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Nutritional Care Process in Patients Receiving Tube Feeding

Year 2023, Volume: 6 Issue: 2, 89 - 100, 30.08.2023
https://doi.org/10.51536/tusbad.1315649

Abstract

The aim of tube feeding, which is one of the enteral nutrition methods, is to prevent or treat malnutrition. Tube feeding is commonly used in patients with severe appetite loss, swallowing problems, or who have undergone surgery that do not respond to oral nutritional support. A standardized Nutritional Care Process is important because it encourages critical thinking, provides safe, effective nutritional care, simplifies continuity of care and coordination of treatment. Many dietitians working in the field of clinical nutrition in tube feeding fully implement the steps of this globally standardized nutritional care process. In this review, the practical steps of the Nutrition Care Process in the follow-up of patients receiving tube feeding are discussed.

References

  • Fitzpatrick F, Skally M, O'Hanlon C, Foley M, Houlihan J, Gaughan L, et al. Food for thought. Malnutrition risk associated with increased risk of healthcare-associated infection. Journal of Hospital Infection. 2019;101(3):300-4.
  • Dent E, Hoogendijk EO, Visvanathan R, Wright ORL. Malnutrition Screening and Assessment in Hospitalised Older People: a Review. J Nutr Health Aging. 2019;23(5):431-41.
  • Bally MR, Blaser Yildirim PZ, Bounoure L, Gloy VL, Mueller B, Briel M, et al. Nutritional Support and Outcomes in Malnourished Medical Inpatients: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016;176(1):43-53.
  • Curtis LJ, Bernier P, Jeejeebhoy K, Allard J, Duerksen D, Gramlich L, et al. Costs of hospital malnutrition. Clin Nutr. 2017;36(5):1391-6.
  • Schuetz P, Seres D, Lobo DN, Gomes F, Kaegi-Braun N, Stanga Z. Management of disease-related malnutrition for patients being treated in hospital. Lancet. 2021;398(10314):1927-38.
  • Bellanti F, Lo Buglio A, Quiete S, Vendemiale G. Malnutrition in Hospitalized Old Patients: Screening and Diagnosis, Clinical Outcomes, and Management. Nutrients. 2022;14(4).
  • Doley J. Enteral Nutrition Overview. Nutrients. 2022;14(11).
  • Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT. Percutaneous endoscopic gastrostomy: indications, technique, complications and management. World J Gastroenterol. 2014;20(24):7739-51.
  • Kirkland LL, Kashiwagi DT, Brantley S, Scheurer D, Varkey P. Nutrition in the hospitalized patient. J Hosp Med. 2013;8(1):52-8.
  • Compher C, Bingham AL, McCall M, Patel J, Rice TW, Braunschweig C, et al. Guidelines for the provision of nutrition support therapy in the adult critically ill patient: The American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr. 2022;46(1):12-41.
  • Lacey K, Pritchett E. Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management. J Am Diet Assoc. 2003;103(8):1061-72.
  • Matthews KL, Palmer MA, Capra SM. The accuracy and consistency of nutrition care process terminology use in cases of refeeding syndrome. Nutr Diet. 2018;75(3):331-6.
  • White JV, Guenter P, Jensen G, Malone A, Schofield M, Academy Malnutrition Work G, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012;36(3):275-83.
  • Mueller C, Compher C, Ellen DM, American Society for P, Enteral Nutrition Board of D. A.S.P.E.N. clinical guidelines: Nutrition screening, assessment, and intervention in adults. JPEN J Parenter Enteral Nutr. 2011;35(1):16-24.
  • Kondrup J, Allison SP, Elia M, Vellas B, Plauth M, Educational, et al. ESPEN guidelines for nutrition screening 2002. Clin Nutr. 2003;22(4):415-21.
  • Skipper A, Coltman A, Tomesko J, Charney P, Porcari J, Piemonte TA, et al. Reprint of: Position of the Academy of Nutrition and Dietetics: Malnutrition (Undernutrition) Screening Tools for All Adults. J Acad Nutr Diet. 2022;122(10S):S50-S4.
  • Seron-Arbeloa C, Labarta-Monzon L, Puzo-Foncillas J, Mallor-Bonet T, Lafita-Lopez A, Bueno-Vidales N, et al. Malnutrition Screening and Assessment. Nutrients. 2022;14(12).
  • Pirlich M, Lochs H, Ockenga J. [Enteral nutrition]. Internist (Berl). 2006;47(4):405-19; quiz 20-21.
  • Dort JC, Farwell DG, Findlay M, Huber GF, Kerr P, Shea-Budgell MA, et al. Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction: A Consensus Review and Recommendations From the Enhanced Recovery After Surgery Society. JAMA Otolaryngol Head Neck Surg. 2017;143(3):292-303.
  • Bossola M, Antocicco M, Pepe G. Tube feeding in patients with head and neck cancer undergoing chemoradiotherapy: A systematic review. JPEN J Parenter Enteral Nutr. 2022;46(6):1258-69.
  • Gill A, Farwell DG, Moore MG. Nutrition and Perioperative Care for the Patient with Head and Neck Cancer. Oral Maxillofac Surg Clin North Am. 2018;30(4):411-20.
  • Swan WI, Pertel DG, Hotson B, Lloyd L, Orrevall Y, Trostler N, et al. Nutrition Care Process (NCP) Update Part 2: Developing and Using the NCP Terminology to Demonstrate Efficacy of Nutrition Care and Related Outcomes. J Acad Nutr Diet. 2019;119(5):840-55.
  • Jensen GL, Cederholm T, Correia M, Gonzalez MC, Fukushima R, Higashiguchi T, et al. GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community. JPEN J Parenter Enteral Nutr. 2019;43(1):32-40.
  • Wetherill MS, White KC, Rivera C. Food Insecurity and the Nutrition Care Process: Practical Applications for Dietetics Practitioners. J Acad Nutr Diet. 2018;118(12):2223-34.
  • McClave SA, DiBaise JK, Mullin GE, Martindale RG. ACG Clinical Guideline: Nutrition Therapy in the Adult Hospitalized Patient. Am J Gastroenterol. 2016;111(3):315-34; quiz 35.
  • Evans DC, Forbes R, Jones C, Cotterman R, Njoku C, Thongrong C, et al. Continuous versus bolus tube feeds: Does the modality affect glycemic variability, tube feeding volume, caloric intake, or insulin utilization? Int J Crit Illn Inj Sci. 2016;6(1):9-15.
  • de Araujo VMT, Gomes PC, Caporossi C. Enteral nutrition in critical patients; should the administration be continuous or intermittent? Nutricion Hospitalaria. 2014;29(3):563-7.
  • McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159-211.
  • Song J, Zhong Y, Lu X, Kang X, Wang Y, Guo W, et al. Enteral nutrition provided within 48 hours after admission in severe acute pancreatitis: A systematic review and meta-analysis. Medicine (Baltimore). 2018;97(34):e11871.
  • Petrov MS, Pylypchuk RD, Uchugina AF. A systematic review on the timing of artificial nutrition in acute pancreatitis. Br J Nutr. 2009;101(6):787-93.
  • Yanni A, Dequanter D, Lechien JR, Loeb I, Rodriguez A, Javadian R, et al. Malnutrition in head and neck cancer patients: Impacts and indications of a prophylactic percutaneous endoscopic gastrostomy. Eur Ann Otorhinolaryngol Head Neck Dis. 2019;136(3S):S27-S33.
  • Schlein KM, Coulter SP. Best practices for determining resting energy expenditure in critically ill adults. Nutr Clin Pract. 2014;29(1):44-55.
  • De Waele E, Opsomer T, Honore PM, Diltoer M, Mattens S, Huyghens L, et al. Measured versus calculated resting energy expenditure in critically ill adult patients. Do mathematics match the gold standard? Minerva Anestesiol. 2015;81(3):272-82.
  • Merker M, Gomes F, Stanga Z, Schuetz P. Evidence-based nutrition for the malnourished, hospitalised patient: one bite at a time. Swiss Med Wkly. 2019;149:w20112.
  • Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48-79.
  • Lucchini A, Bonetti I, Borrelli G, Calabrese N, Volpe S, Gariboldi R, et al. [Enteral nutrition during prone positioning in mechanically ventilated patients]. Assist Inferm Ric. 2017;36(2):76-83.
  • Sams VG, Lawson CM, Humphrey CL, Brantley SL, Schumacher LM, Karlstad MD, et al. Effect of rotational therapy on aspiration risk of enteral feeds. Nutr Clin Pract. 2012;27(6):808-11.
  • Reintam Blaser A, Deane AM, Fruhwald S. Diarrhoea in the critically ill. Curr Opin Crit Care. 2015;21(2):142-53.
  • Pitta MR, Campos FM, Monteiro AG, Cunha AGF, Porto JD, Gomes RR. Tutorial on Diarrhea and Enteral Nutrition: A Comprehensive Step-By-Step Approach. JPEN J Parenter Enteral Nutr. 2019;43(8):1008-19.
  • Green CH, Busch RA, Patel JJ. Fiber in the ICU: Should it Be a Regular Part of Feeding? Curr Gastroenterol Rep. 2021;23(9):14.
  • Bischoff SC, Austin P, Boeykens K, Chourdakis M, Cuerda C, Jonkers-Schuitema C, et al. ESPEN practical guideline: Home enteral nutrition. Clin Nutr. 2022;41(2):468-88.
  • Lovestam E, Orrevall Y, Koochek A, Karlstrom B, Andersson A. Evaluation of a Nutrition Care Process-based audit instrument, the Diet-NCP-Audit, for documentation of dietetic care in medical records. Scand J Caring Sci. 2014;28(2):390-7.

Tüple Beslenme Desteği Alan Hastalarda Beslenme Bakım Süreci

Year 2023, Volume: 6 Issue: 2, 89 - 100, 30.08.2023
https://doi.org/10.51536/tusbad.1315649

Abstract

Enteral beslenme yöntemlerinden biri olan tüple beslenme desteğinin ana hedefi malnütrisyonun önlenmesi veya tedavi edilmesidir. Oral beslenme desteğine yanıt vermeyen şiddetli iştah kaybı, yutma problemleri olan ya da cerrahi işlem geçirmiş hastalarda yaygın olarak tüple beslenme desteği kullanılmaktadır. Standartlaştırılmış bir Beslenme Bakım Süreci, eleştirel düşünmeyi teşvik ettiği, güvenli, etkili beslenme bakımı sağladığı, bakımın sürekliliğini ve tedavinin koordinasyonunu basitleştirdiği için önemlidir. Tüple beslenme desteğinde, klinik nütrisyon alanında çalışan birçok diyetisyen küresel olarak standartlaştırılmış bu beslenme bakım sürecinin adımlarını tam olarak uygulamaktadır. Bu derlemede tüple beslenme desteği alan hastaların takibinde Beslenme Bakım Sürecinin pratik uygulamadaki adımları ele alınmıştır.

References

  • Fitzpatrick F, Skally M, O'Hanlon C, Foley M, Houlihan J, Gaughan L, et al. Food for thought. Malnutrition risk associated with increased risk of healthcare-associated infection. Journal of Hospital Infection. 2019;101(3):300-4.
  • Dent E, Hoogendijk EO, Visvanathan R, Wright ORL. Malnutrition Screening and Assessment in Hospitalised Older People: a Review. J Nutr Health Aging. 2019;23(5):431-41.
  • Bally MR, Blaser Yildirim PZ, Bounoure L, Gloy VL, Mueller B, Briel M, et al. Nutritional Support and Outcomes in Malnourished Medical Inpatients: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016;176(1):43-53.
  • Curtis LJ, Bernier P, Jeejeebhoy K, Allard J, Duerksen D, Gramlich L, et al. Costs of hospital malnutrition. Clin Nutr. 2017;36(5):1391-6.
  • Schuetz P, Seres D, Lobo DN, Gomes F, Kaegi-Braun N, Stanga Z. Management of disease-related malnutrition for patients being treated in hospital. Lancet. 2021;398(10314):1927-38.
  • Bellanti F, Lo Buglio A, Quiete S, Vendemiale G. Malnutrition in Hospitalized Old Patients: Screening and Diagnosis, Clinical Outcomes, and Management. Nutrients. 2022;14(4).
  • Doley J. Enteral Nutrition Overview. Nutrients. 2022;14(11).
  • Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT. Percutaneous endoscopic gastrostomy: indications, technique, complications and management. World J Gastroenterol. 2014;20(24):7739-51.
  • Kirkland LL, Kashiwagi DT, Brantley S, Scheurer D, Varkey P. Nutrition in the hospitalized patient. J Hosp Med. 2013;8(1):52-8.
  • Compher C, Bingham AL, McCall M, Patel J, Rice TW, Braunschweig C, et al. Guidelines for the provision of nutrition support therapy in the adult critically ill patient: The American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr. 2022;46(1):12-41.
  • Lacey K, Pritchett E. Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management. J Am Diet Assoc. 2003;103(8):1061-72.
  • Matthews KL, Palmer MA, Capra SM. The accuracy and consistency of nutrition care process terminology use in cases of refeeding syndrome. Nutr Diet. 2018;75(3):331-6.
  • White JV, Guenter P, Jensen G, Malone A, Schofield M, Academy Malnutrition Work G, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012;36(3):275-83.
  • Mueller C, Compher C, Ellen DM, American Society for P, Enteral Nutrition Board of D. A.S.P.E.N. clinical guidelines: Nutrition screening, assessment, and intervention in adults. JPEN J Parenter Enteral Nutr. 2011;35(1):16-24.
  • Kondrup J, Allison SP, Elia M, Vellas B, Plauth M, Educational, et al. ESPEN guidelines for nutrition screening 2002. Clin Nutr. 2003;22(4):415-21.
  • Skipper A, Coltman A, Tomesko J, Charney P, Porcari J, Piemonte TA, et al. Reprint of: Position of the Academy of Nutrition and Dietetics: Malnutrition (Undernutrition) Screening Tools for All Adults. J Acad Nutr Diet. 2022;122(10S):S50-S4.
  • Seron-Arbeloa C, Labarta-Monzon L, Puzo-Foncillas J, Mallor-Bonet T, Lafita-Lopez A, Bueno-Vidales N, et al. Malnutrition Screening and Assessment. Nutrients. 2022;14(12).
  • Pirlich M, Lochs H, Ockenga J. [Enteral nutrition]. Internist (Berl). 2006;47(4):405-19; quiz 20-21.
  • Dort JC, Farwell DG, Findlay M, Huber GF, Kerr P, Shea-Budgell MA, et al. Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction: A Consensus Review and Recommendations From the Enhanced Recovery After Surgery Society. JAMA Otolaryngol Head Neck Surg. 2017;143(3):292-303.
  • Bossola M, Antocicco M, Pepe G. Tube feeding in patients with head and neck cancer undergoing chemoradiotherapy: A systematic review. JPEN J Parenter Enteral Nutr. 2022;46(6):1258-69.
  • Gill A, Farwell DG, Moore MG. Nutrition and Perioperative Care for the Patient with Head and Neck Cancer. Oral Maxillofac Surg Clin North Am. 2018;30(4):411-20.
  • Swan WI, Pertel DG, Hotson B, Lloyd L, Orrevall Y, Trostler N, et al. Nutrition Care Process (NCP) Update Part 2: Developing and Using the NCP Terminology to Demonstrate Efficacy of Nutrition Care and Related Outcomes. J Acad Nutr Diet. 2019;119(5):840-55.
  • Jensen GL, Cederholm T, Correia M, Gonzalez MC, Fukushima R, Higashiguchi T, et al. GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community. JPEN J Parenter Enteral Nutr. 2019;43(1):32-40.
  • Wetherill MS, White KC, Rivera C. Food Insecurity and the Nutrition Care Process: Practical Applications for Dietetics Practitioners. J Acad Nutr Diet. 2018;118(12):2223-34.
  • McClave SA, DiBaise JK, Mullin GE, Martindale RG. ACG Clinical Guideline: Nutrition Therapy in the Adult Hospitalized Patient. Am J Gastroenterol. 2016;111(3):315-34; quiz 35.
  • Evans DC, Forbes R, Jones C, Cotterman R, Njoku C, Thongrong C, et al. Continuous versus bolus tube feeds: Does the modality affect glycemic variability, tube feeding volume, caloric intake, or insulin utilization? Int J Crit Illn Inj Sci. 2016;6(1):9-15.
  • de Araujo VMT, Gomes PC, Caporossi C. Enteral nutrition in critical patients; should the administration be continuous or intermittent? Nutricion Hospitalaria. 2014;29(3):563-7.
  • McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159-211.
  • Song J, Zhong Y, Lu X, Kang X, Wang Y, Guo W, et al. Enteral nutrition provided within 48 hours after admission in severe acute pancreatitis: A systematic review and meta-analysis. Medicine (Baltimore). 2018;97(34):e11871.
  • Petrov MS, Pylypchuk RD, Uchugina AF. A systematic review on the timing of artificial nutrition in acute pancreatitis. Br J Nutr. 2009;101(6):787-93.
  • Yanni A, Dequanter D, Lechien JR, Loeb I, Rodriguez A, Javadian R, et al. Malnutrition in head and neck cancer patients: Impacts and indications of a prophylactic percutaneous endoscopic gastrostomy. Eur Ann Otorhinolaryngol Head Neck Dis. 2019;136(3S):S27-S33.
  • Schlein KM, Coulter SP. Best practices for determining resting energy expenditure in critically ill adults. Nutr Clin Pract. 2014;29(1):44-55.
  • De Waele E, Opsomer T, Honore PM, Diltoer M, Mattens S, Huyghens L, et al. Measured versus calculated resting energy expenditure in critically ill adult patients. Do mathematics match the gold standard? Minerva Anestesiol. 2015;81(3):272-82.
  • Merker M, Gomes F, Stanga Z, Schuetz P. Evidence-based nutrition for the malnourished, hospitalised patient: one bite at a time. Swiss Med Wkly. 2019;149:w20112.
  • Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48-79.
  • Lucchini A, Bonetti I, Borrelli G, Calabrese N, Volpe S, Gariboldi R, et al. [Enteral nutrition during prone positioning in mechanically ventilated patients]. Assist Inferm Ric. 2017;36(2):76-83.
  • Sams VG, Lawson CM, Humphrey CL, Brantley SL, Schumacher LM, Karlstad MD, et al. Effect of rotational therapy on aspiration risk of enteral feeds. Nutr Clin Pract. 2012;27(6):808-11.
  • Reintam Blaser A, Deane AM, Fruhwald S. Diarrhoea in the critically ill. Curr Opin Crit Care. 2015;21(2):142-53.
  • Pitta MR, Campos FM, Monteiro AG, Cunha AGF, Porto JD, Gomes RR. Tutorial on Diarrhea and Enteral Nutrition: A Comprehensive Step-By-Step Approach. JPEN J Parenter Enteral Nutr. 2019;43(8):1008-19.
  • Green CH, Busch RA, Patel JJ. Fiber in the ICU: Should it Be a Regular Part of Feeding? Curr Gastroenterol Rep. 2021;23(9):14.
  • Bischoff SC, Austin P, Boeykens K, Chourdakis M, Cuerda C, Jonkers-Schuitema C, et al. ESPEN practical guideline: Home enteral nutrition. Clin Nutr. 2022;41(2):468-88.
  • Lovestam E, Orrevall Y, Koochek A, Karlstrom B, Andersson A. Evaluation of a Nutrition Care Process-based audit instrument, the Diet-NCP-Audit, for documentation of dietetic care in medical records. Scand J Caring Sci. 2014;28(2):390-7.
There are 42 citations in total.

Details

Primary Language Turkish
Subjects Nutritional Science
Journal Section Derleme
Authors

Sevgi Kayahan 0000-0002-9670-228X

Eda Köksal 0000-0002-7930-9910

Publication Date August 30, 2023
Published in Issue Year 2023 Volume: 6 Issue: 2

Cite

APA Kayahan, S., & Köksal, E. (2023). Tüple Beslenme Desteği Alan Hastalarda Beslenme Bakım Süreci. Türkiye Sağlık Bilimleri Ve Araştırmaları Dergisi, 6(2), 89-100. https://doi.org/10.51536/tusbad.1315649
AMA Kayahan S, Köksal E. Tüple Beslenme Desteği Alan Hastalarda Beslenme Bakım Süreci. Türkiye Sağlık Bilimleri ve Araştırmaları Dergisi. August 2023;6(2):89-100. doi:10.51536/tusbad.1315649
Chicago Kayahan, Sevgi, and Eda Köksal. “Tüple Beslenme Desteği Alan Hastalarda Beslenme Bakım Süreci”. Türkiye Sağlık Bilimleri Ve Araştırmaları Dergisi 6, no. 2 (August 2023): 89-100. https://doi.org/10.51536/tusbad.1315649.
EndNote Kayahan S, Köksal E (August 1, 2023) Tüple Beslenme Desteği Alan Hastalarda Beslenme Bakım Süreci. Türkiye Sağlık Bilimleri ve Araştırmaları Dergisi 6 2 89–100.
IEEE S. Kayahan and E. Köksal, “Tüple Beslenme Desteği Alan Hastalarda Beslenme Bakım Süreci”, Türkiye Sağlık Bilimleri ve Araştırmaları Dergisi, vol. 6, no. 2, pp. 89–100, 2023, doi: 10.51536/tusbad.1315649.
ISNAD Kayahan, Sevgi - Köksal, Eda. “Tüple Beslenme Desteği Alan Hastalarda Beslenme Bakım Süreci”. Türkiye Sağlık Bilimleri ve Araştırmaları Dergisi 6/2 (August 2023), 89-100. https://doi.org/10.51536/tusbad.1315649.
JAMA Kayahan S, Köksal E. Tüple Beslenme Desteği Alan Hastalarda Beslenme Bakım Süreci. Türkiye Sağlık Bilimleri ve Araştırmaları Dergisi. 2023;6:89–100.
MLA Kayahan, Sevgi and Eda Köksal. “Tüple Beslenme Desteği Alan Hastalarda Beslenme Bakım Süreci”. Türkiye Sağlık Bilimleri Ve Araştırmaları Dergisi, vol. 6, no. 2, 2023, pp. 89-100, doi:10.51536/tusbad.1315649.
Vancouver Kayahan S, Köksal E. Tüple Beslenme Desteği Alan Hastalarda Beslenme Bakım Süreci. Türkiye Sağlık Bilimleri ve Araştırmaları Dergisi. 2023;6(2):89-100.