RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / Name of the candidate and address(in block letters) / JINESH KURIAKOSE
I YEAR M. Sc. NURSING
SHRI B.V.V.SANGHA’S,
SAJJALASHREE INSTITUTE OF NURSING SCIENCE, NAVNAGAR, BAGALKOT, KARNATAKA.
2. / Name of the Institution / SHRI B.V.V.SANGHA’S,
SAJJALASHREE INSTITUTE OF NURSING SCIENCE, NAVNAGAR, BAGALKOT, KARNATAKA
3. / Course of Study and Subject / Ist YEAR M. Sc. NURSING
PAEDIATRIC NURSING
4. / Date of Admission to the course / 5-5-2007
5. / Title of the Topic
“ A STUDY TO ASSESS THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME (PTP) ON KNOWLEDGE AND PRACTICE OF NASOGASTRIC TUBE FEEDING AMONG THE NURSES WORKING IN PAEDIATRIC UNITS IN THE SELECTED HOSPITALS AT BAGALKOT.
Introduction:
Good nutrition in infancy fosters optimal growth and development. It can also establish a basis for developing lasting good eating habits. Health supervision of infants requires knowledge of their nutritional needs.1
Some children’s are unable to take nourishment by mouth because of some conditions such as anomalies of throat, oesophagus or bowel; impaired swallowing; severe debilitation or unconsciousness. Such children are frequently fed by way of a tube inserted nasally into the stomach. This is called nasogastric tube feeding.2
Nasogastric tube feeding is one of the safe means of meeting nutritional requirement of infants less than 32 weeks or those whose weight is less than 1500gms and critically ill children. Nasogastric tube feeding provides adequate nutrition and is an essential component of critical care. Nurses have to decrease the gap between theory and practice by performing proper clinical bed side procedure. A better understanding of nursing practice related to tube feeding is required for providing a better care. A successful nasogastric tube feeding performance requires an expert skilled procedure and monitoring the child efficiently.3
In a critically ill child there is a risk of development of excess or deficiency of nutrients and electrolytes. To overcome this there should be a strict and accurate supply through nasogastric tube feeding and accurate recording of source of fluid, electrolytes and nutrients.2
6 Brief Resume of the Intended Work
6.1 Need for the Study
Children are very important and vulnerable group of overall population and constitute almost 1/3rd of the overall population, and they also have some rights such as protection, security, social identification, basic needs like air, water, food, clothes, shelter etc4
According to WHO report (2005) 11 million children across the world die due to low birth weight. Under nutrition or malnutrition affects every fourth in the world. Worldwide, 150 million children (26.7%) are underweight while 182 million (32.5%) are stunted. More than 70% of PEM (Protein Energy Malnutrition) children are in Asia. In India child malnutrition still remains a major health problem. The proportion of children under 3 years of age is more.5
Malnutrition and under nutrition among the children can be prevented by supplying proper nutrition in early stage of the childhood especially to neonates and infants as more calories are required in this period than in older stage. In this period, paediatric nurses have an important role regarding neonates care and infant care, especially in case of proper or adequate nutrition to prevent infection and provide proper knowledge regarding child nutrition to prevent under-nutrition and malnutrition of the child and other nutritional related problems also.6
A study was conducted on impact of standardised feeding regimen on incidence of neonatal necrotising enterocolitis (NEC)- a systematic review and meta-analysis of observational studies reporting the incidence of NEC before and after implementation of standard feeding regimen(SFR). They reported a pooled risk ratio of 0.13 (95% confidence interval 0.03 to 0.50). The reduced incidence of NEC after the introduction of SFRs was attributed to minimisation of variations in enteral feeding practices. They have proposed that clinical variation in practice determine risk of NEC. However, nursing management of tube feeding also varies from nurse to nurse. Each nurse uses their individual expertise to resolve problems related to regurgitation, abdominal regurgitation, abdominal distension and residuals. A study has shown variability in practice of withdrawing feeding and management of feeding residuals. As success of any nutritional approach depends on neonatal nurses, who spend a significant amount of time feeding and assessing infants before, during and after feeds. A better understanding of nursing practice related to tube feeding is required for providing a better care. Nurses have to decrease the gap between theory and practice by performing proper clinical bedside procedure.7
Nasogastric tube feeding is an essential component of the treatment of severe and persistent diarrhoea. It helps the gut to recover, replaces the nutrients lost in the stool and prevents malnutrition. Often the normal diet of a child with persistent diarrhoea is inadequate and this is a good opportunity to advice the nurses how to feed and improve the nutrition of the child. So, it is very necessary for the nurses for the nurses to have theoretical as well as practical knowledge.8
It has suggested in recent studies that there are benefits of early introduction of small amounts of nasogastric tube feeding in metabolically stable preterm infants. These “minimal enteral feedings” have shown to stimulate the infant’s gastrointestinal tract, preventing mucosal atrophy and subsequent enteral feeding with as little as 0.1ml to 4ml/kg formula.9
A study has reported that more individualised form of disseminating information such as various AV aids, flash cards, planned health teaching lecture cum discussion and demonstration related to nasogastric tube feeding procedure may help to increase the knowledge and practice. This way the information seekers gain knowledge at their own pace and time.10
The investigator’s main purpose of the study is to improve the knowledge and practice regarding the nasogastric tube feeding procedure among the nurses who are working in paediatric ward and provide adequate and expert skill for nasogastric tube feeding procedure and prevent the complication among the children those who are receiving nasogastric tube feeding.
6.2 Review of Literature
A study was conducted on evidenced based feeding guidelines of very low-birth weight infants, and focused on development of research based enteral feeding CPG (Clinical Practice Guidelines) on infants weighing <1500gms. The CPG was based on an extensive literature review and was developed through a process of consensus decision made by a team of clinical researchers. Infants who weigh less than 1000gms initiate minimal enteral nutrition at 48hrs, whereas nutritional feeding begins in 5-6 days of life. For infants between 1000 and 1500gms, nutritional feeding begins at 48hrs and is advanced a rate of less than 30ml/kg/day. The benefit and risks of continuous verses intermittent tube feeding were inconclusive.11
A descriptive study was conducted among 350 randomly selected staff nurses to identify variation in practices in the care of patients with the nasogastric tube. The result shows that wide variations were found in the gastric residual, considered as excessive in stomach. A large percentage of nurses rely on physicians order for gavage feeding rate, giving additional water and using the liquid form of medication. The researcher concluded that there is a need for improvement in theory-practice gap.15
A study was conducted on complication associated with enteral nutrition by nasogastric tube in an internal medicine unit among 64 patients who were fed by nasogastric tube. The result showed several kinds of complications such as diarrhoea, vomiting, constipation, lung aspiration, tube dislodgement, tube clogging, hyperglycaemia and electrolytic alteration. Hence the researcher suggested that need of nursing intervention by checking the gastric residue periodically, attempting to place the tube in the duodenum in the unconscious patients and the use of protective mittens in disturbed patients 13.
An experimental study was conducted on prevalence of feeding tube placement errors and associated risk factors in children. The tube placement error was defined as tube tip or orifices in the oesophagus or intestines. The hospital records of 201 children having both an enteral tube and at least one radiograph showing tube placement were retrospectically reviewed. Hence researcher concluded that nurses need to be especially careful in assessing tube placement if the paediatric patient has one or more of the identified risk factors.14
A study has been conducted for identifying non-invasive techniques and criteria for predicting the proper length for insertion of nasogastric tube such that the tube would be located in the fundus of the stomach. A revive of literature and existing practices revealed unsubstantiated and discrepant methods currently in use and justified the need for the research. The study involved relating several external body measurements from the tip of the nose to the lower oesophageal sphincter, via the oesophagus. A variety of analysis including stepwise multiple regression, were used and are presented. A formula is presented and stated to provide 91% confidence level of tube tip placement in the stomach between 1 and 10 cm. this is compared to a confidence level of 72% using the traditional nose to ear to xiphoid measurement. The formula is ((NEX-50cm)/2)+50cm where NEX is the distance from the tip of the earlobe to the xiphoid. Thus complications can be prevented by proper placement of the tube.9
A retrospective study was conducted on feeding dysfunctions in infants with severe chronic renal failure among 15 patients. The result showed that 13 patients had significant and persistent eating difficulty, with difficulty in chewing and swallowing in 7 and food refusal in 6. for 2 patients panic attacks from swallowing were repeatedly reported. Theses problem persisted for more than year in 5 patients and between 1 and 6 months in 4. The researcher concluded that a possible means of overcoming the difficulties that may follow nasogastric tube feeding might include: encouraging the use of a pacifier, proposing water for spontaneous consumption, leaving the child the possibility of eating food spontaneously during the day time, and increased support for the parents during weaning.16
A study was conducted on mechanical problem with small diameter enteral feeding tubes. They have suggested that the use of nasogastric feeding for nutritional support of hospitalised and home bound chronically ill individuals has been expanding during the past ten years. Nasogastric and naso enteral dimension is safer and more cost effective than total parenteral nutrition. Mechanical problem related to slowing of the formula and/or clogging of the tube have been reported, but have received little attention in the research literature. This explanatory survey was designed to determine the extend of mechanical problems and the procedures used to care for enteral feeding tubes. 58% of 91 hospitals reported a significant occurrence of mechanical problems with small diameter enteral feeding tubes, and only 31% had written procedure for care of the tube.12
6.3 Statement of the Problem
A STUDY TO ASSESS THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME (PTP) ON KNOWLEDGE AND PRACTICE OF NASOGASTRIC TUBE FEEDING AMONG THE NURSES WORKING IN PAEDIATRIC UNITS IN THE SELECTED HOSPITALS AT BAGALKOT.
6.4 Objectives of the Study
The objectives of the study are to:
1. Assess the level of knowledge and practice of nasogastric tube feeding before PTP among paediatric nurses.
2. Assess the level of knowledge and practice of nasogastric tube feeding after the PTP among paediatric nurses.
3. Correlate the pre and post-test knowledge scores and practice scores of nasogastric tube feeding
4. Correlate knowledge and practice scores with related demographic variables.
6.5 Operational Definitions
1. EFFECTIVENESS:
In this study effectiveness means the result of standard teaching programme for improving knowledge and practice of giving nasogastric tube feeding.
2. NURSES:
In this study the persons who are professionally qualified G.N.M. or B.Sc. nursing and registered by state nursing council and engaged in nursing care, especially in paediatric/ neonate ward.
3. KNOWLEDGE:
In this study knowledge means the response of nurses towards nasogastric tube feeding.
4. PRACTICE:
In this study, practice means activities followed by staff nurse in relation to nasogastric tube feeding procedure.
5. PLANNED TEACHING PROGRAMME:
In this study planned teaching programme refers to meaningful systematic planned teaching given to a group of nurses on nasogastric tube feeding.
6. NASOGASTRIC TUBE FEEDING:
Nasogastric tube feeding means giving liquid food to the child through tube inserted from the nose to the stomach, to provide nutrition to a critically ill child.
6.6 Assumptions
1. Staff nurses who are working in paediatric ward have some knowledge about nasogastric feeding.
2. Planned teaching programme improves knowledge and make practice better and reduce the complication of the paediatric patients who are receiving nasogastric tube feeding.
6.7 Hypotheses
At 0.05 level of significance.
H1: The planned teaching programme of nasogastric tube feeding will have a significant effect on knowledge and practice of nasogastric tube feeding among staff nurses of paediatric units.
6.8 Delimitations
The study is delimited to
Nurses working in paediatric unit with professional qualification of GNM OR BSc Nursing and registered under nursing council.
Nurses who can read and write English.
6.8 Projected outcome
The findings of the study will help the nurse to improve her knowledge and practice regarding nasogastric tube feeding.
7. / Material and Methods
7.1 Source of Data
The data will be collected from the nurses working in paediatric units of selected hospitals at Bagalkot.
7.1.1 Research Design
The research design adopted for the study is one group pre-test post-test experimental design.
7.1.2 Setting
The study will be conducted in paediatric units of selected hospitals at Bagalkot.
7.1.3 Population
In this study, the population consists of all the staff nurses working in the paediatric unit of selected hospitals at Bagalkot.
7.2 Method of Data Collection
7.2.1 Sampling Procedure
Sample for the present study will be selected by convenient method.
7.2.2 Sample Size
In this study the sample size will be 50 nurses working in paediatric unit in selected hospitals at Bagalkot.
7.2.3 Inclusion Criteria
1. Staff nurses who are working in the paediatric unit
2. Staff who had completed G.N.M. or BSc. Nursing and recognised by state nursing council.
3. Staff nurses who are willing to participate in the study.