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Difficulty: MediumBasic Care and Comfort

A client who has difficulty swallowing is receiving a continuous enteral feeding via a nasogastric tube. Which actions are appropriate to include in the client's plan of care to maintain safety and comfort? (Select all that apply)

  1. Keep the head of the bed elevated to at least a 30-degree angle.Answer
  2. Clean the oral cavity and teeth with a soft-bristled brush every four hours.Answer
  3. Inspect the skin around the nares for redness or tissue breakdown each shift.Answer
  4. D
    Lower the bed to a completely flat position while performing routine skin care.
  5. E
    Assign the unit technician to aspirate stomach contents to check residual volume.
  6. F
    Confirm the tube location by injecting air and listening over the epigastric area.

Answer

The correct actions include elevating the head of the bed to at least 30 degrees, providing frequent oral hygiene, and inspecting the nares for skin breakdown.
Clients receiving continuous enteral feedings are at high risk for aspiration. Keeping the head of the bed elevated to at least 30 degrees uses gravity to prevent the reflux of gastric contents. Frequent oral hygiene is necessary to keep mucous membranes moist, promote comfort, and prevent infection, as these clients often mouth-breathe and lack oral fluid intake. Routine inspection of the nares is essential to detect and prevent pressure injuries caused by the friction and continuous presence of the tube.

Step-by-Step Solution

1
Analyze the physiological risks associated with continuous nasogastric enteral feeding.
The primary risks include pulmonary aspiration of formula, pressure injuries at the tube insertion site, and impaired oral mucous membranes due to lack of oral intake.
Understanding the baseline risks guides the selection of appropriate basic care and comfort interventions.
2
Evaluate each provided option against evidence-based nursing practices for enteral nutrition.
Elevating the head of the bed, performing routine oral care, and monitoring the nares are standard practices that mitigate the identified risks.
These interventions directly promote comfort and prevent life-threatening complications like aspiration pneumonia.
3
Identify the contraindicated or inappropriate actions among the options.
Laying the client flat during a feeding, delegating assessments to a technician, and using the air-injection method are all unsafe or incorrect practices.
Recognizing improper delegation, outdated assessment techniques, and dangerous positioning is crucial for safe client care.

Key Concept

Basic Care and Comfort during Enteral Nutrition
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Topics

Basic Care and Comfort

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