The nurse is caring for a patient with an enteral feeding tube. During assessment, the nurse finds that the patient's oxygen saturation level has dropped significantly and the respiratory rate and effort have increased
What action should the nurse take first? a. Stop any infusion of fluids or medications through the feeding tube.
b. Assess all of the patient's vital signs.
c. Notify the healthcare provider.
d. Reposition the patient.
A
The patient is exhibiting signs of aspiration, and feeding and medications through the tube must be stopped first. This is done quickly; if not done, none of the other actions will be effective. It's essential that the nurse goes to the source of the problem. The vital signs can be checked after the tube feeding has been stopped and the patient repositioned for better airway clearance. The healthcare provider can be notified after the nurse has intervened by turning off the tube feeding, repositioning the patient for optimal airway clearance, and taking vital signs. Repositioning the patient is important; but, if the pump is left on, more fluid will be instilled into an already stressed patient.
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