series of studies &lectures with a view to improve knowledge. In this study it refers to a formal instruction which is preplanned with definite, objectives, contents, teaching, learning experience and AV aids to impart essential knowledge on tube feeding and how to give feeding safely to the patients.

CAREGIVERS

Caregivers are the relatives of the patients who stay with the patient most of the time and participates in patient care including feeding patients through nasal tube and assume responsibilities in the patient care activities

NASOGASTRIC TUBE FEEDING

Naogastric tube feeding is a method of giving nourishment to patients who were not able to swallow the food through mouth by the help of along soft plastic tube which is inserted through the nose via throat directly into the stomach

ASSUMPTIONS

N.G Tube feeding is a very prevalent and common procedure in both inpatient and home settings. Patients relatives are also participating in feeding the patient. The relatives are carrying out the procedure with or without adequate knowledge, training, and supervision regarding nasogastric tube feeding and hence this leads to a lot of negative effects on the relative-dependent patient.

LIMITATION

The study is conducted in only one hospital. So the result cannot be generalized.

Because of the restrictions from the hospital and due to limitations owing to age parameters, the sample may not be a representative one.

For an education programme to be effective, continuous follow-up is essential. But in this instance, due to limited time availability, it may not be possible.

DELIMITTION

The study is delimited to,

Three observations.

Only one hospital.

An age group of 20-60yrs.

SCOPE OF STUDY

Through this study the researcher can determine the knowledge and techniques of the caregivers about nasogastric tube feeding by assessing the awareness of tube feeding in different aspects. Areas of less knowledge can be focused.

The understanding about the proper knowledge and technique of tube feeding will help them to provide feeding by using correct techniques , avoid potential complications and promote patient’s safety.

These findings will help the health care providers to give necessary attention to provide adequate training to the relatives of the patients who need to feed through nasogastric tube both in home and hospital settings.

RESEARCH FRAMEWORK

A frame work is the building block of a theory, describing mental image of a phenomena which can be abstract or concrete.

A theory is a set of interrelated concepts, adapted for a scientific purpose, definitions and propositions, that present a systematic view of phenomena by specifying relations among variables with the purpose of explaining predicting the phenomena (Kerlinger 1986).

A conceptual framework provides structural foundation to the research study which provides rationale for predictions about relationship among the variables in the study. Conceptual framework forms the base for observations, definitions of concepts, research design, interpretation etc. Conceptual framework gives meaning to the problem and study findings by summarizing existing knowledge in field of inquiry and identifying linkage between concepts.

For this study the Conceptual framework followed is nursing process model based on Dorothy.E.jhonson’s behavioural system theory(1980).The study focus on assessing the effectiveness of providing structured teaching programme on the knowledge and techniques of nasogastric tube feeding among the caregivers of the patient.

According to Jhonson, nursing views the individual as a set of interconnected or independent parts functioning as an integrated whole. Humans seek experiences that may disturb balance and require behavior modifications to re-establish balance. The behavioral system are essential and reflect adaptations that are successful. Jhonson identified seven sub systems. The sub systems are affiliative,aggressive,dependency,eliminative,ingestive,restorative and sexual. These sub systems carryout special function for the system as a whole. Disturbances in any subsystem usually affects the other. The steps of the nursing process is incorporated with Dorothy Jhonson’s behavioural system model. Nursing process is a deliberate activity where the practice of nursing is performed in a systematic order. Dorothy Jhonson presents a three step nursing process. The steps are entitled nursing diagnosis which is parallel to the assessment and diagnostic phase ,the second step nursing goal equals the implementation and third step is evaluation. This study focuses on the caregivers of the patient and the dependency subsystems.

Assessment

Assessment is the process of collecting data regarding each sub-system. In this study assessment was done in the dependency subsystem. Data on the demographic characteristics of the caregivers(age, sex, education, occupation, experience in feeding, instructions and source of instructions received on tube feeding) were collected. The knowledge of caregivers regarding various aspect of nasogastric tube feeding were assessed by an interview schedule and an observational Check list was used to assess

the technique of feeding.

Diagnosis

Through assessment of the subsystem problems are identified and diagnosed which provide the basis for intervention. In this study the data’s were collected through observational Check list and interview schedule was analyzed and the diagnosis was made on knowledge and technique of caregivers and categorized into excellent, good, average and poor.

Nursing goals(planning)

After diagnosis is made the goal is to maintain or restore the dependency subsystem balance and stability through planning interventions. In this study the goal was to improve the caregivers level of knowledge and technique of tube feeding.

Intervention

Nursing activity as an external regulatory force assists the person to regain equilibrium. Based on diagnosis, nursing actions can be planned in terms of teaching or providing resources needed. In this study the nursing activity was a structured teaching including demonstration on different aspects of tube feeding.

Evaluation

Evaluation refers to reassessment the subsystem which is identified as problematic for balance previously. In this study the investigator compared knowledge and technique of experimental group with control group by using criteria and evaluated the effectiveness of the intervention.

Figure-1 High lights the conceptual framework on modified nursing process based on Dorothy.E.Jhonson’s behavioural system model

Implementation

Evaluation

No changes seen in the level of knowledge and technique.

Patients at high risk of getting complications

-Caregivers demonstrate improved levels of knowledge and techniques of feeding.

-patient less risk of getting complications

Control group

-No teaching programmes.

experimental group

-A Structured teaching regarding ding different aspects of tube feeding and demonstration of the technique of tube feeding

Assessment

Diagnosis

goal

FIGURE 1. MODIFIED NURSING PROCESS BASED ON DOROTHY JHONSON’S BEHAVIOURAL SYSTEM MODEL(1980)

Improve the caregivers level of knowledge and technique of tube feeding

Level of knowledge and techniques of tube feeding

-excellent

-good

-average

-poor

Caregiver’s demographic variables

-Age

-Sex

-Education

-Occupation

-Experience in feeding

-instruction and supervision received

-source of instruction

-attitude

-Lack of seriousness

-Fear and anxiety