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Difficulty: HardBasic Care and Comfort

An 82-year-old resident in a long-term care facility receives continuous enteral nutrition via a percutaneous endoscopic gastrostomy (PEG) tube. The nursing staff observes that the resident has recently developed sudden-onset confusion, frequent bowel incontinence, and worsening sacral erythema. Which action by the registered nurse demonstrates safe practice regarding the client's basic care and comfort?

  1. Suspending the enteral infusion before lowering the head of the bed to provide perineal hygiene and relieve sacral pressureAnswer
  2. B
    Placing the resident in a continuous flat, left lateral Sims position to completely offload sacral pressure while the feeding infuses
  3. C
    Delegating the unlicensed assistive personnel (UAP) to evaluate the stool characteristics and apply a medicated barrier ointment
  4. D
    Attributing the sudden cognitive decline to expected age-related dementia and focusing solely on routine moisture management

Answer

The nurse must suspend the enteral infusion before lowering the head of the bed to provide perineal hygiene and relieve sacral pressure.
Suspending the enteral feeding before lowering the head of the bed is the correct priority action. It is essential to prevent regurgitation and pulmonary aspiration during repositioning and hygiene care. Maintaining an elevated head of bed is a mandatory safety parameter for active enteral infusions.

Step-by-Step Solution

1
Analyze the client's current clinical situation and risk factors.
The client is receiving continuous PEG feedings, has sacral erythema requiring offloading and frequent hygiene, and exhibits sudden cognitive changes.
Identifying overlapping needs (skin integrity vs. aspiration risk) is required to prioritize safe care delivery.
2
Evaluate the safety parameters for positioning a client receiving continuous enteral nutrition.
The head of the bed must be elevated at 30 to 45 degrees during active feeding to utilize gravity in preventing reflux.
A flat position during feeding severely increases the risk of gastric contents entering the respiratory tract.
3
Determine the appropriate intervention that addresses skin integrity without compromising airway safety.
The feeding pump must be paused prior to repositioning the client flat for hygiene and pressure relief.
This sequenced approach balances the need for essential incontinence care with critical airway protection.

Key Concept

Basic Care and Comfort: Enteral Tube Feeding Safety and Positioning
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Topics

Basic Care and Comfort

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