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Critical illness places tremendous stress on the body, leading to a series of metabolic changes and resultant malnutrition, complications ensue, with morbidity and mortality rates increase (Sanchez Alvarez, Zabarte Martinez de Aguirre & Bordeje Laguna, 2011). Optimum nutrition support has been found to be crucial in counteracting the accelerated metabolism as well as prevention and management of malnutrition caused by critical illness (Ramakrishnan, Daphnee & Ranagnathan, 2014).
Different types of feeds and methods of feeding are available, none of which have been proved to be superior. Recent studies strongly suggest that patients who receive enteral nutrition (EN) show better outcomes than those on parenteral nutrition (PN) and that EN feeding protocols can improve inadequate delivery of calories and protein with a very slight increase in complications (Taylor, Brody, Denmark, Southard, & Byham-Gray, 2014). Whichever feed or method of feed is chosen, the critical care nurse (CCN) should know the advantages and disadvantages involved as well special considerations regarding each type, be aware of patients at risk of nutrition intolerance management thereof. CCNs play an important role in ensuring that set nutritional targets are met as well as tolerance monitoring and adequacy assessment of nutrition support in critically ill.
Marshall, Cahill, Gramlich, MacDonald, Alberda and Heyland (2012) attest to a consistently revealed wide variation in nutritional practices across intensive care units which leads to suboptimal provision nutrition to critically ill patients. Monitoring and evaluating the effects of nutritional support on clinical outcomes requires a multidisciplinary approach, but CCNs are required to take the lead due to their constant contact with the patients (Urden et al., 2010). The South African Nursing Council (SANC) regulation 2598 of 1984 on the scope of practice of a registered nurse state that a registered nurse should facilitate the maintenance of adequate nutrition of a patient.
Marshall, Cahill, Gramlich, MacDonald, Alberda, & Heyland (2012) recommend the development of evidence-based enteral feeding guidelines as one important step to a consistent approach in ensuring adequate prescription and provision of nutritional support. These guidelines should guide the formulation of nurse-initiated nutritional protocols which should be readily available in each critical care unit (Kreymann, 2010). The non-availability of nutritional protocols to guide the practice may result in inadequacy in the delivery of nutritional support; increased morbidity; prolonged stay in ICU; and an increased mortality rate. This could increase the financial burden on the patients and their families, on institutions, as well as on the state. It is therefore important that nutritional protocols are available in the critical care units and that all the nurses should be familiar with them to effectively monitor tolerance and adequacy of nutritional support, particularly EN.
Methodology
A descriptive correlational design was used to explore the clinical practices relating to how nutritional support to hospitalised critically ill patients is provided, monitored and evaluated by registered nurses. Seventy registered nurses were conveniently selected from the critical care units in the selected hospitals in East London, data were collected from them using questionnaires and statistical analysis was used to detect correlations. Careful assessment of predictable risks as compared to foreseeable benefits to respondents was done, the institutions were protected from harm and the scientific integrity of the research community was respected.
Results
About 60% of the nurses attested to availability of standard protocols for monitoring patient tolerance to nutritional support in their units. Fifty eight percent of nurses confirmed that the algorithm for monitoring tolerance and managing intolerances is clearly stated in these protocols. However, despite the availability of protocols, about half of the respondents agreed that the normal residual gastric volume is 100 ml, 10.6% (n = 7) felt that it was 200 ml, with the rest putting it at 500 ml, which is a wide variation of opinions.
Only twenty seven (39%) nurses agreed on the usefulness of X-rays in monitoring nutritional adequacy and 28.8% (n=19) out of a total of seventy (70) nurses believe in volume tolerance checking. Some nurses, about 43.3% were not sure about the effectiveness of intake and output records for assessing adequacy of nutritional support.
Discussion
Affirming the important role that that CCNs play in evaluating feeding tolerance and adequacy of delivery, research studies report that when nurses complied with feeding protocols, patient outcomes improved (Urden et al., (2010), Woien and Bjork (2006). In support, nurses in this study agree with most of the items recommended for monitoring of tolerance of nutrition in the critically ill. About 60% agreed that there is a standard protocol for monitoring patient tolerance to nutritional support in their units, with 54.4% agreeing that the protocols clearly state the procedures to be followed in monitoring tolerance (algorithms). About 55.2% (n = 39) concur on that their protocols even state the management of intolerances. However, if they are not sure of the importance of chest and abdominal X-rays in monitoring tolerance and ensuring adequacy of nutrition delivery, there is a huge problem. Patients at risk of nutritional intolerance include those with gastroparesis, poorly controlled diabetes mellitus, gastric obstruction, ileus, recent surgery, trauma and those on heavy sedation (Lessler, 2010). Abdominal and chest X-rays are crucial in the diagnosis of these conditions.
One other aspect which emerged from the results was that about half of the respondents were of the opinion that the normal residual gastric volume is 100 ml and only 10.6% (n = 7) felt it was 200 ml, with the rest putting it up to 500 ml. This variation of opinions is another area of concern as it results in suboptimal provision of nutritional support (Marshall et al., 2012). Current evidence shows high GRV ranges from 150 to 500 mL of an aspirate, but a single elevated GRV requires no action, only on-going monitoring (Makic, Rauen & Von Rueden, 2013). On the other hand, Kreymann (2010) suggests that inappropriate cessation of EN should be avoided. Holding EN for gastric residual volumes < 500 mL in the absence of other signs of intolerance is not necessary. Reduction of the feed rate or cessation of the feed is believed to deprive patients of nutritional intake, thereby exposing them to the risk of malnutrition. The concern is that, if more than half of the nurses think that a GRV of 200 to 500 millilitres is high, patients are at a risk of being underfed. Fessler (2010) suggests that other means of managing intolerance be used instead of stopping the feed.
RECOMMENDATIONS FOR IMPLEMENTATION
This study makes the following recommendations:
Recommendations for practice
Nurses need to take a lead in the provision, monitoring and assessment of nutritional delivery to patients because of their constant contact with patients. The most important step recommended to achieve their goal is the development of nurse-led feeding protocols with tolerance monitoring and adequacy assessment algorithms. Through critical analysis of the nutritional support, they should be able to identify patients at risk of feed intolerance. Such information may assist in the development of strategies to monitor and manage nutrition intolerances and increase adequate delivery of nutrients to the critically ill, thus, decreasing morbidity and mortality rates. This can ensure compliance with the South African Department of Health ministerial priorities and WHO recommendations. The result can be the improvement in nursing care practice, as well as a considerable relief in the financial burden associated with the hospitalisation of the critically ill in both public and private hospitals. Efforts should be made to popularise nutritional protocols as well as algorithms for monitoring of tolerance and evaluation of adequacy of nutritional support to all nurses in an institution. Research has proven that there are no standardised methods of checking GRVs (Fessler, 2010).
Recommendations for education
A joint effort by the hospitals and nursing colleges, both public and private, through hospital-based nutritional workshops can have a huge contribution in improving nurses' knowledge on the provision, monitoring and evaluation of nutritional support of ciritically ill patients. Research studies have shown that there is a problem in using methods like GRVs for monitoring nutrition tolerance due to misinterpretation and misunderstanding of such methods (Fessler, 2010). Inclusion of topics on nutritional support monitoring and evaluation in in-service trainings and continuous professional development programmes is recommended Nutritional support should be emphasised in curricula in academic programmes particularly in critical care nursing to bridge the knowledge gaps with regard to nutritional support as an important part of nursing management of the critically ill patients.
Education for patients
Empowerment of patients and their relatives with knowledge about the importance adequate nutritional support during critical illness and symptoms of feed intolerances can promote cooperation and active involvement in the nursing management of the patients. The outcome could be speedy recovery and resultant reduction in complications, the costs of hospitalisation.
Recommendations for further research
Development of theoretical and conceptual frameworks through qualitative research can be provide a knowledge foundation for the development of the practicable and safe nurse-developed nutrition protocols and algorithms. Challenges facing registered nurses in the provision of nutritional support as well as the use and effects of immune boosting and nutrition tolerance enhancing supplements during illness should be further investigated.