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Zorluk: ZorBasic Care and Comfort

A registered nurse is caring for an older adult client with cognitive impairment who is receiving continuous enteral feeding via a percutaneous endoscopic gastrostomy (PEG) tube. The client is increasingly restless, frequently scratching at the peri-stomal skin, and attempting to pull the feeding tubing. Which of the following actions is the most appropriate for the nurse to implement?

  1. A
    Lower the head of the bed to a flat, supine position to stretch the abdominal muscles and reduce physical access to the stoma.
  2. B
    Apply soft bilateral wrist restraints immediately to ensure the continuous feeding delivery remains intact and uninterrupted.
  3. C
    Instruct the unlicensed assistive personnel (UAP) to evaluate the peri-stomal skin for early signs of breakdown during the bed bath.
  4. Route the enteral tubing underneath the client's clothing and provide a tactile activity apron.Cevap

Cevap

The most appropriate action is to route the enteral tubing underneath the client's clothing and provide a tactile activity apron.
Routing the tubing under clothing and providing a tactile apron represents the least restrictive approach to protecting the medical device. It successfully distracts the cognitively impaired client and camouflages the tube, adhering to basic care and comfort principles without resorting to restraints or compromising physiological safety.

Adım Adım Çözüm

1
Analyze the client's presentation and current risk factors.
The client is cognitively impaired, receiving continuous enteral feeding, and at risk for device dislodgement due to restlessness.
Identifying the primary safety and comfort risks dictates the priority of nursing interventions.
2
Evaluate the proposed interventions against safety standards and the nursing scope of practice.
Lowering the head of the bed causes aspiration risk; delegating skin evaluation to a UAP violates delegation principles; and applying restraints skips required alternative measures.
Nursing actions must adhere to safety guidelines (e.g., aspiration precautions), legal standards (e.g., proper delegation), and institutional protocols (e.g., restraint use).
3
Select the intervention that ensures client safety using the least restrictive method.
Camouflaging the tube and providing sensory distraction is selected.
These are effective, first-line restraint alternatives that maintain the integrity of the feeding tube while promoting client comfort.

Anahtar Kavram

Restraint Alternatives and Enteral Feeding Safety
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Konular

Basic Care and Comfort

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