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Zorluk: ZorBasic Care and Comfort

A practical nurse is planning morning hygiene care for an immobile client who receives continuous enteral tube feedings. The client requires a complete bed bath and a bottom sheet change, which will necessitate temporarily lowering the head of the bed. Which action should the nurse take to safely provide this basic care?

  1. A
    Position the client in a right lateral recumbent position with the bed flat so the feeding can continue safely during the bath.
  2. B
    Lower the head of the bed to 15 degrees and leave the feeding infusion running, working as quickly as possible to minimize the time the client is flat.
  3. Pause the continuous feeding pump, lower the head of the bed to perform the care, and elevate the head of the bed to at least 30 degrees before restarting the infusion.Cevap
  4. D
    Instruct assistive personnel to complete the bed bath and tell them to turn off the feeding pump if the client begins to cough.

Cevap

Pause the continuous feeding pump, lower the head of the bed to perform the care, and elevate the head of the bed to at least 30 degrees before restarting the infusion.
To prevent aspiration, the head of the bed must remain elevated at 30 to 45 degrees while continuous enteral feedings are infusing. When basic care, such as a bed bath or linen change, requires lowering the bed to properly turn the client, the nurse must first pause the feeding pump. The infusion can only be safely restarted after the care is complete and the client's head is repositioned to an elevation of at least 30 degrees.

Adım Adım Çözüm

1
Analyze the client's risk factors based on the medical intervention.
Identified that continuous enteral feeding poses a high risk for aspiration if the client is not positioned correctly.
Gravity is required to keep stomach contents from refluxing into the esophagus and airway during active tube feedings.
2
Evaluate the requirements for the planned basic care procedure.
Recognized that completing a full bed bath and changing the bottom linens typically requires lowering the head of the bed to allow for side-to-side turning.
Maintaining proper body mechanics and ensuring skin folds are properly cleaned and dried is difficult when the bed is elevated.
3
Prioritize interventions to maintain airway safety.
Determined that the feeding infusion must be paused prior to altering the bed's elevation.
Protecting the airway (Airway, Breathing, Circulation) is the highest priority; leaving the feeding on while flat compromises the airway.
4
Establish safe parameters for resuming the intervention.
Concluded that the head of the bed must be returned to a minimum 30-degree elevation before the pump is turned back on.
A minimum 30-degree elevation is the standard evidence-based practice to prevent aspiration in clients receiving enteral nutrition.

Anahtar Kavram

Aspiration precautions during continuous enteral feedings and basic hygiene care.
Tahmini Süre:1m 15s
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Konular

Basic Care and Comfort

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