A nurse is caring for a client who is receiving continuous enteral nutrition via a nasogastric tube. The client suddenly begins coughing vigorously, becomes tachypneic, and their oxygen saturation drops to 88% on room air. Arrange the following nursing actions in the correct order of priority to mitigate the risk of further respiratory compromise.
- 1Stop the continuous enteral feeding pump immediately.
- 2Position the client in a high-Fowler's or side-lying position.
- 3Suction the client's oropharynx and trachea.
- 4Administer supplemental oxygen as prescribed.
- 5Auscultate breath sounds and obtain a full set of vital signs.
- 6Notify the healthcare provider of the acute event.
Answer
The correct priority sequence is to stop the feeding, position the client, suction the airway, administer oxygen, assess vital signs, and finally notify the healthcare provider.
When a client aspirates enteral feeding, the nurse must rapidly apply the principles of Airway, Breathing, and Circulation (ABC) to reduce the risk of severe complications such as hypoxic respiratory failure and aspiration pneumonia. The first action must always be to eliminate the cause by stopping the feeding pump. Next, the airway must be protected via positioning and cleared via suctioning. Once the airway is patent, breathing is supported with supplemental oxygen. Only after the client is stabilized should the nurse complete a comprehensive assessment and communicate the findings to the healthcare provider.
Step-by-Step Solution
Key Concept
Prioritization of care for enteral feeding complications using the Airway, Breathing, Circulation (ABC) framework.
Estimated Time:1m 30s