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Zorluk: ZorBasic Care and Comfort

An older adult client with advanced Parkinson's disease is receiving continuous enteral nutrition via a percutaneous endoscopic gastrostomy (PEG) tube. The client has a stage 2 sacral pressure injury and is exhibiting new-onset restlessness. The nurse needs to lower the head of the bed to reposition the client to a lateral position for pressure relief. Which action is the priority for the nurse to implement?

  1. Pause the continuous enteral feeding pump before lowering the head of the bed.Cevap
  2. B
    Delegate the repositioning directly to an unlicensed assistive personnel (UAP) to minimize shearing forces.
  3. C
    Apply temporary soft wrist restraints to prevent the client from dislodging the feeding tube during movement.
  4. D
    Attribute the new-onset restlessness to expected age-related cognitive decline and proceed with the turn.

Cevap

Pause the continuous enteral feeding pump before lowering the head of the bed.
Pausing the continuous enteral feeding before lowering the head of the bed is a critical safety measure to prevent regurgitation and pulmonary aspiration. Even though the client has a percutaneous endoscopic gastrostomy (PEG) tube rather than a nasogastric tube, the risk of aspiration remains high if the client is placed in a flat position while the stomach is being filled. Furthermore, the nurse must personally assess the client's new-onset restlessness prior to proceeding with delegable basic care.

Adım Adım Çözüm

1
Analyze the client's current interventions and the planned procedure.
The client is receiving continuous PEG tube feeding and needs the head of the bed lowered for repositioning.
Identifying the interaction between the feeding and the flat position highlights the primary physiological risk.
2
Evaluate the risk of aspiration associated with enteral feedings.
Lowering the head of the bed while a continuous feeding is infusing significantly increases the risk of regurgitation and pulmonary aspiration.
Even with a PEG tube, gastric contents can reflux if the gastroesophageal sphincter relaxes, making the supine or flat lateral position dangerous during active feeding.
3
Determine the required nursing intervention prior to the procedure.
The nurse must pause the enteral feeding pump before lowering the bed to ensure airway safety.
Airway protection and aspiration prevention take priority in basic care and mobility procedures.

Anahtar Kavram

Aspiration Prevention during Enteral Feeding and Positioning
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Konular

Basic Care and Comfort

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