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Question

Difficulty: MediumBasic Care and Comfort

An older adult client is admitted to the medical-surgical unit following an acute ischemic stroke that has resulted in left-sided hemiparesis and severe dysphagia. The nurse is planning the client's basic care and comfort measures. Which intervention is most appropriate for the nurse to implement?

  1. Elevate the head of the bed to 90 degrees during all oral intake and maintain this position for at least 30 minutes afterward.Answer
  2. B
    Assign the unlicensed assistive personnel (UAP) to perform the client's initial feeding assessment using thickened liquids.
  3. C
    Place the client in a flat, supine position while administering oral hygiene to prevent cervical hyperextension.
  4. D
    Document new-onset acute confusion and lethargy during morning care as an expected physiological change associated with the aging process.

Answer

Elevate the head of the bed to 90 degrees during all oral intake and maintain this position for at least 30 minutes afterward.
Clients with dysphagia are at a high risk for aspiration. Elevating the head of the bed to a high-Fowler's position (90 degrees) uses gravity to facilitate swallowing and prevents gastric reflux. Maintaining this position for 30 to 45 minutes after oral intake further ensures that food and fluids move safely into the stomach, significantly reducing the risk of aspiration pneumonia.

Step-by-Step Solution

1
Identify the client's primary risks based on the clinical presentation.
The client has left-sided hemiparesis and severe dysphagia following a stroke, making aspiration the highest priority risk during basic care and oral intake.
Dysphagia impairs the swallowing mechanism, allowing food or fluids to easily enter the airway.
2
Evaluate each proposed intervention for safety and appropriateness.
Positioning the client in high-Fowler's during and after meals directly and safely addresses the aspiration risk.
Gravity assists the swallowing process and prevents gastric reflux.
3
Rule out unsafe or inappropriate interventions.
Delegating initial feeding assessments, positioning the client flat during oral care, and dismissing acute confusion as normal aging are identified as unsafe practices.
These actions violate delegation principles, safe positioning guidelines, and physiological aging concepts.

Key Concept

Aspiration Precautions and Basic Care in Dysphagia
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Topics

Basic Care and Comfort

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