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Soru

Zorluk: ZorBasic Care and Comfort

A semi-conscious client who underwent a supratentorial craniotomy two days ago receives continuous enteral nutrition via a nasogastric tube. The nurse is preparing to perform a complete bed bath, linen change, and repositioning to maintain skin integrity. Which of the following actions represents the safest approach for providing this care?

  1. Pausing the continuous enteral feeding infusion prior to lowering the head of the bed to turn the clientCevap
  2. B
    Positioning the client in a completely flat, supine posture to facilitate a rapid and efficient linen change
  3. C
    Accepting a directive to administer a prescribed intravenous push sedative to relax the client during the procedure
  4. D
    Applying soft bilateral wrist restraints immediately to prevent the client from displacing the nasogastric tube

Cevap

The safest action is to pause the continuous enteral feeding infusion before lowering the head of the bed.
When a client is receiving continuous enteral nutrition, the head of the bed must remain elevated to at least 30 degrees to prevent regurgitation and aspiration. Because a complete linen change and repositioning require temporarily lowering the head of the bed to safely turn the client side-to-side, the nurse must first pause the feeding infusion. Furthermore, for a client who is recovering from a supratentorial craniotomy, keeping the head elevated promotes venous drainage and prevents increased intracranial pressure. Pausing the feeding before executing any flat positioning is the most critical physiological safety measure.

Adım Adım Çözüm

1
Identify the client's specific risk factors based on the clinical scenario.
The client is semi-conscious, recovering from a craniotomy, and receiving continuous enteral nutrition.
These factors place the client at high risk for aspiration and increased intracranial pressure if positioned incorrectly.
2
Evaluate the physical requirements of the planned basic care procedure.
A complete bed bath and linen change typically require lowering the head of the bed to safely turn and roll the client.
Performing physical turns and linen changes is difficult and often unsafe for the nurse's body mechanics when the bed remains highly elevated.
3
Synthesize the physiological risks with the procedural requirements to determine the priority safety action.
Because the head of the bed must be lowered, the continuous feeding pump must be temporarily stopped.
Lowering the head of the bed while a tube feeding is actively infusing removes gravity's protective effect, dramatically increasing the risk of regurgitation and pulmonary aspiration.

Anahtar Kavram

Aspiration Prevention and Safe Positioning
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Konular

Basic Care and Comfort

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