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Difficulty: Very hardBasic Care and Comfort

A practical nurse (PN) is planning care for an older adult client who is 4 hours postoperative following a percutaneous endoscopic gastrostomy (PEG) tube placement. The client has right-sided hemiplegia from a previous stroke, is receiving continuous enteral tube feedings, and is experiencing frequent episodes of liquid stool. Which of the following actions should the PN include in the client's plan of care? (Select all that apply.)

  1. Maintain the head of the bed elevated between 30 and 45 degrees while the enteral feeding is infusing.Answer
  2. Apply a prescribed moisture barrier cream to the perineal area after each episode of liquid stool.Answer
  3. Pause the continuous enteral feeding pump prior to lowering the head of the bed to turn and reposition the client.Answer
  4. D
    Position the client completely flat in a supine position for extended periods to minimize physical tension on the new PEG tube insertion site.
  5. E
    Administer a prescribed PRN opioid analgesic for abdominal discomfort prior to assessing the client's respiratory rate and oxygen saturation.
  6. F
    Apply bilateral soft wrist restraints to protect the PEG tube if the client appears confused and attempts to touch the surgical dressing.

Answer

The correct actions include maintaining the head of the bed elevated at 30 to 45 degrees during feeding, applying a moisture barrier cream after liquid stools, and pausing the feeding pump before lowering the head of the bed for repositioning.
Appropriate basic care for a client receiving continuous enteral nutrition includes keeping the head of the bed elevated between 30 and 45 degrees to prevent aspiration, and strictly pausing the feeding pump whenever the bed must be lowered to reposition the client. Additionally, applying a moisture barrier cream is a fundamental comfort and skin protection measure for clients experiencing frequent liquid stools.

Step-by-Step Solution

1
Analyze the client's airway and aspiration risks associated with continuous enteral feeding.
Identified that the client requires a 30 to 45-degree head of bed elevation, and that feedings must be paused whenever the bed is lowered.
Enteral formula can easily reflux into the airway if gravity is not utilized, causing aspiration pneumonia.
2
Evaluate the client's skin integrity risk due to frequent liquid stools.
Determined that perineal skin care with a moisture barrier cream is required.
Liquid stool is highly acidic and caustic to the skin, necessitating immediate and ongoing protective basic care.
3
Review the incorrect interventions for safety and scope of practice violations.
Eliminated options that violate ABC prioritization (giving opioids before respiratory assessment), bypass restraint alternatives, or position the client dangerously flat during feeding.
Nursing care must prioritize ABCs (Airway, Breathing, Circulation) and adhere strictly to least-restrictive restraint guidelines.

Key Concept

Basic Care and Comfort for Enteral Nutrition and Immobility
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Topics

Basic Care and Comfort

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