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Difficulty: Very hardBasic Care and Comfort

An older adult client with advanced Parkinson's disease and acute pancreatitis is receiving continuous enteral nutrition through a nasojejunal tube. The client suddenly becomes highly restless, pulls at the bedsheets, and attempts to climb over the side rails. Which nursing action demonstrates the most appropriate approach to this client's basic care and comfort?

  1. A
    Lower the head of the bed to a flat, supine position to safely provide a full bed bath and alleviate the client's physical discomfort.
  2. Keep the head of the bed elevated between 30 and 45 degrees, camouflage the enteral tubing under the client's gown, and assist the client with a urinal or bedpan.Answer
  3. C
    Secure soft wrist safety devices to prevent the client from accidentally dislodging the nasojejunal tube during periods of acute agitation.
  4. D
    Document the sudden restlessness as an expected cognitive progression of advanced Parkinson's disease and darken the room to encourage rest.

Answer

The most appropriate action is to keep the head of the bed elevated between 30 and 45 degrees, camouflage the tubing under the gown, and assist the client with toileting.
Clients receiving continuous enteral nutrition are at a high risk for aspiration and must remain with the head of the bed elevated at 30 to 45 degrees at all times, even during comfort care. Furthermore, acute restlessness in older adults is frequently an indicator of physiological distress, such as a full bladder or pain, rather than simple confusion. By camouflaging the tube under the gown, the nurse utilizes a least-restrictive safety measure to prevent dislodgement, while maintaining safe respiratory positioning and actively addressing a highly probable underlying cause of the agitation.

Step-by-Step Solution

1
Analyze the client's presentation and medical history.
The client is an older adult with Parkinson's receiving continuous enteral feeding who is exhibiting acute, sudden restlessness.
Identifying acute changes helps differentiate between baseline cognitive deficits and acute physiological distress (delirium).
2
Evaluate the safety risks associated with the client's current treatments.
Continuous nasojejunal feeding carries a high risk of aspiration if the client is positioned incorrectly. The restlessness creates a secondary risk of tube dislodgement.
Nursing priorities must center on airway protection (preventing aspiration) and maintaining vital medical therapies.
3
Identify the safest and least restrictive interventions for agitation.
Restraints are contraindicated as a first step. Camouflaging the tube hides it from the client's line of sight, reducing pulling behaviors without restricting movement.
Standards of care mandate utilizing the least restrictive alternative to maintain client safety and comfort.
4
Address the most likely root causes of the sudden restlessness.
Acute agitation is often triggered by basic unmet needs such as a full bladder, unmanaged pain, or hypoxia. Assisting with a urinal addresses a primary physiological trigger.
Treating the underlying cause of delirium is more effective and safer than sedating or restraining the client.

Key Concept

Basic Care and Comfort for Enteral Nutrition and Agitation
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Topics

Basic Care and Comfort

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