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Zorluk: Çok zorReduction of Risk Potential

A practical nurse is caring for an older adult client receiving continuous enteral nutrition via a nasogastric tube. The client suddenly experiences forceful coughing, tachypnea, and expels enteral formula from their mouth. In which order should the practical nurse perform the following actions to minimize the client's risk for severe complications?

  1. 1Pause the continuous enteral feeding pump.
  2. 2Turn the client into a lateral side-lying position.
  3. 3Use a Yankauer catheter to suction the oral cavity.
  4. 4Auscultate bilateral lung sounds and obtain an oxygen saturation reading.
  5. 5Report the clinical findings and interventions to the registered nurse.

Cevap

The correct sequence is to first pause the feeding pump, then turn the client to a side-lying position, suction the oral cavity, auscultate lung sounds with oxygen saturation, and finally report the findings to the registered nurse.
In any acute respiratory emergency where a clear causative agent is actively being introduced, the absolute priority is to stop the agent (pause the pump). Following the ABCs (Airway, Breathing, Circulation), the next immediate steps are to physically protect the airway (lateral position) and clear it (suction). Only after the airway is secured and the immediate physical threat is neutralized should the practical nurse proceed to data collection (auscultation and oxygen saturation) and escalation of care (notifying the RN).

Adım Adım Çözüm

1
Pause the continuous enteral feeding pump.
The flow of enteral formula into the client is halted.
This immediately removes the source of the aspiration, which is the absolute highest priority to prevent further volume from entering the lungs.
2
Turn the client into a lateral side-lying position.
The client's airway is protected by gravity.
This position facilitates the immediate drainage of the expelled formula out of the mouth rather than allowing it to pool and travel down into the trachea.
3
Use a Yankauer catheter to suction the oral cavity.
Visible formula is removed from the oropharynx.
Suctioning physically clears the upper airway, establishing patency and minimizing the risk of secondary aspiration of residual formula in the mouth.
4
Auscultate bilateral lung sounds and obtain an oxygen saturation reading.
Baseline respiratory compromise is quantified.
Once the airway is completely secured and the immediate threat is neutralized, the nurse must assess the extent of the client's physiological reaction to guide further medical interventions.
5
Report the clinical findings and interventions to the registered nurse.
The healthcare team is alerted to the critical event.
Escalation to the supervising RN is required so that higher-level interventions, such as a chest radiograph or provider notification, can be initiated based on the assessment data.

Anahtar Kavram

Prioritization of immediate life-saving interventions (stopping the source and protecting the airway) over data collection during an acute aspiration event.
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Konular

Reduction of Risk Potential

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