Published Oct 2, 2010
sparklie.lady
158 Posts
This is a case study for class and I'm stuck. Patient is on continuous small-bore feeding when nurse notices emesis on her gown. Vitals are T 102/ HR 110/ RR 30/ O2 sat @ 92% on a 35% Venti.
I felt that the first two interventions would be to raise the head of the bed and perform oral suctioning. I feel comfortable that raise the bed would be the first thing to do, unless contraindicated. But is suctioning a reasonable selection? The other thing I could think of would be to turn off the tube feeding. Is this a situation where you would need an MD order to pause it?
The next question is specific to the assessments we should perform, so I didn't think she wanted "assess the patient" as one of the two interventions. Or did she?
AAACK!
thanks for your help!
Hospice Nurse LPN, BSN, RN
1,472 Posts
If your pt is on continuous feeding, the bed should ALWAYS be @ 45 degrees. I'd stop the feeding and call the doc. Assess BBS to check for potential aspiration. This pt, or any pt on continuous feeding, is going to be a high risk for aspiration.
Thanks! Good to know I was on the right track...they always tell us not to read into the questions, but it would have been helpful to know about the bed elevation!
I appreciate your time :)