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Difficulty: Very hardBasic Care and Comfort

A practical nurse (PN) is providing morning basic care for an older adult client on the third day following a partial gastrectomy. The client is receiving continuous enteral nutrition via a jejunostomy tube, requires extensive assistance with all personal hygiene, and has a documented history of early-stage dementia. Which interventions should the PN include in the client's plan of care? Select all that apply.

  1. Maintain the head of the bed elevated at 30 to 45 degrees while assisting the client with a bed bath and repositioning.Answer
  2. B
    Place the client in a flat, supine position to safely perform a complete bed linen change while the enteral feeding pump is running.
  3. Cleanse the jejunostomy tube insertion site gently with warm water and mild soap during daily hygiene, patting the skin dry.Answer
  4. D
    Independently evaluate the client's swallowing ability to determine if they are ready to transition to oral clear liquids.
  5. E
    Document the client's sudden onset of severe agitation during morning care as an expected manifestation of their early-stage dementia.
  6. Apply a moisture-barrier ointment to the client's perineal area and sacrum following each episode of incontinence.Answer

Answer

The correct actions are to maintain head-of-bed elevation during hygiene, cleanse the tube insertion site with mild soap and water, and apply moisture-barrier ointment after incontinence.
The correct interventions prioritize physiological safety and hygiene within the practical nursing scope. Maintaining a 30 to 45-degree elevation during care prevents aspiration of continuous feedings. Cleansing the jejunostomy site and applying perineal barrier creams are fundamental, evidence-based practices for preserving skin integrity in vulnerable, bedbound clients.

Step-by-Step Solution

1
Identify the client's primary risk factors based on the scenario.
The client is at high risk for aspiration (continuous enteral feeding), skin breakdown (incontinence, bed rest), and post-operative complications (gastrectomy).
Recognizing specific vulnerabilities directs the selection of safe basic care interventions.
2
Evaluate the safety of positioning during hygiene tasks.
The head of the bed must remain elevated to prevent aspiration; laying the client flat without pausing the feeding is contraindicated.
Continuous enteral nutrition requires airway protection at all times, including during bed baths and linen changes.
3
Differentiate between PN scope of practice and tasks requiring RN assessment.
Cleansing the stoma and applying barrier creams are within the PN scope, while evaluating swallowing ability for diet transition is an RN responsibility.
Nurses must strictly adhere to their legal scope of practice when implementing care.
4
Analyze the significance of the client's sudden agitation.
Sudden agitation is recognized as acute delirium or a physiological complication, not a normal progression of dementia.
Older adults are highly susceptible to acute delirium; attributing sudden changes to baseline dementia delays critical intervention.

Key Concept

Providing safe basic care and comfort requires synthesizing airway protection (aspiration precautions), maintaining skin integrity, recognizing acute cognitive changes, and adhering to the legal scope of practice.
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Topics

Basic Care and Comfort

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