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Difficulty: Very hardBasic Care and Comfort

A nurse is formulating a comprehensive care plan for an 82-year-old client with advanced Alzheimer's disease, severe osteoarthritis, and dysphagia who is currently receiving treatment for aspiration pneumonia. The client is confined to bed, requires continuous intravenous (IV) fluid therapy, and intermittently attempts to remove the IV catheter. Which of the following interventions should the nurse include in the plan of care to address the client's basic care and comfort needs? Select all that apply.

  1. Elevate the head of the bed to 60 degrees and encourage the client to tuck their chin toward their chest during oral intake.Answer
  2. B
    Place the client in a side-lying position with the head of the bed flat immediately following meals to mobilize pulmonary secretions.
  3. C
    Delegate the initial evaluation of the client's gag reflex and swallowing capability to the assigned unlicensed assistive personnel prior to feeding.
  4. Provide the client with a textured sensory blanket or a soft rolled washcloth to hold in their hands throughout the day.Answer
  5. E
    Apply soft bilateral limb restraints to the client's wrists to facilitate the uninterrupted delivery of prescribed intravenous hydration and medications.
  6. F
    Document the client's sudden onset of severe agitation and restlessness in the medical record as an expected physiological progression of advanced Alzheimer's disease.

Answer

The appropriate nursing actions are to elevate the head of the bed and use the chin-tuck maneuver during feeding, and to provide a sensory distraction such as a textured blanket or washcloth to occupy the client's hands.
Elevating the head of the bed and encouraging a chin-tuck maneuver during oral intake safely facilitates swallowing and prevents aspiration. Providing a sensory blanket acts as a non-pharmacological restraint alternative that addresses the client's cognitive needs, provides tactile comfort, and safely distracts them from pulling at the intravenous line.

Step-by-Step Solution

1
Analyze the client's clinical profile and identify the primary safety and comfort risks.
The client is at high risk for repeated aspiration (due to dysphagia and pneumonia) and interruption of medical therapy (due to pulling at the IV line secondary to cognitive impairment).
Identifying the priority risks dictates which basic care interventions are safe and effective.
2
Evaluate the positioning and feeding interventions for aspiration prevention.
Elevating the head of the bed and utilizing the chin-tuck maneuver closes the epiglottis, safely protecting the airway during swallowing.
Clients with dysphagia require specialized basic care strategies during meals to prevent aspiration pneumonia.
3
Evaluate the interventions for protecting the IV site in a cognitively impaired client.
Providing a textured sensory blanket is a non-pharmacological restraint alternative that distracts the client and safely occupies their hands without restricting movement.
Least restrictive comfort measures must always be implemented and documented before considering physical restraints.

Key Concept

In the provision of basic care and comfort, nurses must prioritize aspiration precautions for clients with dysphagia and utilize non-restrictive comfort measures to ensure safety before resorting to physical restraints.
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Topics

Basic Care and Comfort

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