Addressing the unique needs and quality of life issues for adults receiving long-term home enteral nutrition.

Individuals who require home enteral nutrition (EN)-and, subsequently, their families-undergo major changes in family dynamics. They would benefit from an approach that provides ongoing nutrition, hydration, enteral access, and quality of life assessments from knowledgeable clinicians. Most individuals and families will be new to the enteral access device, handling and administration of the nutrition formula, medication delivery through feeding tubes, and troubleshooting associated complications. Educational sessions are typically given but may not be comprehensive enough to meet all needs, especially in the first weeks to months of home EN therapy. Quality of life assessments obtained in the early stages of EN support would help clinicians identify and focus on areas that need special attention for that individual and family. Ongoing clinical care is essential because over time, the nutrition prescription, delivery methods and schedules typically require alterations and feeding tubes need to be assessed and replaced. In addition to these important physical dimensions of care, attention should be placed on the psychological, cognitive, social, and ethical aspects of life for these individuals and their families.

Religious and Spiritual Implications in Functional Anger.

The topic of spirituality has been of interest for many years in the helping professions ( Matise et al., 2018; Pargament, 2011). Another level of interest is how spirituality may be connected to anger that is culturally informed ( Subarimaniam et al., 2020). This writing approaches the topic of functional anger as impacted by the religious and spiritual beliefs with case vignettes pertinent to students, pastoral counselors, nurses, social workers, psychologists, psychotherapists, and other helping professionals.

Assessment of the effect of colored beverage on gastric returns after gastric tube replacement to enhance placement verification.

BACKGROUND: Verification of appropriate placement of newly replaced gastrostomy tubes is essential prior to use to avoid potentially serious adverse events. PROBLEM: A lack of standardized guidance regarding effective and practical means to verify placement exists. Aspiration or drainage of gastric-like contents is one mean suggested to help determine placement, yet when returns are minimal, this becomes challenging. MATERIALS, METHOD, INTERVENTION: Oral ingestion or the instillation of a colored beverage prior to tube replacement was used in a midwestern healthcare clinical setting to enhance returns in both volume and color via the newly replaced gastrostomy tube. A retrospective review of this practice was conducted, which included 176 gastric tube replacements over 4 years. RESULTS: A significant increase in volume of returns via the newly replaced tube was noted (P < .001) and a strong correlation of color to the ingested or consumed beverage was found with 95% of returns reflecting color tinting of the beverage or in many cases, strong color change to that of the beverage color. CONCLUSION: Presented is a simple, cost-effective method that has shown to be clinically useful in assessing placement of newly replaced gastrostomy tubes that may be useful in other practices and settings.

Development of a Competency Model for Placement and Verification of Nasogastric and Nasoenteric Feeding Tubes for Adult Hospitalized Patients.

Nasogastric/nasoenteric (NG/NE) feeding tube placements are associated with adverse events and, without proper training, can lead to devastating and significant patient harm related to misplacement. Safe feeding tube placement practices and verification are critical. There are many procedures and techniques for placement and verification; this paper provides an overview and update of techniques to guide practitioners in making clinical decisions. Regardless of placement technique and verification practices employed, it is essential that training and competency are maintained and documented for all clinicians placing NG/NE feeding tubes. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

Ethical Aspects of Artificially Administered Nutrition and Hydration: An ASPEN Position Paper.

The American Society for Parenteral and Enteral Nutrition (ASPEN) Position Paper focus is on applying the 4 ethical principles for clinician's decision-making in the use of artificially administered nutrition and hydration (AANH) for adult and pediatric patients. These basic principles are (1) autonomy, respect the patient's healthcare preferences; (2) beneficence, provide healthcare in the best interest of the patient; (3) nonmaleficence, do no harm; and (4) justice, provide all individuals a fair and appropriate distribution of healthcare resources. Preventing and resolving ethical dilemmas is addressed, with an emphasis on a collaborative, interdisciplinary approach. Optimizing early communication and promoting advance care planning, involving completion of an advance directive, including designation of a surrogate decision-maker, are encouraged. Clinicians achieve respect for autonomy when they incorporate the patient, family, community, country, geographical, and presumed cultural values and religious belief considerations into ethical decision-making for adults and children with a shared decision-making process. These discussions should be guided by the 4 ethical principles. Hospital committees and teams, limited-time trials, clinician obligation with conflicts, and forgoing of AANH are addressed. Specific patient conditions are addressed because of the concern for potential ethical issues: coma, decreased consciousness, and dementia; advanced dementia; cancer; eating disorders; and end-stage disease/terminal illness. Incorporated in the Position Paper are ethical decisions during a pandemic and a legal summary involving ethical issues. International authors presented the similarities and differences within their own country or region and compared them with the US perspective.

Dysphagia: Interprofessional Management, Impact, and Patient-Centered Care.

Dysphagia affects a multitude of people worldwide with tremendous impact on the affected individual, families, and caregivers. Understanding dysphagia, as well as the status of screening, evaluation, and treatment, aids in the knowledge required by a interprofessional team to holistically care for patients with dysphagia and their caregivers. The impact of dysphagia includes potential associated risk and a cascade of effects. Conversations regarding meeting nutrition and fluid needs with consideration for quality of life need to be integrated into the plan of care for individuals with dysphagia.

Graduation Day: Healthcare Transition From Pediatric to Adult.

Because more patients with pediatric-onset chronic conditions are surviving into adulthood, they are graduating from pediatric healthcare to self-management and adult healthcare. This transfer of care needs to be a process of transitioning medical and nutrition care. Despite having position statements from professional organizations and several proposed models, issues in the transition process have been well described, and gaps in transition care persist. Healthcare providers need to be aware of special needs of emerging adults related to education on chronic condition and self-management skills, emotional support before and after transition, and legal rights for both the patient and the parent if the emerging adult is not developmentally appropriate to make his or her own healthcare decisions. Both pediatric and adult providers need to be in active communication with each other and the patient to develop trusting relationships and actively support the transition of care. This review of literature describes several models for transitioning, measureable outcomes, insurance provider issues, and legal issues pertaining to healthcare transition.

ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text].

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

Home Nutrition Support: Ethics and Reimbursement.

Ethical dilemmas challenge providers on both sides of the hospital and clinic doors. In addition to establishing the nutrition care plan and guiding the client into the home setting with safe and effective parenteral or enteral nutrition therapy, procuring home nutrition support involves meeting documentation requirements and verifying that clients meet reimbursement criteria for home therapy based on third-party payer criteria. Providers have entered a realm for which training has been scarce and they face moral and ethical dilemmas involving serving as patient advocates, possibly stretching the truth to fit the clinical documentation to criteria vs maintaining professional integrity. Nutrition research and evidence-based practice have outpaced modifications to policies including Medicare's national and local coverage determinations, the bulk of which have not seen revisions in 32 years. This review elucidates clinical dilemmas and urges a political call to action to advocate for changes in current, outdated requirements for reimbursement. Given the current healthcare environment and trend toward expedited hospital stays, patients may be better served (and nourished) with revised guidelines.

The feeding tube bridle: one inexpensive, safe, and effective method to prevent inadvertent feeding tube dislodgement.

Nasally placed feeding tubes are heavily relied on in healthcare. Inadvertent tube removal not only poses safety hazards and discomfort for the patient, but also causes strain on valuable healthcare resources. Because use of restraints can agitate patients, increase safety hazards, and create a sense of depersonalization, alternative methods to prevent inadvertent tube removal are desirable. This article describes a feeding tube bridle constructed with supplies that are inexpensive and readily available to most patient care units. This method has been successfully utilized for patients at significant risk for self-initiated feeding tube removal in one Midwestern facility for many years without adverse effects. The method of bridling feeding tubes described here is effective, safe, and relatively comfortable as well as minimally noticeable to the patient and others.

Nutrition support in the morbidly obese, critically ill patient.

Nutrition support in the critically ill patient is challenging but is even more difficult in a morbidly obese patient. This case report chronicles the care of a 6-foot-tall, 256-kg male (body mass index 76.5 kg/m(2)) who spent over a month in the intensive care unit for respiratory failure, sepsis, and acute renal failure. Parenteral nutrition was provided throughout his critical care course. One of the major difficulties encountered was determining his nutritional needs. A hypocaloric nutritional regimen was used, along with moderate protein provisions. Numerous electrolyte imbalances occurred, including hypercalcemia that did not resolve by eliminating calcium from the parenteral nutrition solution. Enteral nutrition was desired but was not used initially because of a need for vasopressors, a diagnosis of pancreatitis, difficulty in documenting feeding tube placement because of diagnostic limitations secondary to the patient's large size, and concern about managing stools. Eventually, oral intake and supplemental enteral feeding were initiated. Nutrition support team members worked closely with the interdisciplinary care team to develop strategies to manage the nutritional problems related to his obesity. A discussion of the various nutritional issues encountered in the care of this patient is provided. Reasonable nutritional status was achieved, but this case reflects some of the challenges encountered in caring for the nutritional needs of select patient populations in clinical practice and the need for increased research and guidelines in this area.

Parenteral nutrition focus. Nutrition assessment and formula composition.

The infusion therapy nurse often is in a position to intervene by assessing and helping to treat the nutritional status of the patients she or he serves. This article provides an overview of the nutritional assessment process. Tips are offered for estimating patient-specific nutritional needs. Basic components of parenteral nutrition solutions are highlighted, and general guidelines for initiating parenteral nutrition are included. A case study guides the reader through application of some principles offered in the article.