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Zorluk: OrtaBasic Care and Comfort

A practical nurse is preparing to administer a prescribed bolus enteral feeding via a gastrostomy tube to an adult client. Arrange the following actions in the correct chronological sequence.

  1. 1Elevate the head of the client's bed to at least 30 to 45 degrees.
  2. 2Aspirate gastric contents to observe appearance and measure residual volume.
  3. 3Flush the gastrostomy tube with 30 mL of prescribed water.
  4. 4Administer the prescribed bolus feeding formula by gravity.
  5. 5Flush the gastrostomy tube with an additional 30 mL of water.

Cevap

The correct sequence is to first elevate the head of the bed, then check the gastric residual, flush the tube, administer the feeding formula, and finally flush the tube again.
Safe administration of enteral feedings requires a strict sequence to prevent complications, primarily aspiration. The client must first be positioned upright. Next, the nurse must assess gastrointestinal tolerance by checking residual volume. Once tolerance is established, the tube is flushed to ensure patency. The feeding is then administered, followed immediately by a final flush to maintain tube patency and hygiene.

Adım Adım Çözüm

1
Elevate the head of the bed.
The client is placed in a semi-Fowler's or Fowler's position.
This utilizes gravity to keep gastric contents in the stomach, minimizing the risk of reflux and aspiration during the procedure.
2
Check gastric residual volume.
The nurse determines how much formula remains in the stomach from prior feedings.
This assesses gastrointestinal tolerance; a high residual indicates delayed emptying and a high risk for aspiration if more feeding is added.
3
Perform the initial flush.
The tube is cleared with water.
This verifies that the tube is patent and functioning properly before administering a thicker substance.
4
Administer the feeding formula.
The client receives the prescribed nutrition.
Gravity feeding allows for a controlled rate, reducing the risk of nausea, cramping, and diarrhea.
5
Perform the final flush.
The tube is cleared of formula residue.
Formula left in the tube can solidify, causing blockages, and provides a medium for bacterial proliferation.

Anahtar Kavram

Enteral Nutrition Administration and Aspiration Precautions
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