| 119
Pensar Enfermagem / v.27 n.01 / december 2023
DOI: 10.56732/pensarenf.v27i1.265
Review Article
How to cite this article: Sitja LE, Simon BS, Assis MCS, Busanello J, Stamm B. Quality Indicator in
Nutritional Therapy in oncology and the interface with nursing: integrative review. Pensar Enf [Internet].
2023 Dec; 27(1): 119-130. Available from: https://doi.org/10.56732/pensarenf.v27i1.265
Quality indicator in nutritional therapy in oncology
and the interface with nursing: integrative review
Abstract
Objective
To analyze the evidence of the Indicator of Quality in Nutritional Therapy “prescribed
versus infused volume in nutritional therapy” in hospitalized adult cancer patients and the
prospects for nursing practice.
Methods
An integrative review conducted in the Portal Biblioteca Virtual em Saúde, Nursing
Database, Cumulative Index to Nursing & Allied Health Literature, Excerpta Medica
dataBASE, Google Scholar, Latin America and the Caribbean Literature on Health
Sciences, U.S. National Library of Medicine, SciVerse Scopus Web of Science. This
research included studies published in Portuguese, English, or Spanish from 2008 to 2021.
Results
Of the nine studies included most of the authors were nutritionists and/or nutrition
academics (53.8%), followed by nurses and/or nursing academics (30.8%). Most studies
(67%) did not reach the indicator target, being investigated in clinical and/or surgical wards
(27.3%) and adult/general Intensive Care Units (27.3%). The reasons for not meeting the
indicator goal were related to clinical and mechanical complications of the use of nutritional
therapy.
Conclusion
The goal of the indicator in “nutritional therapy prescribed versus infused volume” was not
achieved in most studies, and the adult cancer patient presents clinical difficulties in
achieving it.
Keywords
Quality indicators in Health Care; Quality Indicators in Nutritional Therapy; Enteral
Nutrition; Hospitalization; Neoplasms; Nursing.
Laísa Escobar Sitja1
orcid.org/ 0000-0002-1455-072X
Bruna Sodré Simon2
orcid.org/-0000-0003-3855-1310
Michelle Cristina Silva de Assis3
orcid.org/0000-0003-2632-5885
Josefine Busanello4
orcid.org/0000-0002-9950-9514
Bruna Stamm5
orcid.org/0000-0003-4858-7712
1 Nurse. Multidisciplinary Integrated Residency
Program in Public Health, Federal University of
Pampa, Uruguaiana, Brazil.
2 Nurse. Doctor. Adjunct teacher of the Undergraduate
Nursing Course at the Federal University of Pampa,
Uruguaiana, Brazil.
3 Nurse. Doctor. Adjunct teacher of the Undergraduate
Nursing Course at the Federal University of Rio
Grande do Sul, Porto Alegre, Brazil.
4 Nurse. Doctor. Adjunct teacher of the Undergraduate
Nursing Course at the Federal University of Pampa,
Uruguaiana, Brazil.
5 Nurse. Master. Assistant professor of the
Undergraduate Nursing Course at the Federal
University of Pampa, Uruguaiana, Brazil.
Corresponding author:
Bruna Stamm
E-mail: brunastamm@unipampa.edu.br
Received: 06.03.2023
Accepted: 14.09.2023
120 | Stija, L.
Review Article
Introduction
The hospitalized adult cancer patient due to the clinical
conditions that the disease triggers, such as metabolic
changes, hormonal disorders, and inflammatory responses,
becomes more susceptible to nutritional deficits, which are
related to multifactorial aspects associated with the type of
tumor, clinical staging, therapeutic modality, individual
characteristics of the patient and human and physical
resources of the inpatient unit.1,2 Studies3,4 reveal that the
hospitalized cancer patient is a population at nutritional risk
with a degree of malnutrition of 20% to 80%, especially in
the older people in the advanced stage of the disease.5
Guidelines6,7,8 advise conducting nutritional screening
within a maximum of 48 hours of hospitalization for all
people to monitor the nutritional status of the cancer
patient. Thus, to meet the nutritional demand, Nutritional
Therapy (NT) is used, with Enteral Nutritional Therapy
(ENT) as one of the therapeutic modalities. In Brazil, the
ENT development requires a Multidisciplinary Nutritional
Therapy Team (MNTT)8 consisting of a doctor, a nurse, a
nutritionist, and a pharmacist. The nurse in the MNTT has,
among her attributions, to choose the route of
administration of the ENT together with the doctor; to
proceed and ensure the placement of the naso/orogastric
or transpyloric tube; to guide the patient, the family or the
legal responsible regarding the use and control of the ENT;
and to ensure the clear and accurate recording of
information related to the administration and the evolution
of the patient.9,10
However, ENT has risks and complications, and based on
this, the Indicators of Quality in Nutritional Therapy
(IQNT) were developed,11 which aim to identify failures in
the performance of procedures to generate improvement
in the assistance provided when there is deficits quality.12
In Brazil, the International Life Sciences Institute (ILSI)13
listed 36 IQNTs, aiming to measure the assistance provided
through indicators that translate the actions and
operationalize them for observation and evaluation,
providing correction, redefinition, and improvement of the
established goals. In Spain, the European Society for
Clinical Nutrition and Metabolism (ESPEN),14 one of the
leading NT societies, also provides instruments to measure
the quality of ENT both in clinical nutrition units, and in
any situation where a patient requires the use of this
therapy. The periodic application of the IQNT stands out
as one of the main ways to measure the ENT quality in
public and private hospitals. The Brazilian Society of
Parenteral and Enteral Nutrition (BRASPEN)9 guides the
application of at least three IQNT in health services to
monitor therapy, regardless of the size and human
resources of hospitals, including: nutritional screening,
frequency of patients with NT-related complications and
prescribed and infused volume of ENT.
The IQNT “NT prescribed versus infused volume” aims to
evaluate patients in ENT who have not reached the
estimated nutritional goal, and it is the responsibility of
Nursing to record their infused volume. In 2018, ILSI-
Brazil13 updated the list of IQNT, adding the indicator
“frequency of days of adequate administration of the NT
prescribed versus infused volume” to find out the frequency
of days of adequate volume supply in patients on ENT. The
goal of this IQNT is for at least 80% of the prescribed
volume of ENT to be infused.13 A study conducted by
ILSI-Brazil 13 with hospital, clinical, and research
institutions highlights that one of the most used IQNT is
the “NT prescribed versus infused volume,” represented in
81% of the institutions participating in the survey.
Given the above, the study identified that hospitalized adult
cancer patients present nutritional risks due to their clinical
condition and present nutritional risks, making them
vulnerable to treatment and possible interventions. Despite
the scientific knowledge that the values of the NT
prescribed versus infused volume in the oncological patient
are discrepant in clinical practice,15,16 professionals must
pay attention to the fact that, in addition to defining the diet
appropriate to the cancer patient’s needs, it is necessary to
guarantee the form and condition in which this diet will be
infused. To this end, many of the activities that nursing
undertakes in hospital health services are included, with the
nurse being responsible for recording the IQNT
“frequency of days of administration appropriate to the
prescribed versus infused volume in patients on ENT.” This
reality supports the importance of exploring this theme and
its interface with nursing.
Methods
This is an Integrative Review (IR),17 held in May and June
2022, which structure is based on the International
Recommendations of the Preferred Reporting Items of
Systematic reviews and Meta-Analyses (PRISMA).18
Initially, based on the acronym PICO:19 (P) hospitalized
adult cancer patient; (I) NT; (O) IQNT “NT prescribed
versus infused volume” (the comparator element ‘C’ was
dismissed), the review question was formulated: “what does
the literature refer to the IQNT NT prescribed versus
infused volume of responsibility of the nursing in the care
of hospitalized adult cancer patients?” The review protocol
has not been published.
Regarding the eligibility criteria, the study defined the
original articles; free available online in full; in Portuguese,
English, or Spanish languages; indexed in the Portal
Biblioteca Virtual em Saúde (BVS), Nursing Database
(BDENF), Cumulative Index to Nursing & Allied Health
Literature (CINAHL), Excerpta Medica dataBASE (Base),
Google Scholar, Latin America and the Caribbean
Literature on Health Sciences (LILACS), U.S. National
Library of Medicine (PubMed), SciVerse Scopus
(SCOPUS), and Web of Science; conducted with adult
oncological patients hospitalized and under EN, and
published from 2008 to 2021. The temporal cut is justified
by the incorporation of the IQNT “prescribed versus
infused volume” in 2008 by ILS,11 even if possibly, the
volume of NT has been monitored by other studies in years
prior to the one stipulated in this review. Then, the study
identified the descriptors or associated terms according to
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the acronym PICO 20 and adapted the search strategy for
each source of information, according to Chart 1.
Chart 1 - Search strategies according to each source of information. Uruguaiana, RS, Brazil, 2022.
Strategy
(“Enteral Nutrition” OR “Enteral Feeding” OR “Feeding Tube, Gastric” OR “Feeding Tubes, Gastric” OR “Feeding, Enteral” OR
“Feeding, Tube” OR “Gastric Feeding Tube” OR “Gastric Feeding Tubes” OR “Nutrition, Enteral” OR “Tube Feeding” OR “Tube,
Gastric Feeding” OR “Tubes, Gastric Feeding” AND (“nutrition therapy” OR “medical nutrition therapy” OR “nutrition therapy,
medical” or “therapy, medical nutrition” OR “therapy, nutrition”) and (volume or prescription or administration) AND ( db:(“IBECS”
OR “LILACS” OR BDENF” OR BIGG” OR “LIPECS” OR “colecionaSUS”)) AND (year_cluster:[2008 TO 2021])
(“nutrição enteral” OR “alimentação enteral” OR “alimentação por sonda” OR “alimentação por tubo” OR "Terapia Nutricional") AND
("Indicador de Qualidade" OR “Indicadores de Qualidade em Assistência à Saúde”)
TX (enteral nutrition or enteral feeding or tube feeding) AND TX (quality indicators or qi) AND TX (neoplasms or oncology or cancer)
(neoplasms OR ‘benign neoplasm’ OR ‘benign neoplasms’ OR cancer OR cancers OR malignancies OR malignancy OR ‘malignant
neoplasm’ OR ‘malignant neoplasms’ OR ‘neoplasm OR ‘neoplasm, benign’ OR ‘neoplasm, malignant’ OR ‘neoplasms, benign’ OR
‘neoplasms, malignant’ OR ‘medical oncology’ OR ‘oncology, medical’) AND (‘enteral nutrition’: ti,ab,kw OR ‘enteral feeding’: ti,ab,kw
OR ‘feeding tube, gastric’: ti,ab,kw OR ‘feeding tubes, gastric’: ti,ab,kw OR ‘feeding, enteral’: ti,ab,kw OR ‘feeding, tube’: ti,ab,kw OR
‘gastric feeding tube’: ti,ab,kw OR ‘gastric feeding tubes’: ti,ab,kw OR ‘nutrition, enteral’: ti,ab,kw OR ‘tube feeding’: ti,ab,kw OR ‘tube,
gastric feeding’: ti,ab,kw OR ‘feeding tube’: ti,ab,kw) AND (‘quality indicators, health care’: ab,ti OR ‘quality indicators’: ab,ti OR ‘quality
indicator’: ab,ti OR ‘healthcare quality indicator’: ab,ti OR ‘healthcare quality indicators’: ab,ti OR ‘indicator, healthcare quality’: ab,ti OR
‘indicators, healthcare quality’: ab,ti OR ‘quality indicator, healthcare’: ab,ti OR ‘quality indicators, healthcare’: ab,ti)
(neoplasias OR câncer OR tumor) AND ("nutrição enteral" OR "Alimentação por Sonda" OR "Alimentação por Tubo" OR "Sondas
Gástricas") AND (“Indicador de qualidade" OR “Indicadores de qualidade”)
(“Enteral Nutrition” OR “Enteral Feeding” OR “Tube Feeding” OR “Feeding, Tube” OR “Feeding Tube, Gastric” OR “Feeding Tubes,
Gastric”) AND (“Quality Indicators” OR “Quality Indicator” OR “Quality Indicators, Healthcare” OR “Quality Indicator, Healthcare”)
AND (db: (“LILACS”) AND (year_cluster: [2008 TO 2021]
(“Quality Indicators, Health Care” OR “Quality Indicators, Healthcare” OR “Healthcare Quality Indicator” OR “Healthcare Quality
Indicators” OR “Indicators, Healthcare Quality”) AND (“Enteral Nutrition” OR “Enteral Feeding” OR “Feeding, Enteral” OR “Tube
Feeding” OR “Feeding, Tube” OR “Gastric Feeding Tubes” OR “Feeding Tube, Gastric” OR “Gastric Feeding Tube” OR “tube, gastric
feeding”)
(ALL (neoplasms OR neoplasm OR cancer OR cancers OR tumor OR tumors OR oncology) AND TITLE-ABS-KEY (“Enteral
Nutrition” OR “Enteral Feeding” OR “Tube Feeding” OR “Feeding, Tube” OR “Feeding Tube, Gastric” OR “Feeding Tubes, Gastric”)
AND TITLE-ABS-KEY (“Quality Indicators” OR “Quality Indicator” OR “Quality Indicators, Healthcare” OR “Quality Indicator,
healthcare”)
(“Enteral Nutrition” OR “Enteral Feeding” OR “Tube Feeding” OR “Feeding, Tube” OR “Feeding Tube, Gastric” OR “Feeding Tubes,
Gastric”) (all fields) AND (“Quality Indicators” OR “Quality Indicator” OR “Quality Indicators, Healthcare” OR Quality Indicator,
Healthcare”) (Topic)
The titles and abstracts were then read twice to select the
articles that met the eligibility criteria. Two academic
reviewers from Nursing course analyzed the studies to
qualify the methodological process who, after the selection,
discussed and compared their results. A third reviewer, a
researcher in the EN area, was consulted in cases of
disagreement between the initial reviewers. Finally, the
articles were analyzed integrally, concluding the study
selection phase. The database of studies was organized in
Microsoft Excel®.
Researchers prepared a characterization table to present the
studies that drawn up the analytical corpus, containing title,
reference, objective, design, and level of evidence. 19 Also,
a chart with the results of the IQNT “NT prescribed versus
infused volume” is described, with the aim of summarizing
for nursing the characteristics of the studies according to
whether or not they achieved the indicator’s goal, including
the information: type of cancer, hospital unit, structure for
therapy, characteristics of the NT, length of application of
the ENT, goal of the adopted indicator, values of the
indicator and reasons for stopping the NT (when
mentioned).
Results
According to the search strategies defined for each
information base, researchers identified 602 publications.
After the exclusion of 96 duplicates, 506 studies remained
122 | Stija, L.
Review Article
and, of these, 238 were evaluated according to the eligibility
criteria, and 24 were selected for full reading. Of the 24
studies, 11 were excluded, leaving nine studies included for
review. The description and selection of studies was based
on the PRISMA15 and is illustrated in Figure 1.
Figure 1 - Flowchart of the of studies selected in the review. Uruguaiana, RS, Brazil, 2022.
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic
Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097
For more information, visit www.prisma-statement.org .
Of the nine studies selected, researchers identified that the
years of publication with the highest records were 2017
(n=4) and 2020 (n=2). The authors’ profile was mainly
nutritionists and/or nutrition academics (n=7; 53.8%),
nurses and/or nursing academics (n=4; 30.8%), and
physicians (n=2; 15.4%). Most of the studies were
prospective (n=6; 66.7%) and retrospective (n=3; 33.3%),
descriptive (n=4; 44.4%), and/or observational (n=5;
Records identified through databases
(n = 602)
Seletion
Inclusion
Elegibility
Identification
Records after removing duplicates
(n = 506)
Analyzed records
(n = 506)
Excluded records
(n = 268)
Full-text articles evaluated for eligibility
(n = 24)
Full-text articles excluded
for not presenting
information on the diet
volume indicator
(n = 11)
Studies included in the qualitative synthesis
(n = 09)
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Review Article
55.6%), with evidence level N6 (n=8; 89%). The study
participants totaled 1,371 patients, 438 of whom were
cancer patients, since most of the studies included patients
with other clinical conditions in their sample, as shown in
Chart 2.
Chart 2 - Characterization of the studies selected for the review. Uruguaiana, RS, Brazil, 2022.
Title/Year/ country of origin of the
study
Profile of the
authors
Objective
Design/level of
evidence
Sample
Caloric and Protein Infusion versus
Dietary Prescription in Enteral Nutritional
Therapy
for Cancer Patients/ 2021/ Brazil (21)
Nutritionists and
nutrition
academics
To compare caloric and protein infusion with
dietary prescription in oncological patients under
ENT
Retrospective
analytical
observational
N6
120 records
of cancer
patients
High Frequency of Non-Compliance with
Quality
Indicators of Enteral and Parenteral
nutrition
Therapy in Hospitalized Patients/ 2020 /
Brazil (22)
Nutritionists
To evaluate the frequency of adequacy of the
IQNT in clinical and surgical patients during NE
or NP
Prospective
descriptive
N6
727 patient
records
7 cancer
patients
Are quality indicators of enteral nutritional
therapy useful tools for monitoring
patients with advanced cancer in palliative
care? cancer patients in palliative care?/
2020 / Brazil (23)
Nutritionists
Apply the quality indicators of ENT in patients
with advanced cancer in palliative care
Prospective
descriptive
observational
quantitative
N6
51 cancer
patients
Accidental enteral feeding tube
dislodgement with the use
of a dedicated feeding tube attachment
device versus adhesive tape
as the securing method: a randomized
clinical trial/2019 / Brazil (24)
Teaching nurses
and doctors
To evaluate the impact of the use of the feeding
tube affixation device (FTAD) compared to the
traditional method of fixation with adhesive tape
on the occurrence of accidental displacement of
the enteral feeding tube
Prospective
randomized, single-
center, non-blinded
clinical trial
N3
104 patients
29 cancer
patients
Prescribed enteral diet versus infused
diet/2017 / Brazil (25)
Nutritionists
Evaluate the prescribed volume of enteral diet
versus the infused volume, identifying the causes
of interruption of the diet and expenses generated
by these interruptions
Retrospective
observational
N6
27 patient
records
1 cancer
patient
Quality control of enteral nutrition
therapy in cancer patients at nutritional
risk/ 2017 / Brazil (26)
Nutritionists and
doctors
To analyze the adequacy and quality of ENT used
in patients diagnosed with cancer and undergoing
treatment in specialized public hospitals applying
IQNT
Prospective
observational
descriptive
N6
211 records
of cancer
patients
Cause of interruption of enteral nutrition
in intensive care units/ 2017 / Brazil (27)
Nutritionists and
nurses
To identify the causes of interruption of the
administration of EN in patients admitted to ICUs
of University hospital
Prospective,
observational
quantitative
N6
53 patient
records
6 cancer
records
Monitoring of Enteral Nutritional
Therapy in
Intensive Care Unit: Calorie-protein
adequacy and survival/ 2017 / Brazil (28)
Nutritionists
To assess the nutritional status in patients
admitted to the ICU to monitor the ENT to
identify the causes of interruption of the enteral
diet
Prospective
observational
N6
32 patients
1 cancer
patient
Adverse events related to use
of Enteral Nutritional Therapy/ 2014 /
Brazil (29)
Academic
nursing, teaching
nurse
To verify the occurrence of adverse events related
to the use of EN in patients of a public hospital
Retrospective
longitudinal
exploratory
descriptive
N6
46 records
12 cancer
records
ENT: Enteral Nutritional Therapy; NE: Enteral Nutrition; PN: Parenteral Nutrition; ICU: Intensive Care Unit; IQNT: Quality Indicator in Nutritional Therapy.
Source: own elaboration.
124 | Stija, L.
Review Article
When summarizing the studies that did or did not reach the
goal of IQNT “NT prescribed versus infused volume,”
researchers identified that most studies (n=6; 67%) did not
reach their goal. Among the reasons for not meeting the
goal, gastrointestinal, mechanical, and respiratory
complications are described using NT, as shown in Chart
3.
Chart 3 - Characterization of the IQNT “frequency of days of adequate administration of the prescribed versus infused
volume in patients on nutritional therapy,” according to the goal (ILSI, 2018). Uruguaiana, RS, Brazil, 2022.
Reached
the target
of the
indicator
Study
Type of
cancer
Hospital
unit
Structu
re for
ENT
Characteristic
s of ENT
ENT
application
time
Target of
the
indicator
applied by
the
institution
Indicator
results
Reasons for the
interruption of
ENT*
(23)
Head and
neck,
GIT,
Breast,
Lung
Palliative
care unit
It has a
MNTT
Transpyloric
probe
488 days
≥ 80%
Adequacy of
prescribed and
infused volume:
92.6%
Gastrointestinal
complications,
Mechanics,
Respiratory,
Other**
(27)
Not
described
General and
Cardiologica
l ICU
It has a
MNTT
Transpyloric
probe
16.6 ± 12.2
days
≥ 70%
Adequacy of
prescribed and
infused volume:
82.7%
Complications
gastrointestinal
Mechanics,
Metabolic,
Other**
(28)
Not
described
Adult ICU
It has a
MNTT
Transpyloric
and
nasogastric
tube
Average 20.5
days
≥ 70%
Adequacy of
prescribed and
infused volume:
72.6%
Complications
gastrointestinal,
Mechanics,
Other**
Did not
reach the
target of
the
indicator
(21)
Head and
neck,
Gastrointe
stinal
tract,
Gynecolo
gical and
breast,
Male
reproducti
ve system
Adult ICU
Does
not
have a
MNTT
Transpyloric
probe
4 days
≥ 80%
Average
(difference in
volumes)
Day 1: -477.0
Day 2: -298.0
Day 3: -261.4
(peak)
Day 4: -445.9
Adequacy of
prescribed and
infused volume:
62.5%
Gastrointestinal
complications,
Mechanics
(24)
Not
described
Clinical
Ward
Does
not
have a
MNTT
Transpyloric
probe
16 days
≥ 70%
Adequacy of
prescribed and
infused volume:
58.5%
Complications
mechanics
(25)
Laryngeal
cancer
Adult ICU
Does
not
have a
MNTT
Industrialized
diet by
infusion pump
5 days
≥ 70%
Day 1: 741.5 -
498.6;
Day 2: 741.5 -
587.3;
Day 3: 923.1 -
472.5;
Day 4: 846.2 -
401.2;
Day 5: 769.2 -
351.5.
Average
prescribed
volume:
804.3/462.2
Gastrointestinal
complications,
Mechanics
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DOI: 10.56732/pensarenf.v27i1.265
(26)
Head and
neck,
Gastroint
estinal,
Thoracic,
Gynecolo
gical,
Urological
,
Lymphom
a /
leukemia
/
myeloma
Clinical
Ward
(Treatment
for
complicatio
ns of cancer
and / or
chemothera
py and
radiotherapy
)
It has a
MNTT
Transpyloric
probe
Closed system
diet, by
infusion pump
9.7 ± 7 days
≥ 80%
Adequacy of
prescribed and
infused volume:
74.3%
Gastrointestinal
complications
(29)
Not
described
Adult ICU
and medical
clinic
It has a
MNTT
Naso/orogastr
ic tube
Infusion pump
diet
3-30 days
≥ 70%
Average
difference of
the received
diet volume
(estimated -
received): 176.4
ml
Gastrointestinal
complications,
Mechanics
(22)
Not
described
Clinical and
surgical
ward
It has a
MNTT
Transpyloric
probe
7.41 ± 14.22
days
≥ 90%
Adequacy of
prescribed and
infused volume:
66.7%
Gastrointestinal
complications,
Mechanics
ENT: Enteral Nutritional Therapy; EN: Enteral Nutrition; ICU: Intensive Care Unit; MNTT: Multidisciplinary Nutritional Therapy Team.
*Reasons for the interruption of the EN described in the studies were classified as: (a) gastrointestinal complications: vomiting, abdominal distension,
diarrhea, reflux, emesis, gastric residue fasting for tests or procedures, bulky bleeding, melena, gastrointestinal intolerance; (b) mechanical
complications: tube obstruction, inadvertent exit of the tube, extravasation of the diet, delayed delivery of the NE, extubation,
procedures/examinations/surgeries and errors in the administration of the diet; (c) respiratory complications: bronchoaspiration; (d) metabolic
disorders: hemodynamic instability.
** Others: patient refusal, clinical worsening, lack of net protocol, end-of-life care, and death.
Discussion
Following the purpose of this review, the IQNT “NT
prescribed versus infused volume” in oncology has been
little investigated in the literature, and hospitalized adult
cancer patients have clinical difficulties in achieving their
goal. For nursing, summarizing the information of the
investigated IQNT becomes essential in the sense of
strategically directing care to the need for the nutrition of
the oncological patient to optimize treatment and ensure
better quality of life.30
The review identified that the authors’ profile was
composed mostly of nutritionists,21-23,25-28 although nursing
is responsible for monitoring the indicator under analysis.
13 In Brazil, specific legislation31 standardizes the
performance of the nursing team in the oro/nasogastric
and transpyloric probing and highlights the crucial role of
the nurse in the process of installing the device, choosing
the route of administration together with the doctor, in
addition to registration, patient evaluation and monitoring
of complications. However, when it comes to the EN area,
there is a growing line of research conducted by nurses
aimed at care in relation to assertive probe positioning
techniques,32 safe administration of EN,33 monitoring of
complications,34 and nursing protocols for ENT.35
The scientific literature already describes that hospitalized
cancer patients have some degree of malnutrition,5,36 and
ENT is one of the principal therapeutic resources for their
treatment and prognosis.37,38 In addition, cancer is one of
the main underlying diseases of hospitalized adult patients
in Brazil.39
In analytical corpus in which the IQNT goal was not met21-
26,29 the most prevalent cancers were head and neck21,26,
gastrointestinal tract21,26, gynecological21,26 and
urological.21,29 In those who have reached the goal23,27,28 the
most identified cancers were head and neck23
gastrointestinal tract23,27, breast23,28 and lung.23,24 These
findings corroborate with other Brazilian studies40,41 which
also identified the prevalence of these cancers in
hospitalized patients. This situation reflects the statistics
and estimates of the oncological scenario in Brazil, which
identifies breast and gastrointestinal cancers as the most
prevalent in the Brazilian population.42
The analysis also identified that most of the studies failed
to achieve the goal of the investigated IQNT.21-26,29 This
reality allows us to reflect that, could it be the specific
characteristics of the tumor and the treatment, as well as
the nutritional repercussions triggered in cancer patients37,38
that could condition the prognosis of the treatment and its
repercussions? This review found that the nutritional
supply for the cancer patient hospitalized by enteral route
has not guaranteed the adequate/total infusion of the
prescribed volume of EN, and therefore, this route is not
the most appropriate for these patients, and the parenteral
route may be more effective, given the clinical weakness of
the cancer patient throughout his treatment. Therefore, it
is essential that nursing, together with MNTTs, be able to
recognize such specificities, and direct a singular care plan
to provide adequate nutritional support.43 This result is
126 | Stija, L.
relevant in the context of nursing practices since, when
assisting cancer patients within their basic human needs,
food should be prioritized to contribute to treatment.38,44
The IQNT “NT prescribed versus infused volume” reflects
the evolution and quality of nutritional care, and for the
oncological patient to be able to receive the prescribed
volume of EN, several factors are fundamental, such as the
suitable dietary prescription, the appropriate route of
administration of EN, the quality of the EN device, the
monitoring and control of complications.13. Given this,
research32,33,35 reveals the engagement and protagonism of
Nursing in EN area, with promising results regarding good
practices in the administration of EN (GPAEN). 45 In a
study developed in Israel,46 nurses conducted a protocol to
address and correct the deficiencies of EN in an ICU, and
the feeding of the patient was started significantly earlier
(p = 0.007) in the intervention group (52.3 hours; SD, 42.6)
than in the control group (70.3 hours; SD, 65.2). The use
of the protocol resulted in a significant increase in
nutritional intake in 90% in the intervention group.
Studies that did not reach the IQNT goal21-26,29 identified
that the investigated hospital units were clinical and/or
surgical,22,24,26 adult/general ICU,21,25,29 and medical clinic,
29 and only three of these institutions22,26,29 owned MNTT.
Hospitals that reached the indicator’s goal were
general/adult ICU,27,28 Cardiologic ICU,27 and palliative
care unit.23. In these scenarios, the oncological patient is
already in a state of metabolic stress that triggers numerous
nourishing supplements deficits, which result in increased
nutritional needs.1,2 Thus, the research analyzed that, even
in closed/controlled hospital units, such as the ICU, and
the fact that the hospital institution has MNTTs, the
effectiveness of ENT for adult cancer patients is not
guaranteed, which minimally generates a movement to
(re)think nursing practices in ENT in these care units.
Therefore, especially in specific populations, the goal of the
IQNT “NT prescribed versus infused volume” can be
presented above what the cancer patient can receive, and
the patient’s clinical conditions should be evaluated for the
measurement of the indicator goal.
Regarding the length of application of the EN and the
IQNT, the research found that in studies that did not reach
the goal, oncological patients used the EN, on average, for
more than five days,22,24,26,29 corroborating with a study 47
in an oncology hospital, which identified that none of the
patients (n=96) managed to reach the prescribed volume of
EN, on seven days of exclusive EN. Indicator goals for
these studies alternate between ≥ 70%,24-26 ≥80%,21,26 and
≥ 90%,22 indicating that sometimes Brazilian institutions
follow the ILSI Brazil guidelines,13 sometimes they stipulate
their own targets according to the characteristics of the
hospital unit. For institutions that adopt different goals
(higher) than recommended in the guideline,13 planned care
structure, good health practices, and implementation of
protocols are necessary.13 Thus, one of the fundamental
elements for good results is to have MNTTs, which
perform the appropriate nutritional assessment36, choosing
the adequate device,48 the early onset of EN,39 monitoring
for complications of EN,34 the application of IQNT,49 and
continuing education actions.35,43,50
Among those studies that were able to achieve the goal, the
length of application of EN in cancer patients was greater
than five days,23,27,28 evidencing the existence of a
proportional relationship between time and the ability to
achieve the adequacy of the prescribed volume.47 This
situation can be explained because, in the first days of
hospitalization, cancer patients tend to present an unstable
clinical picture, greater exposure to health procedures and
interventions, and a care plan still in definition and
adaptation.48 Therefore, establishing the number of days
for EN requires more time for its administration. The goals
adopted by these institutions ranged from ≥70%27,28 and ≥
80%,26 following the guidelines of ILSI-Brazil and its
reformulations.13
The clinical repercussion in cancer patients who receive a
lower volume of EN is raised in different studies, 3-6 which
demonstrate that not reaching the goal of EN is correlated
with worse clinical outcomes, such as infection 4 issues and
complications3,5,6 during hospital stay. In this sense, there
must be a reflection to try to minimize the discrepancy
between nutritional planning and the effectiveness of this
plan. For nursing, it is necessary to ensure that the
prescribed volume is adequately infused, and, for this, it is
required to train the nursing team regarding the skills and
competencies that subsidize qualified care with EN and
patient safety.51
One of the reasons why the prescribed volume of EN is
not entirely infused in the adult oncological patient is
associated with gastrointestinal, metabolic, mechanical, and
respiratory character complications. Both in the studies that
reached and in those that did not reach the goal of the
indicator, the reasons for the major complications of EN
were gastrointestinal.21-23,25-29 Therefore, the analysis
observed that the main element that makes the cancer
patient unable to reach the prescribed volume of ENT is
linked to its clinical fragility that triggers gastrointestinal
complications, directly affecting the volume that the patient
should receive. That is, the clinical difficulties of the cancer
patient directly affect the volume of infused EN, and not
only the IQNT processes themselves.
For more than a decade, nurses have been conducting
research on different patient profiles39-40,50-51 to monitor
complications on the use of EN. In a prospective cohort,52
157 ICU patients were followed daily during the first ten
days of hospitalization and, among those who received and
did not receive EN, complications such as diarrhea and the
need for gastric decompression were more frequent in the
EN group (39.7 % vs. 11.7 %, p < 0.001 and 34
% vs. 13.3%, p = 0.004, respectively). Therefore, it is
necessary to constantly reevaluate EN care practices, from
the evaluation of diet formulation, the characteristics of EN
administration, the correct positioning of the tube, and the
continuous infusion mode.53
Among the limitations of the present review are the search
only in the Portuguese language performed in Google
Scholar and the eligibility criteria of complete original
Pensar Enfermagem / v.27 n.01 / december 2023 | 127
DOI: 10.56732/pensarenf.v27i1.265
studies available online may have limited the number of
studies reviewed and/or included.
Conclusion
This study allowed us to analyze the evidence of the IQNT
“NT prescribed versus infused volume” in the hospitalized
adult cancer patient, revealing that in most studies, the
indicator’s goal was not reached, and that the patient has
clinical difficulties in achieving it. The quality of nutritional
care to this population stratum permeates the articulation
between nursing care and the analyzed indicator.
In short, the results of this review point to the aspects of
the IQNT “NT prescribed versus infused volume” in
hospitalized adult cancer patients that weaken their
adequacy, and reflections on nursing care that can be
performed in the hospital setting, to improve GPAEN,
assisting nurses in the development of skills necessary for
clinical decision-making. In addition, the evidence raised in
this study about the interface of nursing practices with the
investigated IQNT can contribute to the planning of
individual nutritional support throughout the disease,
promoting the importance of Nursing in the various
aspects of care for oncological patients using ENTs. New
research must be developed to evaluate, through the IQNT
“NT prescribed versus infused volume,” what institutional
difficulties contribute so that the oncological patient does
not receive the adequate volume of EN.
In addition, the IQNT “NT prescribed versus infused
volume” has been presented in the literature with different
results (sometimes percent, sometimes average), which
makes it difficult to compare them. Another question refers
to the studies that included in their sample patients with
other clinical conditions, not exclusively oncological, in
which, at times, it was not possible to fragment/select the
values of the indicator by disease, which may have indicated
a more significant negative impact on the results of the
IQNT investigated.
Authors’ contributions
L. S. E - Conception and design of the study; data collection;
data analysis and interpretation; statistical analysis; drafting
the manuscript; critical review of the manuscript.
B. S. S - Conception and design of the study; drafting the
manuscript; critical review of the manuscript.
M. C. S. A - Critical review of the manuscript.
J. B - Critical review of the manuscript.
B. S - Conception and design of the study; data collection;
data analysis and interpretation; statistical analysis; obtaining
funding; rafting the manuscript; critical review of the
manuscript.
Conflicts of interest
No conflict of interest has been declared by the authors.
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