INTRODUCTION:

Nasogastric tube feeding also known as enteral feeding or enteral nutrition, refers to the administration of a nutritionally balanced liquefied food or formula, through a nasogastric tube inserted into stomach via nose. Nasogastric tube feeding shall be used to administer the necessary nutrient. it also used to ensure adequate caloric intake, to ensure the growth of the body, to increase energy, to improve lung function and to add fighting power during infection. so nasogastric tube is necessary to maintain adequate nutrition and hydration of the patient. The purposes of the Nasogastric tube feeding includes to provide adequate nourishment to patients who cannot feed themselves, to administer medication, to provide nourishment to patients who cannot be fed through mouth, e g. surgery in oral cavity, unconscious or comatosed state.

Gastric Residual Volume refers to the volume of fluid remaining in the stomach at a point in time during Nasogastric Tube Feeding. Withdraw this fluid via the feeding tube by pulling back on the plunger of a large (usually 60 ml) syringe at intervals typically ranging from four to eight hours. Ideally, most or all of the measured residual fluid should be replaced into the patient’s stomach to prevent fluid, electrolyte, and nutrient loss. For Bolus Feeding, the normal Gastric Residual Volume is less than 250 ml. For Continuous Feeding, the normal Gastric Residual Volume is less than 400 ml. Gastric Residual Volume was measured every 4 hour during Nasogastric Tube Feeding. High Gastric Residual Volume causes vomiting, aspiration pneumonia and regurgitation.

Gastric Residual Volume (GRV) is measured before each intermittent feeding for every 4 hours during feedings. In non critically ill patients, the intervals for checking GRV may be increased to every 6 to 8 hours after the tube feeding goal rate is achieved. Any aspirated fluid is readministered to the patient to prevent a loss of fluids, electrolytes, nutrients and medications that may be administered via the tube. High Gastric Residual Volume (GRV) should alert the nurse to examine the patient more closely but not necessarily stop the delivery of tube feedings.

Various techniques can be used to decrease the gastric residual volume and prevent aspiration include abdominal massage, keeping the head of bed elevated between 30 and 45 degrees, maintaining a continuous drip tube feeding schedule, administering prokinetic agents as prescribed and converting to small bowel tube feedings.

WHO (2001) stated that 34% of population with short bowel syndrome 26% with cancer and 22% with surgery need nasogastric tube feeding Nasogastric feeding related outcomes including safety and tolerance are presented in table 5 full tolerance was achieved in 73of 92 (79.3%). In India, 13.5% of stroke patients receive nasogastric tube feeding.

STATEMENT OF THE PROBLEM:

“A Study to assess the Effectiveness of Abdominal Massage on Gastric Residual Volume among critically ill patients with Nasogastric tube feeding in SMVMCH, Puducherry”.

OBJECTIVES:

1. To assess the level of Gastric Residual Volume among critically ill patients with Nasogastric tube feeding.

2. To evaluate the effectiveness of Abdominal Massage on Gastric Residual Volume among critically ill patients with Nasogastric tube feeding.

3. To associate the effectiveness of Abdominal Massage among critically ill patients with Nasogastric tube feeding.

OPERATIONAL DEFINITIONS:

Assess:

In this study, it refers to the process of measuring the level of Gastric Residual Volume among critically ill patients with Nasogastric tube feedingbefore and after performing Abdominal massage.

Effectiveness:

In this study, it refers to determining the extent to which practice of Abdominal Massageonreducing the level of Gastric Residual Volume among critically ill patients with Nasogastric tube feeding.

Abdominal Massage:

In this study, it refers to the form of five steps massage which can be used to decrease residual volume among critically ill patients.

Gastric Residual Volume:

In this study, it refers to the volume of fluid remaining in the stomach at a point in time during Nasogastric Tube Feeding.

Crtically Ill Patients:

In this study, it refers to the patients with severe and life-threatening illnesses and injuries which require constant, close monitoring and support from special equipment and medications in order to ensure normal bodily functions.

Nasogastric Tube Feeding:

In this study, it refers to the delivery of nutrients from the nasal route to stomach via the feeding tube.

ASSUMPTIONS:

It is assumed that,

· Critically Patients may have various levels of Gastric Residual Volume based on their severity of disease.

· Abdominal Massage will be effective in reduction of Gastric Residual Volume and it may be accepted as a mode of intervention in reducing the Gastric Residual Volume among critically ill patients with Nasogastric tube feeding.

HYPOTHESIS:

H1. There will be a significant difference in the level of Gastric Residual Volume before and after administration of Abdominal Massage among critically ill patients with Nasogastric tube feeding.

H2. There will be a significant association between the effectiveness of Abdominal Massage on Gastric Residual Volume among critically ill patients with Nasogastric tube feedingwith their selected demographic variables.

DELIMITATIONS:

· The study was delimited to Critically Ill patients who were admitted at SMVMCH.

· The study was delimited to 6 weeks period of data collection.

· The study can’t be generalized.

Farzadmomenfar et. al., (2017) has conducted the study on effectiveness of Abdominal massage on Gastric Residual Volume among critically ill patients in 2017 at Ahwaz. The aim of the study is to determining the effect of abdominal massage on the gastric residual volume in patients hospitalized in intensive care units. Samples were 60 patients hospitalized in intensive care units who were randomly divided into case and control groups. The intervention period for the case group was 3 days and twice daily for 20 min. Measuring the gastric residual volume was investigated before the intervention and 1 hour after the second massage each day.The gastric residual volume on the second and third day after the intervention was less than before the intervention (p value<0.05), the gastric residual volume before intervention with after intervention in the control group during different days, on each of the 3 days after the intervention, was more than before the intervention (p value<0.05), and the gastric residual volume after the intervention in different days and the mean of different days in the case group was lower than the control group (p value>0.05).

Ahmad et.al., (2017) has conducted the study of Nasogastric tube feedings and Gastric Residual Volume: a regional Survey. The study was aimed to maintain adequate nutrition for patients who are in need, enteral feeding via nasogastric tube (NGT) is necessary. Although the literature suggests the safety of continued NGT feeding at a gastric residual volume of <400 ml, inconsistencies in withholding tube feeding based on residual volume have been observed in clinical practice. We performed a regional survey to determine the range of current practice among nursing staff regarding the decision to withhold NGT feeding based on residual volume. Residual volumes (milliliters) resulting in the termination of NGT feeding occurred in 89% of nurses at volumes <300 ml and only 3% of nurses at volumes >400 ml. Three main reasons for nurses to withhold NGT feeding were risk of aspiration (90%), potential feeding intolerance (81%), and risk of regurgitation (67%). Other less common concerns were abdominal distension and abdominal discomfort.

MATERIALS AND METHODS:

It includes a description of research approach, research design, setting of the study, population, sample and sample size, sampling technique, sampling criteria, instrument, validity and reliability, pilot study, method of collection of data, plan for data analysis and interpretation and ethical implications of the study.

RESEARCH APPROACH:

A Quantitative Research approach was adopted for this present study.

RESEARCH DESIGN:

A Pre-experimental one group pre-test and post- test design was adopted for this present study.

STUDY VARIABLES:

Independent Variables: Abdominal Massage.

Dependent Variables: Gastric Residual Volume.

SETTING OF THE STUDY:

The study was conducted in Sri Manakula Vinayagar Medical College and Hospital, a 1050-bedded hospital in Puducherry. The hospital has a separate critical care unit consist of ICU, ICCU, RICU, SICU& Casualty. Among that ICU, ICCU, RICU consist of bed strength of 6 and SICU, Casualty consist of 20 bed strength respectively.

POPULATION:

All the Critically Ill patients who are all admitted in Sri Manakula Vinayagar Medical College and Hospital.

SAMPLE:

Critically Ill Patients who are all with Nasogastric Tube Feeding in Critical Care unit at Sri Manakula Vinayagar Medical College and Hospital, Puducherry.

SAMPLING TECHNIQUE:

Purposive Sampling Technique was selected for the present study.

CRITERIA FOR SAMPLE SELECTION:

Inclusion Criteria:

· Patients who is having Gastric residual volume of >100 ml.

· Both Male and Female.

· Patients with Nasogastric Tube feeding over a minimum period of 2 days and above.

· Patients above the age group of 30 yrs.

· Patients who are all willing to participate in this study.

Exclusion Criteria:

· Patients who underwent any abdominal surgeries.

· Patients who are not available at the time of data collection.

· Patients with nasogastric tube feeding for acute illness like poisoning.

TOOLS AND INSTRUMENTS:

Development of Data Collection Instruments:

· The data collection tool consists of 2 sections namely:

· Section A: Socio-Demographic Data

· Section B: Assessment of Gastric Residual Volume

Description of Data Collection Instruments:

Section A:

This section consist of Socio-demographic variables such as age, gender, occupation, marital status, education, previous history of nasogastric tube feeding, reason for nasogastric tube feeding, number of feeding per day, amount of feeding, rate of intervals per day.

Section B:

This section consists of Gastric Residual Volume assessment. The level of gastric residual volume was assessed by using the self-prepared assessment toolfor gastric residual volume.

SCORING	INTERPRETATION
1	Normal (<100 ml)
2	Low risk (100 ml – 150 ml)
3	High Risk (151 ml – 200 ml)
4	Very High Risk (>200 ml)

ANALYSIS AND INTERPRETATION:

TABLE – I: Frequency and percentage wise distribution of demographic variables among critically ill patients.

S. No	DEMOGRAPHIC VARIABLES	FREQUENCY	%
1	Age (in years)
	· 40-50	4	13.3
	· 51-60	4	13.3
	· 61-70	19	63.4
	· Above70	3	10.0
2	Gender
	· Male	20	66.7
	· Female	10	33.3
3	Marital status
	· Married	28	93.3
	· Single	2	6.7
4	Level of education
	· Non- literate	12	40.0
	· Primary level	9	30.0
	· Secondary level	6	20.0
	· Diploma	2	6.7
	· Degree	1	3.3
5	Employment status
	· Unemployed	18	60.0
	· Employee	12	40.0
6	Previous history of Nasogastric Tube Feeding
	· Yes (if yes, specify about duration)	1	3.3
	· No	29	96.7
7	Reason for Nasogasric Tube Feeding
	· Trauma	4	13.3
	· Unconsciousness	2	6.7
	· Neurological problems	15	50.0
	· Other disorders	9	30.0
8	Number of feeding per day(24hours)
	· 2-4 times	3	10.0
	· 5-7 times	15	50.0
	· 8-10 times	10	33.3
	· above 10 times	2	6.7
9	Amount of feeding
	· Less than 100 ml	0	0
	· 100-150 ml	9	30.0
	· 150-200 ml	18	60.0
	· 200-250 ml	3	10.0
10	Rate of intervals among feeding(in hours)
	· 2-3 hours	5	16.7
	· 4-5 hours	20	66.7
	· More than 5 hours	5	16.6

TABLE – II: Frequency and percentage wise distribution on level of gastric residual volume among critically ill patients. (N = 30)

S.NO	LEVEL OF GASTRIC RESIDUAL VOLUME	PRE - TEST		POST - TEST
S.NO	LEVEL OF GASTRIC RESIDUAL VOLUME	n	%	n	%
1	Normal (<100 ml)	01	03.3	27	90.0
2	Low risk (100 ml – 150 ml)	18	59.4	02	06.6
3	High Risk (151 ml – 200 ml)	09	29.7	01	03.3
4	Very High Risk (>200 ml)	02	06.6	00	00
Total		30	100	30	100

TABLE – III: Comparison between pre-test and post-test level of gastric residual volume among critically ill patients. (N=30)

DAYS	COMPARISON	MEAN	S.D	‘t’ TEST	‘p’ VALUE
Day 1	Pre-test	2.93	5.28	09.8	0.001***
Day 1	Post-test	2.61	5.64	09.8	0.001***
Day 2	Pre-test	2.53	5.75	12.7	0.001***
Day 2	Post-test	2.03	5.98	12.7	0.001***
Day 3	Pre-test	2.46	6.09	04.5	0.001***
Day 3	Post-test	1.09	6.81	04.5	0.001***

*-p<0.05, significant and **-p<0.001, highly significant

Table – IV: Association between the selected demographic variables with pre-test level of gastric residual volume among critically ill patients. (N=30)

SL.NO	DEMOGRAPHIC VARIABLE		NORMAL				RISK			X²
			n		%		n		%
1	Age (in years)									9.31** df=3 S
	· 40-50		0		0		4		100
	· 51-60		0		0		4		100
	· 61-70		0		0		19		100
	· Above70		1		33.3		2		66.7
2	Gender									0.51 df=1 NS
	· Male		1		5		19		95
	· Female		0		0		10		100
3	Marital status									0.07 df=1 NS
	· Married		1		3.6		27		96.4
	· Single		0		0		2		100
4	Level of education									1.52 df=4 NS
	· Non- literate		1		8.3		11		91.7
	· Primary level		0		0		9		100
	· Secondary level		0		0		6		100
	· Diploma		0		0		2		100
	· Degree		0		0		1		100
5	Employment status									1.55 df=1 NS
	· Unemployed		0		0		18		100
	· Employee		1		8.3		11		91.7
6	Previous history of Nasogastric Tube Feeding									0.03 df=1 NS
	· Yes		0		0		1		100
	· No		1		3.4		28		96.6
7	Reason for Nasogastric Tube Feeding									1.03 df=3 NS
	· Trauma		0		0		4		100
	· Unconsciousness		0		0		2		100
	· Neurological problems		1		6.7		14		93.3
	· Other disorders		0		0		9		100
8	Number of feeding per day (24 hours)									2.06 df=3 NS
	· 2-4 times	0		0		3		100
	· 5-7 times	0		0		15		100
	· 8-10 times	1		10		9		90
	· above 10 times	0		0		2		100
9	Amount of feeding									0.69 df=3 NS
	· Less than 100 ml	0		0		0		0
	· 100-150 ml	0		0		9		100
	· 150-200 ml	1		5.6		17		94.4
	· 200-250 ml	0		0		3		100
10	Rate of intervals among feeding (in hours)									0.51 df=2 NS
	· 2-3	0		0		5		100
	· 4-5	1		5		19		95
	· More than 5	0		0		5		100

p<0.05, significant and **-p<0.001, highly significant

Table – V : Association between the selected demographic variables with post-test level of gastric residual volume among critically ill patients. (N=30)

SL. NO	DEMOGRAPHIC VARIABLE	NORMAL		RISK		X²
SL. NO	DEMOGRAPHIC VARIABLE	n	%	n	%	X²
1	Age (in years)					0.61 df=3 NS
	· 40-50	4	100	0	0
	· 51-60	3	75	1	25
	· 61-70	17	89.5	2	10.5
	· Above70	3	100	0	0
2	Gender					0.25 df=1 NS
	· Male	19	95	1	5
	· Female	8	80	2	20
3	Marital status					0.80 df=1 NS
	· Married	25	89.3	3	10.7
	· Single	2	100	0	0
4	Level of education					0.28 df=4 NS
	· Non- literate	11	91.7	1	8.3
	· Primary level	9	100	0	0
	· Secondary level	5	83.3	1	16.7
	· Diploma	1	50	1	50
	· Degree	1	100	0	0
5	Employment status					0.65 df=1 NS
	· Unemployed	16	88.9	2	11.1
	· Employee	11	91.7	1	8.3
6	Previous history of Nasogastric Tube Feeding					0.90 df=1 NS
	· Yes	1	100	0	0
	· No	26	89.7	3	10.3
7	Reason for Nasogastric Tube Feeding					0.70 df=3 NS
	· Trauma	3	75	1	25
	· Unconsciousness	2	100	0	0
	· Neurological problems	14	93.3	1	6.7
	· Other disorders	8	88.9	1	11.1
8	Number of feeding per day (24 hours)					0.02 df=3 S
	· 2-4 times	3	100	0	0
	· 5-7 times	12	80	3	20
	· 8-10 times	10	100	0	0
	· above 10 times	2	100	0	0
9	Amount of feeding					0.001 df=3 S
	· Less than 100 ml	0	0	0	0
	· 100-150 ml	8	88.9	1	11.1
	· 150-200 ml	16	88.9	2	11.1
	· 200-250 ml	3	100	0	0
10	Rate of intervals among feeding (in hours)					0.05 df=2 S
	· 2-3	5	100	0	0
	· 4-5	17	85	3	15
	· More than 5	5	100	0	0

*-p<0.05, significant and **-p<0.001, highly significant

DISCUSSION:

The goal of the study was to evaluate “the effectiveness of abdominal massage on Gastric Residual Volume among Critically ill patients with Nasogastric tube feeding atSri Manakula Vinayagar Medical College and Hospital, Puducherry”. A total number of 30 patients were selected for the study. The effectiveness was assessed by using self-prepared assessment tool among critically ill patients with nasogastric tube feeding in critical care unit. The investigator has assessed the pre-test level of gastric residual volume among critically ill patients with nasogastric tube feeding and according to inclusion criteria the samples were administered the intervention Abdominal massage.

SUMMARY:

A pre experimental research design was selected for this study to assess the effectiveness of Abdominal Massage on gastric residual volume among crtically ill patients with nasogastric tube feeding at Sri Manakula Vinayagar Medical College & Hospital, Puducherry.

The investigator obtained formal permission from Ethical committee of Sri Manakula Vinayagar Medical College and Hospital. The main study was conducted in Sri Manakula Vinayagar Medical College and Hospital (Critical Care Unit), Puducherry. The period of data collection was six weeks. Totally 30Critically ill patients were selected by using the purposive sampling technique. The purpose of the study was explained to the patients.

The pre-test was done to 30 patients by using self-prepared assessment tool to assess the level of gastric residual volume. After the 3 days of regular abdominal massage the post-test was done for those 30 patients.

MAJOR FINDINGS IN THE STUDY:

· Frequency and percentage wise distribution on level of gastric residual volume among critically ill patients. In Pre - Test 01 (3.3%) of them in normal level, 18 (59.4%) of them in low risk, 09 (29.7%) of them in high risk and 02 (6.6%) of them in very high risk. Whereas in Post - Test 27 (90%) of them in normal level, 2 (6.6%) of them in low risk, 01 (3.3%) of them in high risk and none of them in very high risk.

· On day 1, the overall average score is 2.93 with the standard deviation of 5.28, after the administration of Abdominal massage the level of gastric residual volume the average score was reduced to 2.61 with the standard deviation of 5.64 respectively.

· On day 2, the overall average score is 2.53 with the standard deviation of 5.75, after the administration of Abdominal massage the level of gastric residual volume the average score was reduced to 2.03 with the standard deviation of 5.98 respectively.

· On day 3, the overall average score is 2.46 with the standard deviation of 6.09, after the administration of Abdominal massage the level of gastric residual volume the average score was reduced to 1.09 with the standard deviation of 6.81 respectively.

· Association between the selected demographic variables with pre-test level of gastric residual volume among critically ill patients. It was statistically found that age has significantly relationship with the pre-test level of gastric residual volume at the level of p<0.05 level.

· Association between the selected demographic variables with post-test level of gastric residual volume among critically ill patients. It was statistically found that number of feeding per day, amount of feeding, rate of intervals among feeding has significantly relationship with the post-test level of gastric residual volume at the level of p<0.05 level.

CONCLUSION:

This study implies that the level of gastric residual volume among critically ill patients with nasogastric tube feeding were in high risk. And thus abdominal massage is an effective intervention on reducing gastric residual volume among critically ill patients with nasogastric residual volume.

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Received on 27.06.2019 Modified on 11.07.2019

Int. J. of Advances in Nur. Management. 2019; 7(3):243-250.

DOI: 10.5958/2454-2652.2019.00056.8