A practical nurse is caring for a client who had a stroke resulting in right-sided weakness and expressive aphasia. The client is receiving continuous enteral nutrition via a nasogastric tube and requires repositioning. Which action by the nurse is essential to prevent a care-related error or injury?
- Pause the continuous enteral feeding pump before lowering the head of the bed to turn the client.Answer
- BApply physical wrist restraints to prevent the client from pulling at the feeding tube.
- CSkip scanning the client's identification band prior to administering medications since the client cannot speak.
- DContinue to provide morning hygiene care instead of immediately evaluating the client's sudden, new-onset coughing.
Answer
Pause the continuous enteral feeding pump before lowering the head of the bed to turn the client.
Clients receiving continuous enteral feedings are at a highly elevated risk for aspiration pneumonia. To safely turn and reposition a client, the nurse often needs to lay the bed flat to maintain spinal alignment and use lifting devices properly. However, the feeding pump must always be paused before lowering the head of the bed to prevent the gastric formula from refluxing into the esophagus and entering the lungs. Once the client is safely repositioned and the head of the bed is elevated back to a minimum of 30 degrees, the feeding can be safely resumed.
Step-by-Step Solution
Key Concept
Aspiration Prevention during Enteral Feeding