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Difficulty: MediumBasic Care and Comfort

A hospitalized client with an acute exacerbation of congestive heart failure experiences significant respiratory distress and exhaustion when attempting to consume lunch. Which intervention should the nurse implement to best support the client's comfort and ability to eat?

  1. Elevate the head of the bed to a high-Fowler's position and provide an overbed table to support the client's arms.Answer
  2. B
    Delegate the feeding process to an unlicensed assistive personnel (UAP) to ensure the client finishes the entire meal.
  3. C
    Place the client in a recumbent position immediately following the meal to decrease metabolic demand and promote rest.
  4. D
    Explain to the client that severe breathlessness and loss of appetite are expected age-related changes that do not require intervention.

Answer

The nurse should elevate the head of the bed to a high-Fowler's position and provide an overbed table to support the client's arms.
The correct action maximizes thoracic expansion and decreases the overall work of breathing. The high-Fowler's position combined with arm support (orthopneic positioning) allows the accessory muscles of respiration to function more effectively, thereby reducing dyspnea and enabling the client to eat with less exertion.

Step-by-Step Solution

1
Assess the client's respiratory status and tolerance for oral intake.
The nurse identifies that the client is experiencing acute dyspnea and fatigue related to a heart failure exacerbation.
Determines the need for immediate comfort measures and physical support before the client attempts to continue the meal.
2
Adjust the client's physical positioning in the bed.
The client is placed in a high-Fowler's position with the arms supported on a bedside table.
This specific orthopneic positioning drops the diaphragm and allows accessory respiratory muscles to work optimally, significantly decreasing dyspnea.
3
Monitor the client during the meal for improved breathing and safety.
The client can consume the meal with reduced respiratory effort and a lowered risk of aspiration.
Ensures the non-pharmacological intervention is effective and that the unstable client remains safe while eating.

Key Concept

Basic Care and Comfort: Positioning for Cardiopulmonary Compromise
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Topics

Basic Care and Comfort

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