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Difficulty: Very hardBasic Care and Comfort

A nurse is developing a plan of care for a 76-year-old client admitted with a severe exacerbation of chronic obstructive pulmonary disease (COPD). The client has a newly placed percutaneous endoscopic gastrostomy (PEG) tube for continuous enteral nutrition, requires maximal assistance with mobility, and has been experiencing new-onset nocturnal confusion. Which of the following basic care and comfort interventions should the nurse include in the client's care plan? (Select all that apply.)

  1. A
    Delegate the initial connection and administration of the continuous enteral feeding via the newly placed PEG tube to the Unlicensed Assistive Personnel (UAP).
  2. B
    Obtain a PRN (as-needed) prescription for bilateral soft wrist restraints to ensure the PEG tube is not dislodged during episodes of nocturnal confusion.
  3. C
    Educate the family that the client's new-onset nocturnal confusion is a typical and expected cognitive decline associated with the advanced aging process.
  4. D
    Position the client in a flat, supine position for at least 30 minutes following respiratory treatments to promote optimal diaphragmatic resting.
  5. Maintain the head of the bed at an elevation of 30∘30^\circ to 45∘45^\circ continuously while the enteral nutrition is infusing.Answer
  6. Assist the client into an orthopneic position, sitting up and leaning forward over an overbed table, during episodes of severe dyspnea.Answer

Answer

The correct interventions are maintaining the head of the bed elevated between 30∘30^\circ and 45∘45^\circ during continuous enteral feedings, and assisting the client into an orthopneic position during acute dyspneic episodes.
Maintaining the head of the bed elevated between 30∘30^\circ and 45∘45^\circ uses gravity to prevent esophageal reflux and subsequent pulmonary aspiration of the continuous enteral feeding. Assisting the client into an orthopneic position (sitting up and leaning forward over an overbed table) optimizes diaphragmatic excursion, recruits accessory respiratory muscles, and significantly decreases the work of breathing during severe dyspneic episodes.

Step-by-Step Solution

1
Analyze the client's primary diagnoses and compounding physiological risks.
The client presents with a severe COPD exacerbation (high risk for hypoxia and respiratory failure) and is receiving nutrition via a newly placed PEG tube (high risk for pulmonary aspiration).
Identifying overlapping physiological risks is essential for prioritizing safe and effective basic care interventions.
2
Evaluate the safety and therapeutic appropriateness of the proposed positioning interventions.
Elevating the head of the bed to 30∘30^\circ-45∘45^\circ safely mitigates aspiration risk. The orthopneic position safely maximizes lung expansion. A flat supine position is strictly contraindicated as it worsens both COPD respiratory distress and PEG aspiration risk.
Correct client positioning is a fundamental basic care intervention that directly impacts both respiratory efficiency and gastrointestinal safety.
3
Assess the administrative, delegation, and educational interventions for clinical and regulatory compliance.
Delegating initial PEG feedings and obtaining PRN restraint prescriptions are fundamentally unsafe and violate legal practice standards. Furthermore, dismissing acute sudden-onset confusion as normal aging ignores a critical warning sign of systemic hypoxia.
Safe nursing care plans must strictly adhere to legal delegation boundaries, rigorous restraint protocols, and accurate pathological assessment.

Key Concept

Basic Care and Comfort: Positioning and Safety Interventions for Complex Respiratory and Enteral Needs
Estimated Time:2m 0s
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Basic Care and Comfort

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