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Zorluk: Çok zorBasic Care and Comfort

A nurse is caring for an intubated client with acute respiratory distress syndrome (ARDS) who has just been placed in the prone position. The client is receiving continuous enteral nutrition via a nasogastric tube. Which basic care and comfort intervention is the priority for the nurse to implement?

  1. A
    Pause the continuous enteral infusion for the entire duration the client remains in the prone position.
  2. B
    Apply prophylactic foam dressings bilaterally to the client's sacrum, ischial tuberosities, and heels.
  3. Adjust the entire bed frame into a reverse Trendelenburg tilt to maintain head elevation.Cevap
  4. D
    Delegate the repositioning of the client's head and endotracheal tube every two hours to the unlicensed assistive personnel (UAP).

Cevap

Adjust the entire bed frame into a reverse Trendelenburg tilt to maintain head elevation.
When a client is positioned prone, standard elevation of the head of the bed is not physically possible without compromising spinal alignment and respiratory mechanics. Because the client is receiving continuous enteral nutrition, maintaining head elevation relative to the stomach is critical to utilize gravity, prevent gastric reflux, and eliminate the risk of pulmonary aspiration. The reverse Trendelenburg position tilts the entire bed frame, safely achieving this necessary elevation.

Adım Adım Çözüm

1
Identify the client's current clinical state and positioning constraints.
The client is intubated, receiving continuous enteral nutrition, and positioned prone (on their abdomen).
Establishing the specific physiological parameters is essential to identifying safety risks related to basic care.
2
Analyze the risks associated with the concurrent therapies.
Enteral feeding carries a high risk of aspiration if the head is not elevated, but the prone position prevents standard articulation of the head of the mattress.
Aspiration of gastric contents can be rapidly fatal, especially in a client already suffering from ARDS.
3
Determine the appropriate biomechanical intervention that satisfies all requirements.
Tilting the entire bed frame (reverse Trendelenburg) elevates the head and thorax relative to the stomach without bending the client's spine.
This utilizes gravity to promote gastric emptying and prevent reflux while allowing the life-saving prone therapy to continue.
4
Evaluate the remaining options for safety and scope of practice.
Stopping nutrition causes harm, assessing posterior pressure points is irrelevant for a prone client, and delegating airway management to a UAP is unsafe practice.
Ensuring all aspects of basic care adhere to safety standards and legal delegation rules.

Anahtar Kavram

Safe administration of enteral nutrition and physiological adaptation in the prone position
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Konular

Basic Care and Comfort

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