Rajiv Gandhi University of Health Scienceskarnataka

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCESKARNATAKA,

BANGALORE

“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING ENTERAL FEEDING IN CHILDREN AMONG STAFF NURSES IN SELECTED HOSPITALS AT MYSORE.”

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

Mr. JOBIN G.PANICKER

I YEAR M.Sc NURSING

PAEDIATRIC NURSING

COLLEGE OF NURSING,

GOPALA GOWDA SHANTHAVERI MEMORIAL HOSPITAL TRUST ®

T.N. PURA ROAD, NAZARBAD

MYSORE-570010

KARNATAKA

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

PROFORMA SYNOPSIS FOR REGISTERATION OF SUBJECT FOR DISSERTATION

1. / Name of the Candidate and Address / Mr. JOBING. PANICKER,
M.Sc NURSING 1ST YEAR,
COLLEGE OF NURSING,
GOPALA GOWDA SHANTHVERI MEMORIAL HOSPITAL TRUST®,
T.N. PURA ROAD, NAZARBAD,
MYSORE-570010
2. / Name of the Institution / College Of Nursing,
Gopala Gowda Shanthaveri Memorial Hospital Trust®.
3. / Course of study and subject / 1st Year M.Sc Nursing,
Paediatric nursing.
4. / Date of admission to course / 04-07-2011
5. / Title of the Topic:
“Effectiveness Of Structured Teaching Programme On Knowledge Regarding Enteral Feeding In ChildrenAmong Staff Nurses”
6. / Brief resume of the intended work:
6.1 Need for the study
6.2 Review of literature
6.3 Objectives of the study
6.4 Operational definitions
6.5 Hypothesis of the study
6.6 Assumptions
6.7 Delimitations of the study
6.8 Pilot study
6.9 Variables / Enclosed
Enclosed
Enclosed
Enclosed
Enclosed
Enclosed
Enclosed
Enclosed
Enclosed
7. / Materials and methods:
7.1 Source of data:Staff nurses working in a selected hospitals at Mysore.
7.2 Methods of data collection- The data will be collected after obtaining permission from concerned authorities by using a baseline proforma and a structured questionnaire.
7.3 Does the study require any interventions or investigation to the patients or other human being or animals? Yes, Structured teaching programme will be administered to the selected samples.
7.4 Has ethical clearance been obtained from your institution?
Yes, ethical committee’s report is here with enclosed.
8. / List of references / Enclosed

Rajiv Gandhi University of Health Sciences, Karnataka,Bangalore.

PROFORMA SYNOPSIS FOR REGISTERATION OF SUBJECT FOR DISSERTATION

6. BRIEF RESUME OF THE INTENDED WORK.

INTRODUCTION:

“The first wealth is health.” ~ Emerson

Nutrition as a new field of study is about one hundred years old. Even though Hippocrates had recognized dieton a component of health as early as300BC,only in the past one hundred years people began to realize theimportance of carbohydrates,lipids and proteins for normal growth and development.Good nutrition maintains health as well as promotes normal growth and development.1

A poor diet can have an injurious impact on health, causing deficiency diseases such asscurvyandkwashiorkor;health-threatening conditions likeobesityandmetabolic syndromeand common chronic systemic diseases likecardiovascular disease,diabetesandosteoporosis.Many children with different medical problems receive treatment with a nasogastric tube (NG) or gastrostomy tube (GT). Children may need these tubes for several reasons. The child may not be able to eat at all, or may not eat enough to meet their nutritional requirements, or they may not be able to swallow safely.

Enteral feeding is a way to deliver nutrients and medications through a tube when a person cannot take food or drink through the mouth. Possible reason for tube feedings are central nervous system problems, severe cerebral palsy, burns, head injury, after surgery,inherited metabolic disorders gastrointestinal diseases, severe gastro oesophageal reflux, failure to thrive, severe refusal of food, severe food allergy, disorders of the oesophagus,abnormalities of the anatomy of the gastrointestinal tract, severe cleft lip/cleft palate andcancer of oesophagus.2

Enteral feeding is named according to the point the tube enters the body and the point where the nutrition is delivered. Basically, there are five types of enteral feeding. Nasogastric (NG) is from the nose to the stomach; nasoduodenal (ND) is from the nose to the duodenum, or the upper part of the small intestine; nasojejunal (NJ) from the nose to the jejunum, or the middle part of the small intestine; gastrostomy (GT) from a surgical opening in the skin through abdomen into the stomach and jejunostomy (JT) from a surgical opening in the skin through the abdomen to the jejunum. The type of tube feeding chosen will be depended on the child's condition and how long the tube is anticipated to be in place.

Nasogastric feedings are done via a small tube that is in the nose and runs to the stomach. Some children receive all nutrition from NG feedings, while others get supplementary feedings via the tube. NG feedings do not require surgery for tube placement and are favoured for short-term tube feedings. Minor complications can be a sore throat, nose bleeds and sinusitis.3

Nasoduodenal feeding tubes allow for enteral nutrition when gastric stasis and/or aspiration risk precludes the NG route.Nasoduodenal feeding tubescan be placed manually (blindly at the bedside or intraoperatively), endoscopically, or by fluoroscopic technique.It must be managed carefully in order to ensure safe and cost-effective enteral nutrition.

Nasojejunal feeding is favoured when child cannot eat by mouth or hold food in the stomach,so giving feeding through a tube that is placed innose just passes the stomach into small bowel (jejunum).Nasojejunal tubes are for feeding only with an enteral pump. Bolus feeding cannot be given through the NJ tube.

Agastrostomytubeisatubeinsertedthroughtheabdomenthatdeliversnutritiondirectlytothestomach.Gastrostomy is favoured for long-term enteral feeding and can last for up to six months, with replacement not requiring surgery. Complications include infection, tube migration, tube malfunction and the local skin irritation.

Jejunal feeding is used for children who are unable to use their upper gastrointestinal (GI) tract because of congenital anomalies, GI surgery, immature or inadequate gastric motility and severe gastric reflux or a high risk of aspiration. The jejunal tube bypasses the stomach decreasing the risk of gastric reflux and aspiration.4

Enteral feedings are administered either on a continuous or intermittent basis. Continuous feedings are used to prevent GI intolerance and minimize risk of aspiration. Intermittent feedings may be used in medically stable patients who have adequate absorptive capacity to tolerate bolus feedings. An enteral infusion device (feeding pump) may enhance the safety and accuracy of enteral feedings.5Enteral feedingplays a role in both short-term rehabilitation and long-term nutritional management. The extent of its use ranges from supportive therapy, in which the tube supplies a portion of the needed nutrients, to primary therapy in which the tube delivers all the necessary nutrients. Most children receiving enteral feedings may continue to receive oral feedings to fulfill the pleasurable and social aspects of eating because all infants and young children require oral-motor stimulation for developmental reasons.

Possible complications of enteral feeding includediarrhoea, constipation, nausea, vomiting,abdominal cramping, breakdown of the skin surrounding the feeding tube, infection of stoma, hyperglycaemia, aspiration, and clogging or dislodgment of feeding tube.6 Nursing management of patients receiving enteral feedings encompasses patient instruction, tube insertion and placement confirmation, securing the tube, monitoring the patient during administration of enteral feedings and maintaining tube function, providing oral and nasal hygiene, assessing and preventing complications, and tube removal.

6.1 NEED FOR STUDY:

Enteral feeding refers to the delivery of a nutritionally complete feed, containing protein, carbohydrate, fat, water, minerals and vitamins, directly into the stomach, duodenum or jejunum. Enteral feeding should be considered for malnourished patients, or in those at risk ofmalnutritionwho have a functional gastrointestinal tract but are unable to maintain an adequate or safe oral intake.7

Enteral feeding is considered a relatively safe method of providing nutritional support to high-risk neonates. Nonetheless, there are associated risks, which could be classified as follows factors to consider before initiating enteral feeding, feeding tube placement, delivery of milk feedings, gastrointestinal, environmental and technical factors.8Nurses working in neonatal units must be aware of these factors to ensure safe and comfortable care for high-risk neonates receiving enteral feedings.

Enteral feeding is particularly beneficial for critically ill patients to promotethe gut barrier integrity and reduces rates of infection and mortality. It is beneficial for postoperative patients with limited oral intake. Early enteral feeding aftergastrointestinal surgery reduces the complication rate and duration of hospital stay. Although gastric and colonic function is impaired postoperatively, early post-pyloric feeding (duodenal or jejunal) will be useful as small bowel function is often normal.Feeding is usually introduced after 1 to 5 days. Inpatients with severepancreatitis, without pseudo cyst or fistula complication, enteral feeding promotes the resolution of inflammation and reduces the incidence of infection. Low flow enteral feeding may also be useful in combination withparenteral nutritionto maintain gut function and reduce the likelihood ofcholestasis.9

Health care professionals should aim to provide adequate nutrition to every patient unless prolongation of life is not in the patient’s best interest. It should be the hospital policy to record“admission nutritional screening”results in the notes of all patients with serious illness or those needing major surgery.Nutritional screening involves consideration of a patient’s weight for height and recent history of weight loss. Biochemical measurements also can be used for this purpose. 10

Artificial nutritional support is needed when oral intake is absent or likely to be absent for a period exceeding 5–7 days. Earlier instigation may be needed in malnourished patients. Support may also be needed in patients with inadequate oral intake over longer periods. Decisions on route, content and management of nutritional support are best made by multidisciplinary nutrition teams. Enteral Tube Feeding(ETF) can be used in unconscious patients, those with swallowing disorders, and those with partial intestinal failure. It may be appropriate in some cases of anorexia nervosa also.Nutritional support should also be considered in all patients with excessive nutrient losses such as vomiting, diarrhoea, or fistulae along with those who have high potential demands for nutrients like surgical stress, trauma, infection and metabolic diseases. 11

Aquasi-experimental research design with pre-post intervention assessments was done on Educational outcomes. It was associated with providing a comprehensive guidelines program about nursing care of preterm neonates received total parenteral nutrition. The study was conducted in NICU at Ain Shams University Hospital in Cairo, Egypt. Data was collected using a self-administered questionnaire sheet and an observation checklist and developed a comprehensive guidelines program about nursing care of TPN of preterm neonates. Results revealed that the program had a significant positive impact on nurses’ knowledge and practice outcomes.12

Blind placement of a feeding tube by the nurses can result in serious complications. Given the widespread use of tube feedings, even a small percentage of such problems can affect a significant number of people. Therefore it is extremely importantthat the nurses and health care professionals should be provided with all possible information regarding this.

A study was conducted to describe recent reports of feeding tube placement problems and to examine possible solutions. Multiple case reports of complications of malpositioned feeding tubes continue to surface; most are due to inadvertent placement in the respiratory tract. A tube with feeding ports in the esophagus, and the displacement of a small bowel tube into the stomach of a patient with significantly slowed gastric motility significantly increased the risk for aspiration. Isolated reports of a nasally placed tube entering the brain following head injury also identified as per the reports, of esophageal and gastric perforation in neonates. A recent study showed that malpositioned tubes are not routinely recorded in risk management databases; it further demonstrated that a comprehensive intervention to reduce complications from small-bore nasogastric feeding tubes was effective. The study concluded that, complications related to malpositioned feeding tubes were usually preventable if effective protocols were adodted.13

It has long been recognised that nursing care which promotes nutritional intake when and as appropriate can aid recovery from illness and enhance the quality of life of patients. Recently there has been growing concern that nurses do not pay sufficient attention to the nutritional needs of patients or clients.

Nutritional support, as complete enteral tube feeding, is needed by many paediatric patients and must provide sufficient nutrients for normal growth and development. Enteral feeding is an effective method with good result. The researcher observed that many of the nursing personnel’s were followingimproper methods of tube insertion, placement, feeding and care of enteral feeding. Hence the researcher felt to conduct a research study to improve the knowledge of staff nurses regarding enteral feeding. The structured teaching programmewould provide opportunity for knowledge enhancement of nursesand undeniably benefit children receiving enteral feeding.

6.2REVIEW OF LITERATURE:

A study was conducted to monitor the enteral nutrition support tolerance in Infants and Children. Enteral nutrition support was used extensively in the care of infants and children, both for acute and chronic conditions. Monitoring a child's tolerance of enteral feedings is an ongoing challenge. Monitoring routines vary significantly between institutions, practitioners, and patient settings, and a number of definitions are used for intolerance. Some guidelines have scientific basis and others are passed along in a more anecdotal fashion. This review described commonly used monitors for tolerance to enteral nutrition for infants and children and discussed pertinent data relevant to practice.14

A study was conducted in Brazil to describe the nutrition therapy (NT)used in a tertiary paediatric intensive care unit (PICU). The authors evaluated NT administered to 90 consecutive patients who were hospitalized for 7 days in the PICU. NT was established according to the protocol provided by the institution’s NT team. NT provided a balance of fluids and nutrients and was monitored with a weekly anthropometric nutrition assessment and an evaluation of complications.The result of study stated that NT was initiated, on average, within 72 hours of hospitalization. Most children (80%) received enteral nutrition (EN) therapy; of these, 35% were fed orally and the rest via nasogastric or post pyloric tube. There were gastrointestinal complications in patients (5%) who needed a post pyloric tube. Parenteral nutrition (PN) was used in only 10% of the cases, and the remaining 10% received mixed NT (EN + PN). The average calorie and protein intake was 82 kcal/kg and 2.7 g/kg per day. Arm circumference and triceps skin fold thickness decreased. The study concluded that the use of EN was prevalent in the tertiary PICU, and few clinical complications occurred. There was no statistically significant change in most anthropometric indicators evaluated during hospitalization, which suggested that NT probably helped patients maintain their nutritional status.15

An article reviewed the current literature and report on the author's experience of routine feeding jejunostomy insertion following oesophagectomy. The records of forty-eight consecutive patients undergone oesphagectomy under the author's care were reviewed. Although the evidence of benefit of pre-operative feeding in patients undergoing oesophagectomy was limited, there was a clear need to establish a feeding route at the time of surgery. Oesophagectomy wouldassociate with a mortality rate of 5-10% and a morbidity rate of 30-40% even in high-volume specialist centers. Over 50% of patients developed complications would require an alternative to oral feeding beyond 30 days. The enteral route was preferred in terms of safety and cost. A surgical feeding jejunostomy was associated with a low complication rate and a mortality rate of less than 1%. In forty-eight patients undergone oesophagectomy the average weight loss at 6 months was 8·4 kg with only 8% regaining their pre-operative weight. Large reductions in weight at 6 months post-operatively were recorded irrespective of the development of post-operative complications or early recurrent disease. The study concluded thatroutine jejunostomy insertion was recommended to ensure adequate nutrition in patients who developed post-operative complications and for those patients with long-term reduced appetite and poor oral intake.16

A retrospective analysis was done on enteral feeding in children with Crohn's disease(CD) aimed to demonstrate the short-term benefits of enteral feeding in children upon disease activity and nutrition parameters.Twenty-seven children received exclusiveenteral feeding (EEN) with polymeric formulae. Fifteen children had newly diagnosed CD and 12 had known long-standing CD. Twenty-four children completed the prescribed period of EEN. Twelve of 15 (80%) newly diagnosed CD and seven of 12 (58%) with long-standing disease entered remission. Children with newly diagnosed CD responding to EEN took all feeds orally and gained an average of 4.7+/-3.5 kg with mean PCDAI decreased from 37.1+/-10.8 to 6.7+/-5.1 after 8 weeks. In addition, four children continued supplementary polymeric formula (without other medical therapies) and all had maintained remission during an average follow-up period of 15.2 months. The study concluded that exclusive enteral feeds induced remission in 80% of children with newly diagnosed CD (on intention-to-treat basis) when used as sole initial therapy while also improved nutritional status. All newly diagnosed children treated with EEN, who were able to establish feeds, achieved remission.17

A descriptive survey was conducted to study the characteristics of obstruction of enteral feeding catheters in ICU patients and current knowledge and practices of ICU nurses of administering medications at a relevant seminar or in-service training through such catheters. A postcard invitation to participate in this descriptive survey was mailed to a random sample of 12,069 members of the American Association of Critical-Care Nurses. The 52-item investigator-designed questionnaire was mailed to the 1700 critical care nurses who agreed to participate; 1167 (68.6%) returned completed survey questionnaires. Nurses estimated that 33.8% of their patients received 8.9 doses of medication per day through the enteral feeding catheter. The rate of obstruction of the tube by medications was 15.6%. Crushed medications contributed to obstruction, although liquid forms of the medications often were available. Nurses' primary source of knowledge about administering medications through enteral feeding catheters was clinical practice (56.9%) and consultation with peers (21.7%); only 19% had had in-service training on the topic. Written agency guidelines varied considerably, and 74% of nurses used two or more techniques that were contrary to recommendations. Factors significantly associated with lower rates of obstruction of enteral feeding catheters included assistance from the pharmacy service to ensure liquid forms of medications, nurses' attendance program, and not routinely crushing and administering enteric-coated or sustained-release medications through the enteral feeding catheter.18