A nurse is preparing to administer an intermittent bolus enteral feeding to a client via a gastrostomy tube. Place the following nursing actions in the correct chronological order.
- 1Position the client with the head of the bed elevated 30 to 45 degrees.
- 2Aspirate and measure the gastric residual volume.
- 3Flush the gastrostomy tube with 30 mL of water.
- 4Administer the prescribed volume of enteral feeding formula.
- 5Flush the tube with an additional 30 mL of water and clamp the device.
Answer
The correct sequence is: Position the client, measure gastric residual volume, flush with water, administer formula, and perform a final flush before clamping.
Administering a bolus enteral feeding requires a logical sequence prioritizing safety and aspiration prevention. First, the client must be placed in a semi-Fowler's position (30-45 degrees) to enlist gravity in preventing aspiration. Second, the nurse must assess the gastric residual volume to evaluate tolerance of previous feedings and confirm the stomach is not overly full. Third, a pre-flush of 30 mL of water is administered to confirm tube patency and clear the line. Fourth, the prescribed feeding formula is administered. Finally, a post-flush of 30 mL of water is required to clear formula from the tube lumen, preventing bacterial growth and tube occlusion, followed by clamping the tube.
Step-by-Step Solution
Key Concept
Safe administration of enteral tube feedings involves strict adherence to sequencing: positioning for aspiration precautions, assessing tolerance, verifying patency, administering the nutrient, and maintaining patency post-feed.
Estimated Time:1m 30s