A client with right-sided hemiparesis is receiving continuous enteral nutrition via a nasogastric tube. When organizing the client's daily care and hygiene, which interventions should the nurse include? Select all that apply.
- Pause the enteral nutrition infusion prior to lowering the head of the bed for repositioning.Answer
- Elevate and support the right arm with pillows to prevent shoulder subluxation.Answer
- Incorporate passive range-of-motion exercises for the right-sided extremities during the bath.Answer
- DInstruct the unlicensed assistive personnel (UAP) to assess the client's skin for pressure injuries while bathing.
- EProhibit positioning the client on the right side to avoid tissue damage to the affected limbs.
- FAttribute sudden episodes of acute confusion to expected age-related cognitive changes.
Answer
The correct interventions include pausing the enteral infusion before lowering the bed, supporting the affected arm with pillows, and performing passive range-of-motion exercises on the affected extremities.
The correct interventions directly address the client's risks. Pausing continuous feeds before lowering the head of the bed is essential to prevent aspiration of stomach contents. Elevating and supporting the flaccid right arm with pillows prevents shoulder subluxation and dependent edema. Integrating passive range-of-motion exercises into daily care prevents joint contractures and maintains flexibility in the hemiparetic limbs.
Step-by-Step Solution
Key Concept
Basic care and comfort measures for clients with hemiparesis and enteral feedings focus on aspiration prevention, maintaining joint mobility, proper positioning, and safe delegation.