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Difficulty: Very hardBasic Care and Comfort

A nurse is directing the basic care and comfort measures for an 82-year-old client admitted to the medical-surgical unit with severe bilateral pneumonia. The client has a history of mild dementia and is currently experiencing significant dyspnea, generalized fatigue, and an oxygen saturation of 88% on room air. Which of the following nursing actions should the nurse include in the client's plan of care? (Select all that apply)

  1. Assist the client into an orthopneic position, leaning forward over a padded overbed table, to maximize lung expansion and ease respiratory effort.Answer
  2. B
    Instruct the unlicensed assistive personnel (UAP) to evaluate the client's respiratory tolerance and work of breathing while providing morning hygiene care.
  3. C
    Apply bilateral soft limb restraints to secure the client's hands if the client becomes delirious and repeatedly attempts to remove the supplemental oxygen cannula.
  4. Provide meticulous oral care every two to four hours to clear dried secretions, moisten mucous membranes, and enhance overall physical comfort.Answer
  5. E
    Lower the head of the bed to a flat, supine position when performing routine perineal care to ensure complete visualization and thorough cleansing.
  6. F
    Document the sudden onset of profound disorientation and combativeness as an expected behavioral change associated with the client's advancing age and dementia.

Answer

The correct nursing actions are to assist the client into an orthopneic position to maximize lung expansion, and to provide meticulous oral care every two to four hours to maintain mucosal moisture and clear secretions.
The correct nursing actions prioritize both critical respiratory function and fundamental physical comfort. Assisting the client into an orthopneic position (leaning forward over an overbed table) allows for maximum downward displacement of the diaphragm and recruits accessory muscles, which significantly decreases the work of breathing. Additionally, providing meticulous oral care every two to four hours is essential to clear dried secretions and moisturize mucous membranes that become rapidly dehydrated due to tachypnea and supplemental oxygen therapy.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The 82-year-old client has severe pneumonia, significant dyspnea, hypoxia (88% SpO2), and a history of mild dementia.
Understanding the physiological limitations imposed by severe respiratory distress and geriatric factors is required to plan safe basic care and comfort measures.
2
Evaluate the positioning and hygiene interventions.
Orthopneic positioning actively recruits accessory muscles for breathing. Frequent oral care prevents mucosal drying from tachypnea and oxygen therapy. Conversely, lowering the bed to a flat position for perineal care is unsafe and will severely worsen dyspnea.
Basic care interventions must always prioritize airway and breathing (ABCs) while simultaneously addressing hygiene and physical comfort.
3
Evaluate the delegation and safety interventions.
Delegating the evaluation of respiratory tolerance to a UAP is unsafe and outside their scope. Applying restraints without trying alternatives violates safety protocols. Dismissing acute confusion as normal dementia progression ignores a critical sign of worsening hypoxia.
The RN must retain all assessment responsibilities, utilize the least restrictive safety measures, and immediately recognize acute changes from baseline in older adults.

Key Concept

Providing basic care and hygiene for clients with severe respiratory compromise requires adapting standard procedures (such as avoiding supine positioning) to prioritize the ABCs, while adhering strictly to RN scope of practice and recognizing acute geriatric physiological changes.
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Topics

Basic Care and Comfort

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