A client receiving continuous enteral nutrition via a nasogastric tube suddenly begins to cough forcefully. The practical nurse observes that the client is experiencing severe dyspnea and has developed circumoral cyanosis. In what order should the practical nurse prioritize the following immediate actions? Arrange the actions in chronological order from first to last.
- 1Stop the continuous enteral feeding pump.
- 2Turn the client to a lateral, side-lying position.
- 3Suction the client's oropharynx.
- 4Administer supplemental oxygen as prescribed.
- 5Report the acute event to the registered nurse (RN).
Answer
The correct sequence is to first stop the feeding, then position the client laterally, suction the airway, administer oxygen, and finally notify the registered nurse.
When a client receiving continuous enteral feeding exhibits signs of acute aspiration (such as coughing, dyspnea, and cyanosis), the practical nurse must follow a strict prioritization sequence. The absolute first priority is to stop the source of the aspiration by turning off the feeding pump; failing to do so allows further fluid to compromise the lungs. Second, the airway must be protected physically by turning the client to a lateral position, which uses gravity to drain secretions and prevent further inhalation. Third, the nurse suctions the oropharynx to actively clear the airway of aspirated formula. Fourth, with a clear airway established, supplemental oxygen is administered to treat the resulting hypoxia. Finally, after resolving the immediate life-threatening crisis at the bedside, the nurse reports the event to the registered nurse (RN) to coordinate ongoing evaluation, such as diagnostic imaging and provider notification.
Step-by-Step Solution
Key Concept
Prioritization during acute aspiration: Stop the causative agent first, followed by Airway, Breathing, and Notification.