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Difficulty: MediumBasic Care and Comfort

An adult client is admitted to the medical-surgical unit and requires continuous enteral feedings through a newly placed percutaneous endoscopic gastrostomy (PEG) tube. The nursing team is establishing a daily care routine to maintain skin integrity, prevent complications, and ensure physiological stability. Which of the following actions are appropriate for the nurse to implement? (Select all that apply)

  1. Elevate the head of the bed to at least 30 degrees while the enteral formula is infusing.Answer
  2. B
    Assign the unlicensed assistive personnel (UAP) to evaluate the stoma site for signs of infection.
  3. Provide comprehensive oral hygiene every 4 hours using a soft-bristled toothbrush or oral swab.Answer
  4. D
    Leave the continuous feeding running while lowering the bed flat to reposition the client.
  5. Wash the skin immediately surrounding the gastrostomy tube daily with mild soap and warm water.Answer
  6. F
    Document the client's sudden onset of confusion and pulling at the tube as an expected age-related cognitive change.

Answer

The correct actions include elevating the head of the bed to at least 30 degrees, providing oral hygiene every 4 hours, and washing the skin around the tube daily with mild soap and warm water.
Appropriate care for a client with a PEG tube includes measures that prioritize airway safety and basic tissue integrity. Elevating the head of the bed prevents aspiration of gastric contents. Providing frequent oral care keeps mucous membranes moist and prevents bacterial overgrowth, which is common when clients are not eating by mouth. Cleansing the stoma site daily with mild soap and water removes irritating gastric enzymes and prevents skin breakdown.

Step-by-Step Solution

1
Analyze the client's primary intervention: continuous enteral feeding via a PEG tube.
Identify that the primary risks associated with this therapy are aspiration, impaired skin integrity at the stoma site, and poor oral hygiene due to lack of oral intake.
Understanding the physiological impact of enteral nutrition directs appropriate basic care and comfort measures.
2
Evaluate each option against safe nursing practice and basic care guidelines.
Positioning the head of the bed at 30-45 degrees prevents aspiration. Washing the stoma daily and providing frequent oral care maintain tissue integrity and promote comfort.
These actions align directly with fundamental nursing protocols for enteral nutrition support.
3
Identify contraindicated actions and improper delegations.
Delegating assessment to a UAP, feeding while flat, and dismissing sudden confusion as normal aging are dangerous practices that violate safety and assessment principles.
Recognizing what not to do is critical for preventing client harm and practicing within the RN scope.

Key Concept

Basic care for clients with enteral feeding tubes focuses on aspiration prevention (positioning), maintaining skin integrity (stoma care), and ensuring oral comfort.
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Topics

Basic Care and Comfort

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