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Difficulty: Very hardBasic Care and Comfort

An 82-year-old client with a history of vascular dementia and right-sided hemiparesis is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client is currently positioned with the head of the bed elevated at 45 degrees. The nurse notes the client has become acutely restless, is repeatedly pulling at the NG tube, and has not voided in the past 8 hours. Which of the following nursing interventions best demonstrates appropriate management of this client's basic care and comfort needs?

  1. Temporarily pause the enteral feeding, maintain the head of the bed at 30 degrees while assessing for urinary retention, and wrap the NG tube out of the client's visual field.Answer
  2. B
    Continue the continuous enteral infusion but lower the head of the bed to 10 degrees to facilitate optimal body alignment for bedpan placement.
  3. C
    Secure the client's hands with prescribed bilateral soft wrist restraints to prevent aspiration from tube dislodgment before conducting a physical assessment.
  4. D
    Attribute the acute increase in restlessness to the expected trajectory of vascular dementia and focus on decreasing environmental stimuli.

Answer

The correct approach is to temporarily pause the enteral feeding, maintain safe head elevation while assessing for the underlying cause of the acute agitation (such as urinary retention), and use non-restrictive methods (like camouflage) to protect the feeding tube.
The correct intervention effectively synthesizes three critical elements of basic care: preventing aspiration by pausing the feed and maintaining head elevation during care, assessing for a physiological cause of acute agitation (urinary retention) rather than assuming it is cognitive decline, and utilizing a non-restrictive alternative (camouflage) to protect the medical device.

Step-by-Step Solution

1
Analyze the client's sudden change in behavior.
Identify that acute restlessness and pulling at devices in a client with dementia often indicates an unmet physiological need, such as a full bladder after 8 hours without voiding.
Clients with cognitive impairment may lack the ability to verbally communicate physical discomfort, expressing it through agitation instead.
2
Prioritize airway safety during the required physical assessment.
Determine that the continuous enteral feeding must be paused and the head of the bed maintained at a minimum of 30 degrees during any assessment or bedpan placement.
Supine or low-Fowler's positioning during active continuous enteral feeding significantly increases the risk of regurgitation and aspiration pneumonia.
3
Select the appropriate intervention for device protection.
Choose to route or wrap the NG tube out of the client's visual field rather than applying restraints.
Nursing standards require the implementation of the least restrictive alternatives (such as tube camouflage) before utilizing physical restraints.

Key Concept

Integration of Aspiration Precautions, Atypical Presentation in Older Adults, and Restraint Alternatives
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Topics

Basic Care and Comfort

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