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Difficulty: Very hardBasic Care and Comfort

A nurse is planning care for a 78-year-old client with Parkinson's disease and severe dysphagia who was recently admitted with aspiration pneumonia. The client is receiving continuous enteral feedings via a nasogastric tube and has a highly friable stage 3 sacral pressure injury. Upon assessment, the nurse notes the client is newly confused, restless, and repeatedly grasping at the nasogastric tube. Which comprehensive intervention is the most appropriate for the nurse to implement?

  1. Maintain the head of the bed at exactly 30 degrees while utilizing a 30-degree lateral tilt, and provide the client with a textured sensory apron.Answer
  2. B
    Elevate the head of the bed to 60 degrees to maximize gravity flow and prevent aspiration, and instruct the unlicensed assistive personnel to evaluate the sacral wound during each repositioning.
  3. C
    Apply bilateral soft wrist restraints to secure the nasogastric tube from immediate dislodgement, recognizing that the sudden confusion is an expected manifestation of advanced Parkinson's disease.
  4. D
    Position the client completely flat in a supine position to entirely eliminate shearing forces on the sacrum, ensuring the continuous enteral feeding is paused only while actively turning the client.

Answer

Maintain the head of the bed at exactly 30 degrees while utilizing a 30-degree lateral tilt, and provide the client with a textured sensory apron.
The correct action expertly navigates two conflicting basic care priorities. To prevent aspiration from the continuous feeding, the head of the bed must be at least 30 degrees. To prevent shearing forces on the sacral pressure injury, the head of the bed must be no more than 30 degrees. Therefore, exactly 30 degrees is the optimal angle. The 30-degree lateral tilt effectively offloads pressure from the sacrum without causing trochanteric breakdown. Finally, the sensory apron acts as a safe, less-restrictive distraction technique (restraint alternative) for the client's hands.

Step-by-Step Solution

1
Analyze the competing physiological priorities presented in the clinical scenario.
The client has a high aspiration risk requiring head elevation, but also a stage 3 sacral pressure injury requiring minimal head elevation to prevent shear.
Standard aspiration precautions require the head of the bed (HOB) to be elevated 30-45 degrees. However, standard pressure injury guidelines state the HOB should not be elevated above 30 degrees to prevent shear.
2
Identify the precise positioning parameters that satisfy both safety constraints.
Maintaining the HOB at exactly 30 degrees is the critical intersection that satisfies both guidelines. Adding a 30-degree lateral tilt further offloads the sacral pressure without placing undue weight on the greater trochanter.
This specific geometric positioning provides optimal respiratory and nutritional safety while actively promoting wound healing.
3
Evaluate the behavioral symptoms and select an appropriate safety intervention.
The new confusion requires medical evaluation, but the immediate grasping behavior must be managed with the least restrictive alternative first, such as a sensory apron.
Applying physical restraints without attempting distraction or sensory alternatives violates the standard of care for restraint use.

Key Concept

Synthesis of complex positioning parameters to balance aspiration risk against sacral shearing forces, combined with the use of least-restrictive behavioral interventions.
Estimated Time:2m 0s
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Topics

Basic Care and Comfort

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