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Difficulty: MediumBasic Care and Comfort

An older adult resident in a long-term care facility requires a bed linen change and perineal care. The resident is currently receiving continuous enteral nutrition via a gastrostomy tube. What is the most important action for the nurse to perform before adjusting the bed to a flat position?

  1. Pause the continuous enteral feeding pump.Answer
  2. B
    Turn the resident onto the right side to promote gastric emptying.
  3. C
    Assess the resident's baseline respiratory rate and oxygen saturation.
  4. D
    Instruct the nursing assistant to monitor the tube insertion site during the turn.

Answer

Pause the continuous enteral feeding pump.
Clients receiving continuous enteral feedings must have the head of the bed elevated to at least 30 to 45 degrees to prevent regurgitation and aspiration. When the head of the bed must be lowered for basic care procedures, such as a linen change or repositioning, the priority is to pause the feeding pump first. This action directly protects the client's airway.

Step-by-Step Solution

1
Identify the primary risk associated with lowering the head of the bed for a client receiving continuous enteral nutrition.
Laying the client flat increases the risk of gastric reflux and pulmonary aspiration.
Gravity is required to keep the enteral formula in the stomach and prevent it from flowing back up into the esophagus and airway.
2
Determine the necessary preventive intervention prior to moving the client.
The continuous feeding must be temporarily stopped.
Halting the flow of formula ensures the stomach volume does not increase while the client lacks the protective effect of gravity.

Key Concept

Aspiration Precautions and Enteral Feeding Management
Estimated Time:1m 0s
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Topics

Basic Care and Comfort

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