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Zorluk: OrtaBasic Care and Comfort

A registered nurse is preparing to administer an intermittent bolus enteral feeding via a nasogastric (NG) tube to a client with dysphagia. Place the following steps in the correct chronological sequence from first to last.

  1. 1Elevate the head of the bed to 30 to 45 degrees.
  2. 2Verify correct tube placement by aspirating and checking the pH of gastric contents.
  3. 3Assess the gastric residual volume (GRV) and return the aspirate to the client.
  4. 4Administer the prescribed enteral feeding formula by gravity.
  5. 5Flush the nasogastric tube with 30 mL of water.

Cevap

The correct sequence is to first elevate the head of the bed, then verify tube placement, check the gastric residual volume, administer the feeding, and finally flush the tube.
Safe administration of enteral feedings requires a strict sequence to prevent life-threatening complications. Positioning the client upright is the foundational step. Next, the nurse must verify the tube is actually in the stomach by checking the pH of aspirated contents. Once confirmed, the nurse assesses gastric residual volume to ensure the stomach is emptying properly, returning the aspirate to maintain electrolyte balance. The feeding formula is then administered, and finally, the tube is flushed to clear the formula and maintain patency.

Adım Adım Çözüm

1
Elevate the head of the bed to 30 to 45 degrees.
The client is in a semi-Fowler's position.
Reduces the risk of aspiration by utilizing gravity to keep stomach contents from refluxing.
2
Verify correct tube placement by aspirating and checking the pH of gastric contents.
The tube's location in the stomach is confirmed.
Ensures fluids will be instilled into the gastrointestinal tract, not the lungs.
3
Assess the gastric residual volume (GRV) and return the aspirate to the client.
Feeding tolerance is established and gastric contents are replaced.
High residual volumes indicate poor digestion and risk for aspiration. Returning the aspirate prevents electrolyte imbalances.
4
Administer the prescribed enteral feeding formula by gravity.
The client receives the required nutrition.
Provides caloric and nutritional intake as prescribed.
5
Flush the nasogastric tube with 30 mL of water.
The tube is cleared of formula.
Prevents tube occlusion and bacterial growth within the lumen.

Anahtar Kavram

Enteral Nutrition Administration and Aspiration Prevention
Tahmini Süre:1m 30s
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Konular

Basic Care and Comfort

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