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Question

Difficulty: MediumBasic Care and Comfort

The healthcare team is preparing to perform a bed bath and linen change for a client receiving continuous enteral nutrition via a nasogastric tube. Which action should the registered nurse take to maintain safety during this care?

  1. Pause the continuous enteral feeding pump before lowering the head of the bed to reposition.Answer
  2. B
    Delegate the verification of gastric residual volume to the unlicensed assistive personnel before the bath.
  3. C
    Maintain the head of the bed at a 15-degree elevation while the enteral feeding continues.
  4. D
    Apply sterile gloves and a gown prior to handling the enteral feeding tubing and equipment.

Answer

The nurse must pause the continuous enteral feeding pump before lowering the head of the bed.
Clients receiving continuous enteral feedings are at a high risk for aspiration. To safely perform procedures that require lowering the head of the bed, such as a complete linen change or lateral turning, the nurse must first pause the feeding pump. The bed should only be lowered after the feeding is stopped, and the head of the bed must be returned to a minimum 30-degree elevation before the feeding is resumed.

Step-by-Step Solution

1
Analyze the current therapy against the physical requirements of the planned care procedure.
The client requires a linen change (which typically requires lowering the bed flat to reposition) while receiving a continuous tube feeding.
Identifying conflicts between ongoing treatments and hygiene care is essential to prevent complications.
2
Determine the primary safety risk associated with the procedure.
Lowering the head of the bed while formula is actively infusing places the client at a severe risk for pulmonary aspiration.
Enteral formula can easily regurgitate up the esophagus and into the airway if gravity is not assisting gastric emptying.
3
Select the appropriate nursing intervention to eliminate this risk.
The continuous feeding must be temporarily paused before the bed is lowered, and only resumed once the client is repositioned with the head elevated appropriately.
Stopping the flow of formula ensures the stomach is not actively filling while the client is supine during the linen change.

Key Concept

Aspiration Precautions and Safe Positioning During Enteral Feeding
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Topics

Basic Care and Comfort

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