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Soru

Zorluk: ZorBasic Care and Comfort

An older adult client with a history of moderate dementia is receiving continuous enteral nutrition via a nasogastric (NG) tube. During the night shift, the client becomes acutely restless, exhibits new-onset confusion, and repeatedly attempts to pull at the NG tube. The client also requires frequent linen changes due to urinary incontinence. What nursing action demonstrates the safest approach to managing this client's basic care and comfort?

  1. A
    Apply bilateral soft wrist restraints immediately to prevent the client from dislodging the nasogastric tube.
  2. B
    Delegate the task of evaluating the client's perineal skin integrity to the unlicensed assistive personnel (UAP).
  3. C
    Attribute the sudden increase in restlessness and confusion to the expected nocturnal progression of dementia.
  4. Pause the continuous enteral feeding infusion pump before lowering the head of the bed to perform hygiene care.Cevap

Cevap

The nurse must pause the continuous enteral feeding infusion pump before lowering the head of the bed to perform hygiene care.
Clients receiving continuous enteral feedings are at a high risk for aspiration. Standard safety protocols require maintaining the head of the bed at an elevation of at least 30 to 45 degrees. When a basic care task, such as incontinence care or a complete linen change, requires the client to be placed in a flat or supine position, the nurse must first pause the enteral feeding pump. The feeding can safely resume once the procedure is complete and the client's head is re-elevated.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and concurrent care needs.
The client has a continuous NG tube feeding running, requires incontinence care which necessitates lowering the bed, and is exhibiting signs of acute confusion.
Identifying all simultaneous needs helps prioritize immediate safety risks during care delivery.
2
Evaluate the physiological safety implications of lowering the head of the bed.
Lowering the head of the bed while a continuous enteral feeding is actively infusing significantly increases the risk of aspiration.
Gravity is required to keep gastric contents in the stomach when the lower esophageal sphincter is held open by a nasogastric tube.
3
Determine the priority nursing intervention for the basic care task.
The feeding pump must be temporarily paused before placing the client in a supine position to safely perform the linen change.
This is a critical standard of care to prevent aspiration pneumonia during basic hygiene procedures.

Anahtar Kavram

Basic Care and Comfort: Enteral Tube Feeding Safety and Positioning
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Konular

Basic Care and Comfort

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