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Soru

Zorluk: OrtaBasic Care and Comfort

An older adult client in a long-term care facility is receiving a continuous enteral feeding via a nasogastric tube. The practical nurse is preparing to perform a complete bed bath and change the client's bed linens, which requires lowering the head of the bed. Which action is essential for the nurse to take?

  1. Stop the enteral feeding pump before lowering the head of the bed to a flat position.Cevap
  2. B
    Keep the feeding pump running but place the client in a right side-lying position during the linen change.
  3. C
    Delegate the pausing and restarting of the enteral feeding pump to the unlicensed assistive personnel.
  4. D
    Increase the feeding rate by 10 mL/hr after the bath is complete to compensate for the time the pump was turned off.

Cevap

The nurse must stop the enteral feeding pump before lowering the head of the bed to a flat position.
Clients receiving continuous enteral feedings are at a high risk for aspiration if they are laid flat, as the formula can easily reflux from the stomach into the esophagus and airway. To safely perform a bed bath or linen change that requires a flat bed position, the practical nurse must first stop the feeding pump. The feeding should only be resumed once the procedure is finished and the head of the bed is returned to an elevation of at least 30 to 45 degrees.

Adım Adım Çözüm

1
Identify the client's current treatment and the physical requirements of the planned basic care procedure.
The client is receiving a continuous enteral feeding, and a complete bed bath requires the bed to be temporarily lowered to a flat position.
Understanding the intersection of prescribed therapies and basic care activities is necessary to identify potential safety hazards.
2
Recognize the primary safety risk associated with enteral feedings and patient positioning.
Administering enteral feedings while the client is supine creates a high risk for regurgitation and pulmonary aspiration.
Gravity is required to help keep the nutritional formula in the stomach and prevent reflux into the esophagus and airway.
3
Determine the necessary nursing intervention to mitigate this risk during the procedure.
The continuous feeding must be temporarily paused before the head of the bed is lowered.
Stopping the introduction of new formula into the stomach before laying the client flat prioritizes airway protection and physiological safety.

Anahtar Kavram

Aspiration Precautions during Enteral Nutrition and Basic Care
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Konular

Basic Care and Comfort

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