The nurse is planning care for the client receiving nasogastric tube feedings. Which does the nurse use to evaluate a successful therapeutic regimen?
1. Respirations 28 to 32 breaths/min
2. Residual volume less than 100 ml
3. 4-pound weight loss over 1 month
4. Urine output from 10 to 15 ml/hr
2
2. A clinical indicator of a successful therapeutic regimen is a residual volume below 100 ml because the nurse understands this means the gastric feeding is stimulating the stretch receptors in the stomach to empty gastric contents into the duodenum and to precipitate intestinal peristalsis. The peristaltic action moves the formula through the gastrointestinal tract to prevent formula accumulation in the stomach.
1. Tachypnea in a client with gastric tube feedings warrants further investigation by the nurse because tachypnea is consistent with clinical indicators for aspiration.
3. Significant weight loss that is not the result of decreased fluid volume is consistent with delivering inadequate calories and protein to prevent muscle wasting.
4. The nurse expects urine output between 30 and 50 ml/hr depending on the client.
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