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Zorluk: ZorBasic Care and Comfort

A nurse is managing the care of an older adult client who is receiving continuous enteral nutrition via a nasogastric tube. As part of the client's pressure injury prevention plan, the nurse must reposition the client into a flat, lateral recumbent position. Which action is the most appropriate?

  1. Suspend the continuous enteral feeding for at least 30 minutes before lowering the head of the bed.Cevap
  2. B
    Maintain the continuous feeding and place the client in a flat, right lateral position to promote gastric emptying.
  3. C
    Delegate the task of temporarily pausing the feeding pump and securing the tubing to the unlicensed assistive personnel.
  4. D
    Continue the infusion during the procedure, interpreting the client's weakened gag reflex as a normal physiological change of aging.

Cevap

Suspend the continuous enteral feeding for at least 30 minutes before lowering the head of the bed.
To prevent regurgitation and aspiration, continuous enteral feedings must be paused for 30 to 60 minutes before placing a client in a flat position, allowing sufficient time for gastric emptying.

Adım Adım Çözüm

1
Identify the primary safety risk associated with continuous enteral feeding.
The highest risk is aspiration of gastric contents into the lungs.
Enteral formulas introduced into the stomach can easily reflux up the esophagus if gravity is not utilized.
2
Determine the necessary positioning requirements for continuous enteral feeding.
The head of the bed must be maintained at an elevation of at least 30 degrees.
Elevation uses gravity to keep gastric contents in the stomach and prevent regurgitation.
3
Analyze the procedural requirement (flat, lateral recumbent position) against the feeding safety requirement.
The procedural position contradicts the safety requirement for active feeding.
Lying flat removes the gravitational barrier to reflux, making active feeding unsafe.
4
Select the appropriate nursing intervention to resolve the conflict.
The nurse must pause the feeding pump for 30 to 60 minutes before lowering the head of the bed.
This waiting period allows sufficient time for gastric emptying, significantly reducing the risk of aspiration when the client is laid flat.

Anahtar Kavram

Aspiration prevention during continuous enteral nutrition and client repositioning.
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Konular

Basic Care and Comfort

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