Question

Before administering a nasogastric feeding to a client hospitalized following a CVA, the nurse aspirates \(40 \mathrm{~mL}\) of residual. The nurse should: A. Replace the aspirate and administer the feeding B. Discard the aspirate and withhold the feeding C. Discard the aspirate and begin the feeding D. Replace the aspirate and withhold the feeding

Short answer

Answer: The most appropriate nursing action depends on the client's acceptable residual volume. If 40mL is within the acceptable range, the nurse should replace the aspirate and administer the feeding (Option A). If 40mL is above the acceptable range, the nurse should replace the aspirate and withhold the feeding (Option D), and inform the healthcare provider for reassessment.

Step-by-step solution

Understand the situation

The client has had a CVA and is hospitalized. They are receiving a nasogastric feeding, and the nurse has aspirated 40mL of residual before administering the feeding.

Evaluate Option A

Replace the aspirate and administer the feeding - This option would involve returning the residual to the client's stomach and proceeding with the feeding. This option may not be ideal because it can cause overfeeding, which could lead to complications such as aspiration, vomiting, or diarrhea.

Evaluate Option B

Discard the aspirate and withhold the feeding - Withholding the feeding would be an appropriate action if the residual volume is significantly above the acceptable range established for the client. However, discarding the aspirate may not be necessary, and it would be better if the client's healthcare provider is informed to reassess their condition.

Evaluate Option C

Discard the aspirate and begin the feeding - In this option, the nurse would discard the residual and start the feeding. Administrating the feeding without considering the residual volume might not be optimal because it can cause overfeeding and other complications mentioned in option A.

Evaluate Option D

Replace the aspirate and withhold the feeding - This option involves returning the residual to the client's stomach and withholding the feeding. This would be appropriate if the residual volume is significantly above the acceptable range established for the client. After evaluating each option, we can conclude that the best nursing action will depend on the acceptable residual volume for this specific client. If 40mL is within the acceptable range, then Option A may be appropriate. However, if 40mL is above the acceptable range, then Option D would be the best nursing action. Informing the client's healthcare provider to reassess the situation is necessary in these cases.

Key concepts

CVA (Cerebrovascular Accident) care

Caring for a patient who has suffered a Cerebrovascular Accident (CVA), commonly known as a stroke, requires a multifaceted and careful approach. A stroke occurs when there is a disruption of blood supply to a part of the brain, which can result in a loss of neurological function.

Nursing care for stroke patients often focuses on preventing complications, promoting optimal recovery, and addressing the patient's functional and emotional needs. One of the primary concerns is ensuring that the patient maintains proper nutrition, hydration, and medication management. Since many stroke patients may experience difficulty with swallowing, known as dysphagia, nasogastric (NG) tube feeding is often utilized.

The NG tube allows for the direct delivery of nutrients to the stomach, bypassing the need for oral intake which may be compromised due to the stroke. The nurse's role includes monitoring for signs of dysphagia, ensuring proper tube placement, administering feedings, and checking gastric residual volumes to prevent overfeeding and associated complications such as aspiration pneumonia, which is a lung infection caused by inhaling food or liquids.

In all actions taken, the nurse has to consider the individual patient's condition, their pre-stroke state of health, current medications, and the overall feeding plan established by the healthcare team to optimize recovery.

Nursing Interventions

Nursing interventions in the context of NG tube feedings are critical for patient safety and the effectiveness of nutritional support. Initial steps include verifying the correct placement of the NG tube to ensure that feedings and medications are delivered to the stomach and not the lungs.

Before administering the feeding, the nurse aspirates gastric contents to measure the gastric residual volume. This volume indicates the stomach's contents before adding more nutrition. If the residual volume is too high, it may suggest delayed gastric emptying, placing the patient at risk for complications such as gastric distention, discomfort, or aspiration of the gastric contents into the lungs.

Interventions include adjusting feeding rates, volumes, or the concentration of the feed based on the residual volumes and the patient's tolerance. Nurses also need to be vigilant for signs of intolerance to feedings, such as nausea, vomiting, diarrhea, abdominal distension, or discomfort. Critical decision-making is essential, and nurses often collaborate with dietitians and physicians to ensure the nutritional regimen is appropriate for the patient's current state and recovery trajectory.

Gastric Residual Volume

Gastric residual volume (GRV) is the amount of content present in the stomach at a given time, and measuring it is a standard practice in managing patients with NG feedings. The measurement of GRV helps in assessing the patient's gastric emptying rate.

A certain amount of GRV is considered normal and ensures that there's not an excess of feed sitting in the stomach. However, there is variation among healthcare providers about what constitutes an acceptable GRV, with some considering volumes less than 250 mL as safe, while others may have stricter thresholds.

High GRV can indicate potential problems such as delayed gastric emptying or an obstruction. Decision-making based on GRV is not trivial and should take into account recent GRV trends, patient's overall clinical status, and existing evidence-based practices. Some current guidelines suggest re-evaluating the need for continued NG feeding if consistently high GRVs are noted, and considering alternate routes of nutrition, such as jejunal feeding or parenteral nutrition.

It is also important to consider patient comfort; a distended stomach can cause discomfort or pain, so nurses monitor patients closely. Documenting and reporting GRV and related nursing interventions are necessary for quality patient care and should be done meticulously.