Precision of Assessments for Feeding Intolerance
Precision of Assessments for Feeding Intolerance
This study is the first to examine the precision of the physiologic clinical signs associated with FI in preterm infants. Specifically, interpretation of abdominal and emesis photographs by NICU nurses were measured. Variability of the assessments based on years of clinical experience also was examined. NICU nurses displayed a wide variability in the interpretation of abdominal and emesis assessment photographs of preterm infants. Nurses also displayed a wide variation in how they charted these assessments in the medical record. No relationships between assessment interpretation and charting were found based on years of clinical experience.
As discussed by Carter, the bedside nurse's assessments of the clinical signs and symptoms of FI in preterm infants is essential. The results of this study suggest that there is a great deal of variability in these assessments as well as in the way nurses record their assessments in the medical record. In the first case, the lack of consistency across nurses in judging abdominal distention may result in one of the earliest warning signs of FI going undetected, potentially resulting in dangerous medical situations. In the second case, lack of consistency in recording assessments in the medical record may result in further failure of communication within the health care team to act on abnormal physical assessments. In either case, these inconsistencies may disrupt and delay the critical process of identification and prevention for major complications such NEC.
No prior studies evaluating either the accuracy or precision of nursing assessments of abdominal distention were found in the literature. Thus, it is not possible to know if the study findings reflect a new phenomenon. One study authored by Craft was found where nursing students and practicing pediatric nurses (n = 109) were presented with visual displays of formula on receiving blankets and asked to determine the volume. Findings showed that few displays were assessed accurately and that error increased with the increase in displayed volume which is consistent with the findings in the current study. Additional analyses by Craft and colleagues revealed that practice role, nature of clinical practice, and number of displays assessed accounted for significant proportions of variance in the relative error, suggesting that visual assessment techniques require a mental frame of reference with which they compare the observed volume. This is also consistent with a more recent cross-sectional study comparing a visual dental examination method with assessment of intra-oral photographs as means of detecting dental caries in children. The researchers found good intra-examiner reliability for both the visual and the photographic methods with no clinically significant differences between the photographic scores and the visual assessments. The researchers concluded that the photographic approach was equivalent in diagnostic utility to the visual system in a group of well-trained clinicians.
NICU educators need to develop policies that support standardized interpretation and recording visual assessments, such as the guidelines provided by Carter. Few studies have used routine abdominal girth measurements as an objective measure of abdominal distention. This simple evaluation technique may provide individualized, yet standardized, patient assessments. Another potential standardization method may be the estimation of emesis. Often times, emesis is difficult to measure because of varying and numerous weights and sizes of blankets involved. Whether the NICU identifies a method for object comparison (i.e., less than a half-dollar is small) or education for estimations, thoughtful and strategic discussions of these basic assessments need to occur to guide the standardization policies and procedures.
In addition to education, practitioners need to be aware of the variability of visual assessments associated with FI when considering the feeding care plan. Certainly any inconsistencies in charting or in their own assessments as compared to the assessments recorded in the medical record should be questioned. The clinicians making the feeding care decisions also need to be involved in the discussion of standardizing assessments and the entire team would likely benefit from interdisciplinary training.
Previous studies have demonstrated the benefits of decision trees and clinical guidelines to help bedside nurses evaluate and interpret assessments for early diagnosis and interventions to prevent major complications. Although these clinical tools are helpful, psychometric testing of the tools and of the clinical assessments associated with FI is needed.
Additionally, and perhaps more fundamentally, more research about FI in preterm infants is needed. First, researchers need to develop methods to increase reliability and validity of visual assessments used as measures of FI. The reliability and precision of the physiologic measurements believed to be associated with FI needs to be established. This will allow researchers to identify valid and accurate methods of measurement for FI. Second, more research is needed to conceptually and operationally define FI in this population. To advance the science for the phenomenon of FI, a universal definition for FI in preterm infants is necessary. However, a reliable and valid measurement tool is needed before a universal definition is identified and tested. Once these fundamental steps have been explored, promotion and intervention studies can be researched.
Discussion
This study is the first to examine the precision of the physiologic clinical signs associated with FI in preterm infants. Specifically, interpretation of abdominal and emesis photographs by NICU nurses were measured. Variability of the assessments based on years of clinical experience also was examined. NICU nurses displayed a wide variability in the interpretation of abdominal and emesis assessment photographs of preterm infants. Nurses also displayed a wide variation in how they charted these assessments in the medical record. No relationships between assessment interpretation and charting were found based on years of clinical experience.
As discussed by Carter, the bedside nurse's assessments of the clinical signs and symptoms of FI in preterm infants is essential. The results of this study suggest that there is a great deal of variability in these assessments as well as in the way nurses record their assessments in the medical record. In the first case, the lack of consistency across nurses in judging abdominal distention may result in one of the earliest warning signs of FI going undetected, potentially resulting in dangerous medical situations. In the second case, lack of consistency in recording assessments in the medical record may result in further failure of communication within the health care team to act on abnormal physical assessments. In either case, these inconsistencies may disrupt and delay the critical process of identification and prevention for major complications such NEC.
No prior studies evaluating either the accuracy or precision of nursing assessments of abdominal distention were found in the literature. Thus, it is not possible to know if the study findings reflect a new phenomenon. One study authored by Craft was found where nursing students and practicing pediatric nurses (n = 109) were presented with visual displays of formula on receiving blankets and asked to determine the volume. Findings showed that few displays were assessed accurately and that error increased with the increase in displayed volume which is consistent with the findings in the current study. Additional analyses by Craft and colleagues revealed that practice role, nature of clinical practice, and number of displays assessed accounted for significant proportions of variance in the relative error, suggesting that visual assessment techniques require a mental frame of reference with which they compare the observed volume. This is also consistent with a more recent cross-sectional study comparing a visual dental examination method with assessment of intra-oral photographs as means of detecting dental caries in children. The researchers found good intra-examiner reliability for both the visual and the photographic methods with no clinically significant differences between the photographic scores and the visual assessments. The researchers concluded that the photographic approach was equivalent in diagnostic utility to the visual system in a group of well-trained clinicians.
Implications for Nursing Practice
NICU educators need to develop policies that support standardized interpretation and recording visual assessments, such as the guidelines provided by Carter. Few studies have used routine abdominal girth measurements as an objective measure of abdominal distention. This simple evaluation technique may provide individualized, yet standardized, patient assessments. Another potential standardization method may be the estimation of emesis. Often times, emesis is difficult to measure because of varying and numerous weights and sizes of blankets involved. Whether the NICU identifies a method for object comparison (i.e., less than a half-dollar is small) or education for estimations, thoughtful and strategic discussions of these basic assessments need to occur to guide the standardization policies and procedures.
In addition to education, practitioners need to be aware of the variability of visual assessments associated with FI when considering the feeding care plan. Certainly any inconsistencies in charting or in their own assessments as compared to the assessments recorded in the medical record should be questioned. The clinicians making the feeding care decisions also need to be involved in the discussion of standardizing assessments and the entire team would likely benefit from interdisciplinary training.
Implications for Nursing Research
Previous studies have demonstrated the benefits of decision trees and clinical guidelines to help bedside nurses evaluate and interpret assessments for early diagnosis and interventions to prevent major complications. Although these clinical tools are helpful, psychometric testing of the tools and of the clinical assessments associated with FI is needed.
Additionally, and perhaps more fundamentally, more research about FI in preterm infants is needed. First, researchers need to develop methods to increase reliability and validity of visual assessments used as measures of FI. The reliability and precision of the physiologic measurements believed to be associated with FI needs to be established. This will allow researchers to identify valid and accurate methods of measurement for FI. Second, more research is needed to conceptually and operationally define FI in this population. To advance the science for the phenomenon of FI, a universal definition for FI in preterm infants is necessary. However, a reliable and valid measurement tool is needed before a universal definition is identified and tested. Once these fundamental steps have been explored, promotion and intervention studies can be researched.
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