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Difficulty: HardBasic Care and Comfort

The nursing care team is managing the daily needs of a client who is non-ambulatory and receiving continuous enteral feedings via a gastrostomy tube following a recent abdominal surgery. When implementing basic hygiene and comfort measures, which actions are appropriate for the practical nurse (PN) to perform? Select all that apply.

  1. Maintain the head of the bed elevated at 30 to 45 degrees while assisting the client with repositioning.Answer
  2. Utilize a friction-reducing draw sheet and an additional staff member when sliding the client up in bed.Answer
  3. C
    Position a ring-shaped cushion under the client's sacrum to alleviate pressure on bony prominences.
  4. D
    Assign the assistive personnel (AP) to evaluate and document the healing progress of a sacral abrasion.
  5. E
    Lower the bed to a flat, supine position with the feeding actively infusing while changing the bed linens.
  6. Apply a zinc oxide-based moisture barrier cream to the client's perineal area after cleansing incontinent episodes.Answer

Answer

The correct actions are maintaining the head of the bed elevated, utilizing a draw sheet for repositioning, and applying a moisture barrier cream to the perineal area.
Maintaining the head of the bed at an angle of 30 to 45 degrees prevents aspiration of gastric contents during continuous tube feedings. Using a draw sheet with assistance minimizes shearing forces that can cause skin breakdown when moving a bedbound client. Applying a moisture barrier cream protects fragile skin from the corrosive effects of urine and feces, thereby preventing maceration and perineal dermatitis.

Step-by-Step Solution

1
Analyze the client's primary clinical risks based on the scenario.
The client is bedbound, increasing the risk for skin breakdown, and receives continuous enteral feedings, increasing the risk for aspiration.
Identifying the client's vulnerabilities is the first step in determining safe and effective basic care interventions.
2
Evaluate each care intervention against safety standards and the PN scope of practice.
Elevating the head of the bed, using a draw sheet, and applying barrier cream are safe, evidence-based practices. Ring cushions, flat positioning during feeding, and delegating assessment are unsafe or out of scope.
Nursing actions must protect the airway, maintain skin integrity without causing harm, and remain within legal practice boundaries.
3
Select all interventions that correctly address the client's comfort and basic care needs while maintaining safety.
The appropriate actions are maintaining head elevation, using a draw sheet, and applying barrier cream.
These interventions directly mitigate the identified risks of aspiration and tissue damage.

Key Concept

Basic Care and Skin Integrity for Enteral Nutrition Clients
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Topics

Basic Care and Comfort

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