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Difficulty: HardBasic Care and Comfort

A practical nurse (PN) is providing basic care and comfort for an older adult client who returned to the unit 4 hours ago following a right femoral cardiac catheterization. The client has a history of mild dementia and requires assistance with activities of daily living (ADLs). Which actions should the PN include in the plan of care? (Select all that apply.)

  1. Assist with feeding while keeping the head of the bed elevated no more than 30 degrees.Answer
  2. Place the client on a fracture bedpan for elimination to minimize movement of the right leg.Answer
  3. Support the right leg with a trochanter roll to maintain proper alignment and promote comfort.Answer
  4. D
    Assist the client to sit on the side of the bed to facilitate a comfortable position for a bed bath.
  5. E
    Delegate the evaluation of the client's right pedal pulse to the unlicensed assistive personnel (UAP) during hygiene care.
  6. F
    Attribute the client's sudden onset of extreme restlessness to their dementia and dim the room lights.

Answer

The correct actions are to assist with feeding while keeping the head of the bed elevated no more than 30 degrees, use a fracture bedpan to minimize leg movement, and support the right leg with a trochanter roll.
Following a femoral cardiac catheterization, the client must remain on bed rest with the affected leg completely straight and the head of the bed elevated no more than 30 degrees to prevent dislodging the clot at the arterial puncture site. Using a fracture bedpan allows for elimination without excessive lifting or bending of the hips. A trochanter roll maintains alignment and prevents external rotation, promoting comfort. Assisting with feeding at a safe, low elevation ensures basic nutritional needs are met without compromising the surgical site.

Step-by-Step Solution

1
Identify the physiological constraints based on the recent procedure.
The client had a right femoral cardiac catheterization, which requires strict bed rest, the right leg to be kept completely straight, and the head of the bed to be elevated no more than 30 degrees.
Bending the hip increases pressure on the femoral artery puncture site, risking severe hemorrhage.
2
Evaluate the proposed basic care interventions against the procedural constraints.
Feeding at a 30-degree angle, using a fracture bedpan, and applying a trochanter roll all allow for necessary ADLs while maintaining the required straight-leg and low-elevation position.
Basic care must be adapted to prioritize client safety and prevent procedural complications.
3
Analyze the clinical presentation and delegation tasks for safety.
Evaluating a pedal pulse is an assessment that cannot be delegated, and sudden restlessness is a critical sign of potential shock, not a baseline dementia symptom.
The PN must practice within their legal scope and prioritize physiological life-threatening changes over routine comfort measures.

Key Concept

Adapting Basic Care to Post-Procedural Positioning Restrictions
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Topics

Basic Care and Comfort

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