A nurse is developing a comprehensive care plan for an elderly client with end-stage heart failure who is experiencing profound dyspnea at rest, severe fatigue, and anorexia. Which of the following basic care and comfort interventions should the nurse include in the client's plan of care? (Select all that apply.)
- Position the client in an orthopneic posture, leaning forward over an overbed table with arms supported by pillows.Answer
- Provide small, nutrient-dense meals on a frequent basis rather than three large meals daily.Answer
- CDelegate the evaluation of the client's peripheral edema and sacral skin breakdown to the unlicensed assistive personnel (UAP).
- DMaintain the client in a flat, supine position to promote venous return and decrease lower extremity peripheral edema.
- EReassure the family that the client's sudden onset of acute confusion and agitation is a normal, expected consequence of the advanced aging process.
- Direct a gentle stream of cool air from a handheld fan toward the client's face during episodes of severe breathlessness.Answer
Answer
The correct interventions include positioning the client in an orthopneic posture, providing small and frequent nutrient-dense meals, and directing a gentle stream of cool air toward the client's face during breathless episodes.
The correct interventions prioritize airway management, breathing efficacy, and energy conservation. The orthopneic posture maximizes chest expansion and decreases the work of breathing. Small, frequent meals prevent excessive energy expenditure and avoid the diaphragmatic pressure associated with large meals. Using a fan to blow cool air on the face safely stimulates the trigeminal nerve, effectively reducing the uncomfortable sensation of breathlessness.
Step-by-Step Solution
Key Concept
Prioritization of non-pharmacological dyspnea management, safe positioning, and appropriate nursing delegation in the context of severe cardiopulmonary disease.