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Difficulty: Very hardPhysiological Adaptation

A practical nurse (PN) is caring for a client who is receiving continuous enteral tube feedings via a nasogastric (NG) tube. The client suddenly begins to vomit and cough forcefully, and their oxygen saturation drops to 88%. Arrange the following nursing actions in the correct priority order from first to last.

  1. 1Stop the continuous enteral feeding pump immediately.
  2. 2Turn the client into a side-lying position.
  3. 3Suction the oropharynx to clear emesis and secretions.
  4. 4Apply supplemental oxygen to address the hypoxia.
  5. 5Notify the registered nurse (RN) regarding the aspiration event.

Answer

The correct priority order is to first stop the continuous enteral feeding pump, then turn the client to a side-lying position, next suction the oropharynx, apply supplemental oxygen, and finally notify the registered nurse (RN).
In any acute aspiration event associated with a continuous infusion, the nurse must first stop the source of the problem (the feeding pump). Next, the nurse must immediately protect the airway by utilizing gravity (side-lying position) to allow emesis to drain. Once positioned, the nurse suctions the oropharynx to actively clear residual fluid. Only after the airway is patent and clear should supplemental oxygen be applied to treat the hypoxia. Finally, after these rapid, life-saving bedside interventions are implemented, the nurse must notify the RN and healthcare provider for further assessment and orders.

Step-by-Step Solution

1
Stop the continuous enteral feeding pump immediately.
The infusion of formula into the stomach is halted.
Removing the ongoing source of potential aspiration is the absolute first priority to prevent worsening of the respiratory compromise.
2
Turn the client into a side-lying position.
The airway is protected via gravity.
Allowing emesis to drain out of the mouth prevents fluid from pooling into the trachea. This must be done before suctioning if the client is actively vomiting.
3
Suction the oropharynx to clear emesis and secretions.
The airway is actively cleared of residual fluid.
Ensuring a patent airway is required before any oxygen therapy can be effective.
4
Apply supplemental oxygen to address the hypoxia.
Oxygen saturation levels improve.
Treats the acute hypoxia (88% SpO2) caused by the aspiration event now that the airway is clear.
5
Notify the registered nurse (RN) regarding the aspiration event.
The healthcare team is alerted.
Escalates the situation for further medical assessment, respiratory therapy involvement, and provider orders after the client is initially stabilized.

Key Concept

Airway Protection and Emergency Prioritization in Enteral Feeding
Estimated Time:2m 0s
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Topics

Physiological Adaptation

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