Managing nasogastric tube feeding and maintaining nutrition

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. Maslows 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). . 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 tubes 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 nurses 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 nurses 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 patients 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.jhonsons 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 Jhonsons 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 implement ation 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 datas 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.Jhonsons 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 JHONSONS 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 Caregivers demographic variables -Age -Sex -Education -Occupation -Experience in feeding -instruction and supervision received -source of instruction -attitude -Lack of seriousness -Fear and anxiety

Contributors to the Evolution of American Higher Education System

The evolution of Higher Educational System the United States can be attributed from several components. Among these attributes are the 1944 GI Bill of Rights and the appointment of the President's Commission on Higher Education by President Truman in 1946. Such significant contributions not only greatly affected the American Education System during those times but also served as catalysts that continue to benefit the modern society. These also paved the way improvement, acceleration and the widening the system of education as well as has opened opportunities for Americans of past, present and future generations.The significant development of the American higher education system can be traced from the enactment by President Franklin Roosevelt on June 22, 1944 of the â€Å"GI Bill of Rights† which was also called as the â€Å"Servicemen's Readjustment Act of 1944† (cited in Greenberg, 2007, p. 47). The law changed the American economic and social standpoints since among i ts provisions provided veterans of World War II an easy and immediate financial assistance by means of unemployment insurance.Most importantly, the law gave American veterans big opportunities such as vocational and practical activities relating to college learning as well as free access to housing and business loans (Greenberg, 2007). One of the permanent legacies of the GI Bill of Rights is now the ordinary impression that anyone can and should have education irrespective of â€Å"age, sex, race, religion, or family status† (Greenberg, 2007, p. 49). The law was also noted for bringing back the veterans' interest in education, majority of who have not achieved even secondary diplomas because of the World War II.With the provision of a better quality of higher education which the veterans have longed for, the law provided a broad and lasting acceptance of the notion that learning, particularly post-secondary or college education is the Americans' pathway to an improved employ ment and life (Greenberg, 2007). Aside from providing Americans from all walks of life a practical access to higher education, the GI Bill of Rights has also altered the definition of college learning in public awareness starting from 1950s until today.Before the war, the system was characterized mostly by â€Å"private, liberal arts, small-college, rural, residential, elitist, and often discriminatory from institution to institution with respect to race and religion† (Greenberg, 2007, p. 50). However, the current higher education system now is noticeably public that centers on â€Å"occupational, technical, and scientific education, huge, urban-oriented, suitable for commuter attendance, and highly democratic† (Greenberg, 2007, p. 50).At present, the system focuses and offers quality cultural, learning and financial aspects of higher education instead of just authorization of the upper members of the society. Lastly, the law is best noted as one factor that led to tre mendous social change. Since there was shake up of perspectives as regards â€Å"sex, religion, and race,† the law subjected even the ordinary Americans to liberated ideas of the society by means of higher education (Greeberg, 2007, p. 51). Meanwhile, a lot of veterans returned to college or post-secondary education in 1946.The heavy influx of students and industrialization of the economy, however, overstressed the system, curriculum and facilities. Additionally, the increasing number of war veterans studying again aggravated the existing educational problems being experienced by regular college students. This is because the group of veterans has to struggle it out with the American youth in their pursuit of a quality higher education. Hence, both the two groups increased the demands of college education.However, government assets and means of instrument are unable to adapt with the requirements such as an increased enrollees as well as variety of needs and involvements of bo th the veterans and youth as college students (Alexander, 1998). With the above situation in 1946, President Truman established a â€Å"President's Commission on Higher Education† and said that â€Å"we should now reexamine our system of higher education in terms of its objectives, methods, and facilities; and in the light of the social role it has to play† (President's Commission on Higher Education, 1947).The committee was composed of 28 prominent and outstanding Americans such as professionals and laymen like George F. Zook. The group immediately worked and in December of 1947, made a 377-page report titled â€Å"Higher Education for American Democracy† which was composed of six volumes under the following titles: â€Å"Establishing the Goals, Equalizing and Expanding Individual Opportunity, Organizing Higher Education, Staffing Higher Education, Financing Higher Education and Resource Data† (President's Commission on Higher Education, 1947, pp.1-3, 5- 8, 25-29, 32-39, 47-49). With a task to carry out what President Truman has said and define the obligations of colleges and universities, the commissions worked it out with the said educational facilities but were initially unsatisfied with the results. This is because education experts noted an apprehensive sense of failure or defect in the system. They also felt that the facilities are unable to keep up with the pace of the ever-changing state of the system as the society.Additionally, they see a need to re-pattern everything in order to meet the needs and address the concerns of the veterans and youth students which eventually will bring out the effectiveness of the modern education and system and society Moreover, the escalating desire of Americans to aspire for college education and critical necessity for such effective system became the determining factors for the need to improve the execution of the conventional tasks.This, in effect, eventually enabled the system, to assume the new challenge such the as re-entry in college of war veterans as the growing number of youth students, who are both motivated to improve their worth as a free and educated Americans (Alexander, 1998). The above-cited commission and measure are both significant as they greatly contributed on the evolution of the American Higher Education System. This is because the improved system of American higher education enabled the achievement of a more quality of living and democracy in the country for the reason that the benefits equally extended to all citizens.The GI Bill of Rights and 1947 President's Commission on Higher Education have proven their existence and worth because they paved the way for renouncing the unfair education practices of discrimination and separation. Moreover, the said two contributors have resulted in leaders' realization of the importance of quality and accessible college education system and equal opportunities in life. Ultimately, higher education system sho uld be targeted at weakening as well as getting rid of learning discrimination and eventually establishing attitude that will offer the system freely accessible to all Americans. ReferencesAlexander, F. K. (1998). The President's Commission Higher Education for Democracy, 1947. The American College and University EOL 474. Retrieved June 20, 2008 from University of Illinois at Urbana-Champaign database. Greenberg, M. (2007). The GI Bill of Rights. Historians on America: Decisions that Made America (pp. 46-54). Washington, DC: U. S. Department of State's Bureau of International Information Programs President's Commission on Higher Education. (1947). Higher Education for American Democracy: A Report of the President's Commission on Higher Education. Washington, D. C. : Government Printing Office.a

Components of civic education Essay

The core meaning of civic education is that it is a subject that promotes civic knowledge, civic skills, civic values and civic dispositions. Civic knowledge is concerned with the content or what citizens out to know, it is thorough familiarization with what civic life constitutes. It is having an understanding about basic principles of democracy, politics, elections, institutions. Having the understanding of the rights and responsibilities, knowledge of what rights and responsibilities our political leaders have. Social relationships in the community entails levels of civic knowledge, an understanding that their different cultures. It is about having an understanding of current issues, the functionality of institutions and sustainable development. Civic skills, with regard to the three positions given on the meaning of civic education it promotes practical skills meaning service learning and common awareness hence for people to discharge their responsibilities and exercise their rig hts as citizens, the need for skills, participatory and intellectual capabilities becomes paramount. Intellectual skills in civics and government are inseparable from content, these skills are sometimes called thinking skills. The National Standards of Civics and Government categorize these skills as identifying and describing; explaining and analyzing; and evaluating, taking and defending positions in public affairs. A good civic education enables one to identify or give the meaning or significance of things that are tangible such as the flag, national monuments or civics and political events. It also enables one to give the meaning or significance of intangibles, such as ideals or concepts including patriotism, majority and minority rights, civil society, and constitutionalism. Civic disposition’s refers to the traits of private and public character essential to maintenance and improvement of constitutional democracy. Civic dispositions develop slowly as a result of what one learns and experiences in the home, school, community and organization of civil society. These experiences include understanding that democracy requires the responsible self governance of each individual; one cannot exist without the other. Traits of private character, such as moral responsibility, self discipline, and respect for the worth and human dignity of every individual are imperative. Traits of public character are public spiritedness, civility, respect for the rule of law, crucial/ critical mindedness and  willingness to listen, negotiate and compromise are inseparable to democracy’s success. These bring about the intention to be active in the community, to participate in civil society as well as in particular political community. The importance of civic dispositions, or the â€Å"habits of the heart† as Alexis de Tocqueville called them, can scarcely be overemphasized.

Winfield Scotts Relationships with the Various Presidents

1. Discuss and analyze in depth Winfield Scotts relationships with the various Presidents which he served under from James Monroe through Lincoln, the critical role he played in US history and challenges he faced while in serving his country. Popularly known as Old Fuss and Feathers for his notorious vanity, egoism and love of military pomp and ceremony, General Winfield Scott was one of the ablest soldiers in the United States between George Washington and Ulysses S. Grant, although he is far less well-remembered at written about than either one. He was not a graduate of West Pint but a lawyer in Virginia who was directly commissioned as a captain in 1808 and served from 1814 until his death in 1866 as a general. By the beginning of the Civil War in 1861, when he supported the Union side and devised a strategy to defeat the South, he was general-in-chief. Like other famous generals of his generation, including Andrew Jackson, William Henry Harrison and Zachary Taylor, he also sought the presidency, but his 1852 campaign was a disaster. As a supporter of the Federalist and later the Whig Parties, he was politically out of favor with almost all the presidents he served, including Thomas Jefferson, James Madison, Andrew Jac kson and James K. Polk. He opposed their expansionist policies as well, as did most members of his party, and was privately critical of most of the wars he fought. Jefferson and Madison planned to annex Canada in the War of 1812, although their