Marie E. Riley, RN, Dip Adult Critical Care.
Staff Nurse, Cardiothoracic Intensive Care Unit, The General Infirmary at Leeds, LeedsProviding nutrition to hospitalised patients has long been acknowledged as an important component of their care. This paper reviews the author's attempts to provide evidence-based guidelines for such care within the intensive care environment (Box 1).
In order to identify the basis for nutritional intervention certain questions need to be answered. These are the same whatever the area of nursing:
It is evident from the literature that malnutrition is a common problem in the hospitalised patient (Lennard-Jones et al, 1995; Norton, 1996; Young, 1988). Overall, incidence is cited at around 40% (Lennard-Jones et al, 1995; Norton, 1996; Reilly et al, 1995). This malnutrition often has serious implications (Norton, 1996) (Box 2). Ultimately, the prevalence of minor complications is doubled, major complications trebled, hospital stay protracted and mortality increased four-fold (Dickerson, 1986; Holmes, 1998; Norton, 1996).
Many authors suggest that the consequences of malnutrition defined in Box 2 develop subtly and that warning signs are often missed (Reilly et al, 1995; Norton, 1996; Sizer, 1996), thereby highlighting the need for adequate assessment. Variations on the components of assessment considered appropriate exist. These include body mass index (BMI), weight loss (amount and duration), food intake and the ability to retain food. The inability to eat independently (Norton, 1996), height, weight and biochemical factors, including alterations in serum albumin and vitamin levels, should also be taken into consideration (TWENG, 2001; Verity, 1996). Stress factors ranging from minor surgery to multiple trauma exacerbate any problems (Reilly et al, 1995).
Having shown that the detrimental effects of malnutrition are multiple (Box 2) decisions have to be made about the timing and type of any intervention. Bower et al (1995) identify the ability of nutrition to support immune function while correcting nutritional deficits. Chan et al (1999) give unsupported and uncorroborated advice that enteral nutrition does not improve outcome if used for less than a week. However, McClave et al (1999) suggest that even two days of non-feeding can have deleterious effects that are not easily corrected by re-feeding. Finally, Bradley (2001) identifies an improved survival in those patients receiving early enteral feeding.
There are no easy answers to the ethical and legal issues surrounding nutrition. The provision of quality nutritional care is underpinned by the need to consider and meet with its ethical and legal requirements. While oral nutrition is defined as basic care, enteral and parenteral interventions are considered to be treatments (MacFie, 2000). Basic care is a right which can never be denied to a patient who does not refuse it; whereas treatment is not always compulsory (MacFie, 2000). The main areas for consideration include:
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