الفهرس 
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Abstract
Critically ill patients are usually unable to maintain adequate oral intake to meet their metabolic demands. They cannot be fed orally because of their disease or condition (e.g., gastrointestinal, trauma, Mechanical Ventilation, risk of aspiration). These physical stressors induce a catabolic response, leading to muscle wasting and weakness, longer Intensive Care Unit length of stay and poor outcome. So, these patients need their basic energy supplemented through enteral and parenteral nutrition. Nutritional support therefore plays an important role in caring for patients in the ICU (Lee et al., 2023).
Enteral nutrition is the most common means of providing nutritional support because it is convenient, safe and effective, which not only could reduce the risk of serious complications in patients but also help patients to restore normal intestinal function, reduce infectious complications and shortening the length of stay in the ICU (Jeong et al., 2023; O’Connor et al., 2023). Although EN provided statistically significant benefits to patients, a complication emerges feeding intolerance which include increase gastric residual volume and several gastrointestinal disorders (Wang et al., 2023; Zhang et al.,2023).
Care bundle of enteral feeding that can be performed by critical care nurses to prevent enteral feeding complications in critically ill patients is a safe, inexpensive, and noninvasive intervention that minimizes side effects, reduces gastric residual volume, reduces gastric distension, reduces constipation, and facilitates patient comfort, indicating an increase in gastrointestinal function, reduces the incidence of enteral feeding complications and optimize nutrition in critically ill patients (Thong et al., 2022).
Purpose of the study
The purpose of the current study was to evaluate the effect of implementing care bundle to prevent enteral feeding complications in critically ill patients.
Research Design: - A quasi-experimental design (study /control) was utilized to test study hypotheses.
Setting: -
The current study was conducted at the neurosurgical and medical intensive care units, at Menoufia University Hospital, Menoufia Governorate, Shebin El-kom, Egypt.
Sample: -
A convenient sample of 80 patients who were admitted to the neurosurgical and medical ICUs of university hospital of Menoufia university were approached over 12 months from the beginning of May 2022 to the end of April 2023. These patients met the following inclusion criteria a) adult patients from both gender, age from 18 to 65 years old; b) patients with newly inserted nasogastric tube for bolus enteral feeding and tolerate enteral feeding; and c) patients who Hemodynamically stable. Patients were excluded to participate in the study if they had any of the following conditions a) patients whose ICU length of stays less than 48 hours; b) Patients with hemodynamic instability (decrease BL.P may predispose to bowel ischemia); c) patients who have any contraindications to abdominal massage such as diarrhea, active bleeding, spinal cord injury or recent abdominal surgery and pregnancy; and d) patients who have any contraindications to entral feeding such as (bowel ischemia or necrosis, small or large bowel obstruction, Paralytic ileus, Diverticular disease and Fistula in the small bowel).
Instruments
In order to achieve the purpose of the present study, the following instruments were used:
I) Demographic and Clinical Data Sheet: developed by the researcher and included data about patient’s age, gender, past medical history, admission date, current diagnosis, duration of mechanical ventilation and ICU length of stay.
II) Modified Nutrition Risk Assessment in Critically ill (mNUTRIC): to identify patients at risk for malnutrition.
III) Acute Physiology and chronic Health Evaluation II (APACHE II) Scale: to measure the mortality indicator for adult patients admitted to ICU.
IV) Sequential Organ Failure Assessment (SOFA) Score: to estimate the morbidity and mortality for critically ill patients according to the level of organ dysfunction.
V) Observational Sheet: A sheet designed by the researcher to assess enteral feeding complications which include the presence and frequency of diarrhea, constipation, vomiting, abdominal distension and the amount of gastric residual volume as observed and recorded by the researcher.
Ethical Consideration
The Research Ethical Committee at the Faculty of Nursing granted written approval to conduct the study, with an assigned approval number (Ethics code 863) and an official permission was obtained by the researcher from hospital director to conduct the study after explaining the purpose of the study. A written consent was obtained from patient’s relatives to participate in the study after explanation of the purpose, procedure and benefits of the study and the researcher explained to patients’ relatives that participation in the study is voluntary and they can withdraw from the study at any time without any negative impact on their course of treatment. Confidentiality and anonymity of patient information was assured through coding all data and keeping all data in a secured cabinet.
Data Collection Procedure
Data were collected over 12 months from the beginning of May 2022 to the end of April 2023. The participants were recruited to participate in the study after 24 hours of ICU admission and after stabilization of the condition. The participants were matched against the study inclusion criteria. The researcher handled the control group first to prevent contamination of data. The control group received the routine hospital care only which includes measuring gastric residual volume and sometime rinsing nasal feeding tube after nasal feeding. Study group received the care bundle of enteral feeding.
Result
• The mean age of the participants in the study and the control group was (51.88 ± 8.812 and 53.28 ± 7.504) years old respectively. Regarding sex, more than half of the participants in both study and control groups were male 55.0% and 60.0% respectively. Concerning ICU diagnosis, about (22.5%) and (25.0%) of participants in the study and control group had Respiratory Failure respectively. Regarding past medical history, (22.5%) in the study group had Diabetes Mellitus & (22.5%) in the control group had Hypertension. There was no statistically significant difference in the demographic characteristics between both groups (p value= >0.05).
• The mean APACHE II score was (20.23 ± 3.254 & 20.43 ± 3.096) in the study and the control group respectively pre intervention. Regarding mean score of SOFA was (11.35 ± 1.875&11.93 ± 1.831) in the study and the control group respectively pre intervention. There was no statistically significant difference between both groups regarding the severity of disease and comorbidity.
• There is statistically significant difference between the study and the control group regarding occurrence of enteral feeding complications post intervention with percentage of the study and the control group regarding occurrence of Diarrhea (10.0%) (32.5%) respectively, Vomiting (10.0%) (35.0%) respectively, Constipation (7.5%) (25.0%) respectively, Abdominal Distention (7.5%) (25.0%) respectively and High gastric residual volume (12.5%) (37.5%) respectively post intervention (p value<0.05).
• There is a highly statistically significant improvement in the nutritional status with mean score of mNUTRIC in the study group (2.75 ± 1.171) compared to control group(4.65 ± 1.406) post intervention (p<0.000).
• There is a highly statistically significant reduction in the mean duration of mechanical ventilation in the study group (4.13 ± 1.43) days compared to (6.18 ± 2.17) days in the control group post intervention (P< 0.000). Also, there is a highly statistically significant decrease in the mean score of the ICU length of stay in the study group
(7.13 ± 1.95) compared to the control group (9.05 ± 2.12) post intervention (P< 0.000).
• There is a statistically significant positive correlation between enteral feeding complications and duration of MV between the study and the control groups post intervention with r = 0.378 (P< 0.025) and r = 0.475 (P< 0.004) respectively. Also, there is a statistically significant positive correlation between enteral feeding complications and ICU length of stay r = 0.356 (P< 0.036) and r= 0.819 (P< 0.000) respectively. Which indicate that the participants with lower enteral feeding complications had short duration of MV and ICU length of stay.
There is a positive relationship between APACHE II and enteral feeding complications
in both groups post intervention with r = 0.399 (P< 0.011) in the study group and r =
0.241 (P< 0.013) in the control group. Also, there is a positive relationship between
SOFA and enteral feeding complications in both groups post intervention with r =
0.391 (P< 0.013) in the study group and r= 0.163 (P< 0.025) in the control group.
Which indicate that participant who had low mean score of APACHE II and SOFA score had lower incidence of enteral feeding complications.
• CONCLUSION
The present study findings supported the use of care bundle of enteral feeding in clinical practice as an effective, safe and feasible nursing intervention that has a positive effect on reducing enteral feeding complications, improving nutritional status and reducing duration of mechanical ventilation and ICU length of stay among critically ill patients.
RECOMMENDATIONS
Implication for Nursing Practice
• Care bundle of enteral feeding should be incorporated as a routine practice in the ICU to prevent the enteral feeding complications and promote patient’s nutritional status.
• Continuing training for critical care nurses to practice care bundle of enteral feeding as a regular procedure of critically ill patients is crucial.
Implication for Future Research
• Replication of the study with large probability sample and different geographical area is recommended.