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Difficulty: Very hardBasic Care and Comfort

An 84-year-old client with advanced dementia, left-sided hemiplegia from a previous stroke, and a stage 3 sacral pressure injury is receiving continuous enteral feeding via a nasogastric (NG) tube. The client has become acutely restless, is repeatedly pulling at their soiled incontinence brief, and requires immediate perineal care. Which action by the nurse represents the safest integration of basic care and comfort principles?

  1. Pause the continuous enteral feeding, assess for physiological causes of the acute restlessness, and enlist assistance to safely logroll the client to provide perineal care.Answer
  2. B
    Delegate the perineal care to the Unlicensed Assistive Personnel (UAP) while the nurse immediately contacts the healthcare provider to request soft wrist restraints to protect the NG tube.
  3. C
    Maintain the head of the bed at 60 degrees to prevent aspiration, independently roll the client onto their left side, and perform the perineal care while the feeding continues.
  4. D
    Continue the enteral feeding and perform the perineal care, attributing the sudden restlessness and pulling behavior to the expected progressive cognitive decline associated with advanced dementia.

Answer

The correct action is to pause the continuous enteral feeding, assess for physiological causes of the acute restlessness, and enlist assistance to safely logroll the client to provide perineal care.
This action synthesizes multiple essential basic care principles. Acutely restless behavior in a client with dementia typically indicates a new physiological problem (like a full bladder, skin irritation from a soiled brief, or pain) requiring assessment rather than assumption. Furthermore, to safely provide perineal care and protect the stage 3 sacral pressure injury from devastating shearing forces, the client must be logrolled with assistance while the bed is lowered. Lowering the head of the bed requires pausing the continuous enteral feeding to eliminate the risk of pulmonary aspiration.

Step-by-Step Solution

1
Analyze the client's behavioral change.
Recognize that acute restlessness in a client with dementia often indicates a new physiological stressor (such as a full bladder, skin irritation, or pain) rather than normal disease progression.
Sudden behavioral changes require immediate nursing assessment to rule out acute medical issues before implementing interventions.
2
Prioritize airway and aspiration precautions.
Determine that the continuous enteral feeding must be paused before lowering the head of the bed.
Lowering the head of the bed while a continuous feeding is infusing places the client at a high risk for pulmonary aspiration.
3
Plan for safe mobility and skin integrity preservation.
Decide to enlist assistance to logroll the client rather than turning independently or with the head of the bed elevated.
Logrolling with the bed lowered prevents severe shearing forces on the existing stage 3 sacral pressure injury and avoids dangerous pulling on the client's hemiplegic side.

Key Concept

Synthesis of Aspiration Precautions, Safe Mobility, and Delirium Assessment
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Topics

Basic Care and Comfort

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