The nurse assesses the patient who receives continuous enteral nutrition through a nasointestinal tube. What is the priority intervention by the nurse if the patient's bowel sounds are inaudible?
a. Document "absent bowel sounds.".
b. Gradually decrease the rate of the tube feeding.
c. Monitor the patient for possible diarrhea.
d. Stop the feeding and notify the healthcare provider.
D
The nurse stops the tube feeding and collaborates with the healthcare provider after assessing a patient who receives a continuous tube feeding with no evidence of peristalsis. Without peristal-sis, the formula accumulates in the stomach, and eventually the patient can vomit, increasing the risk of aspiration. The nurse should document that bowel sounds are inaudible because he or she cannot attest to the absence of peristalsis but relies on clinical indicators consistent with de-creased peristalsis. Any patient receiving tube feedings receives nursing assessments for diarrhea and constipation; in addition, if the patient has diarrhea, bowel sounds are likely to be loud, fre-quent, and high pitched.
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