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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is caring for a client who is receiving continuous enteral tube feedings. The client suddenly begins coughing vigorously, becomes cyanotic, and exhibits intercostal retractions. In what order should the PN perform the following actions? Arrange the actions from first to last.

  1. 1Stop the continuous enteral tube feeding.
  2. 2Elevate the head of the bed to a high-Fowler's position.
  3. 3Obtain current vital signs and oxygen saturation.
  4. 4Notify the supervising registered nurse (RN).
  5. 5Document the sudden change in condition and actions taken.

Answer

The correct sequence is: Stop the feeding, elevate the head of the bed, obtain vital signs, notify the RN, and then document the event.
In any acute emergency, the practical nurse must follow the Airway, Breathing, Circulation (ABC) framework. When a client receiving an enteral feeding shows signs of respiratory distress (coughing, cyanosis), aspiration is suspected. The absolute first action is to stop the feeding (Airway protection). Next, positioning the client upright assists with Breathing. Once these immediate life-saving interventions are done, the nurse assesses the client (vital signs) to gather data. This data is then reported to the RN for further intervention. Documentation is always the final step after the client's immediate needs are met.

Step-by-Step Solution

1
Stop the continuous enteral tube feeding.
The flow of formula is halted.
This is a potential aspiration event. The Airway must be protected first by removing the source of the aspiration.
2
Elevate the head of the bed to a high-Fowler's position.
The client is sitting upright.
This position facilitates optimal lung expansion, eases work of breathing, and uses gravity to keep stomach contents away from the airway.
3
Obtain current vital signs and oxygen saturation.
Baseline physiological data during the acute event is collected.
Once the immediate airway and breathing interventions are applied, the PN must gather data to determine the severity of the client's respiratory distress.
4
Notify the supervising registered nurse (RN).
The RN is made aware of the emergency.
The PN must report the acute change and the obtained vital signs so the RN can assess the client and coordinate further medical interventions.
5
Document the sudden change in condition and actions taken.
The event is recorded in the medical record.
Accurate documentation is legally and clinically necessary but is always the lowest priority during an active bedside emergency.

Key Concept

Airway, Breathing, Circulation (ABC) Prioritization in Acute Emergencies
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Topics

Physiological Adaptation

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