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Difficulty: MediumPhysiological Adaptation

During rounds, a client receiving continuous enteral tube feeding suddenly begins to cough vigorously, displays audible wheezing, and appears acutely dyspneic. In which order should the practical nurse (PN) perform the following actions? Arrange the interventions from highest priority (first) to lowest priority (last).

  1. 1Stop the continuous enteral tube feeding pump.
  2. 2Place the client in a high Fowler's or side-lying position.
  3. 3Suction the client's oropharyngeal airway.
  4. 4Obtain the client's vital signs and oxygen saturation.
  5. 5Notify the supervising registered nurse (RN) of the event.

Answer

The correct sequence prioritizes immediate airway protection: stop the feeding, position the client, suction the airway, obtain vital signs, and finally notify the registered nurse.
When managing an acute aspiration event, the nurse must immediately apply the airway, breathing, and circulation (ABC) prioritization framework. The absolute first priority is to stop the source of the aspiration. Next, physically positioning the client and clearing the airway take precedence over diagnostic assessment (vital signs) and communication (notifying the RN).

Step-by-Step Solution

1
Stop the continuous enteral tube feeding pump.
Further aspiration of formula is prevented.
Removing the source of harm is always the first action in an aspiration emergency.
2
Place the client in a high Fowler's or side-lying position.
The airway is physically protected using gravity.
Elevating the head of the bed or turning the client to the side prevents further aspiration of stomach contents and maximizes chest expansion.
3
Suction the client's oropharyngeal airway.
Aspirated formula and mucus are cleared from the upper airway.
Clearing the airway resolves the immediate physical obstruction to breathing.
4
Obtain the client's vital signs and oxygen saturation.
Objective data regarding the client's respiratory compromise is collected.
Assessment data is necessary to determine the severity of the hypoxia and need for further interventions like supplemental oxygen.
5
Notify the supervising registered nurse (RN) of the event.
The healthcare team is alerted to the critical change in condition.
Medical evaluation is required to assess for complications such as aspiration pneumonia and to order subsequent treatments.

Key Concept

Prioritization of Airway, Breathing, and Circulation (ABC) during aspiration emergencies
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Topics

Physiological Adaptation

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