A nurse is preparing to administer an intermittent bolus enteral feeding to a client via a gastrostomy tube. Place the following nursing actions in the correct chronological order.
- 1Position the client with the head of the bed elevated 30 to 45 degrees.
- 2Aspirate and measure the gastric residual volume.
- 3Flush the gastrostomy tube with 30 mL of water.
- 4Administer the prescribed volume of enteral feeding formula.
- 5Flush the tube with an additional 30 mL of water and clamp the device.
Cevap
The correct sequence is: Position the client, measure gastric residual volume, flush with water, administer formula, and perform a final flush before clamping.
Administering a bolus enteral feeding requires a logical sequence prioritizing safety and aspiration prevention. First, the client must be placed in a semi-Fowler's position (30-45 degrees) to enlist gravity in preventing aspiration. Second, the nurse must assess the gastric residual volume to evaluate tolerance of previous feedings and confirm the stomach is not overly full. Third, a pre-flush of 30 mL of water is administered to confirm tube patency and clear the line. Fourth, the prescribed feeding formula is administered. Finally, a post-flush of 30 mL of water is required to clear formula from the tube lumen, preventing bacterial growth and tube occlusion, followed by clamping the tube.
Adım Adım Çözüm
Anahtar Kavram
Safe administration of enteral tube feedings involves strict adherence to sequencing: positioning for aspiration precautions, assessing tolerance, verifying patency, administering the nutrient, and maintaining patency post-feed.
Tahmini Süre:1m 30s