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Difficulty: Very hardBasic Care and Comfort

A 78-year-old client is 2 days postoperative following a right total hip arthroplasty (posterior approach). The client has a history of chronic obstructive pulmonary disease (COPD) and a recent stroke resulting in dysphagia. They are receiving continuous enteral feeding via a nasogastric (NG) tube. The client is intermittently confused and attempting to pull at the NG tube. Which nursing action is most appropriate when providing basic care and comfort?

  1. Maintain the head of the bed elevated at 30 to 45 degrees, utilize an abduction wedge when repositioning the client to the unoperated side, and apply a secondary securement device or tube camouflage to deter pulling.Answer
  2. B
    Elevate the head of the bed to a high-Fowler's position (90 degrees) to maximize diaphragmatic excursion, and ensure the right leg is internally rotated when resting in a supine position.
  3. C
    Delegate the task of turning the client every 2 hours to the unlicensed assistive personnel (UAP), instructing them to evaluate the sacral skin integrity during each turn.
  4. D
    Document the intermittent confusion as a normal age-related change, and immediately apply bilateral soft wrist restraints to prevent the life-sustaining feeding tube from being dislodged.

Answer

The correct action balances respiratory and feeding needs by keeping the head of the bed at 30 to 45 degrees, protects the hip joint with an abduction wedge, and uses non-restrictive alternatives to prevent tube pulling.
The correct action demonstrates high-level clinical judgment by synthesizing multiple complex care needs. A 30 to 45-degree head elevation safely prevents aspiration during continuous enteral feeding and assists with COPD breathing effort, while strictly avoiding a 90-degree angle that would violate posterior hip precautions. Utilizing an abduction wedge prevents adduction, and using tube camouflage is an appropriate, less-restrictive alternative to physical restraints.

Step-by-Step Solution

1
Analyze the client's postoperative positioning requirements.
Posterior hip arthroplasty requires preventing hip flexion of 90 degrees or greater, internal rotation, and adduction.
To prevent dislocation of the newly placed hip prosthesis.
2
Evaluate the respiratory and nutritional positioning needs.
Continuous NG feeding and a history of COPD require elevating the head of the bed.
To prevent pulmonary aspiration of enteral formula and to facilitate downward movement of the diaphragm for lung expansion.
3
Synthesize the conflicting positioning needs to find a safe compromise.
A 30 to 45-degree elevation satisfies the airway and feeding requirements without exceeding the dangerous 90-degree hip flexion limit.
Placing the client in a high-Fowler's position (90 degrees) would violate the hip precautions and risk dislocation.
4
Determine the appropriate nursing intervention for the client's confused behavior and tube pulling.
Implement less restrictive safety alternatives, such as tube camouflage or specialized garments, while assessing for the root cause of the sudden confusion.
Physical restraints are a last resort, and acute confusion in an older adult is abnormal, often pointing to hypoxia, infection, or delirium.

Key Concept

Complex client positioning requiring synthesis of surgical precautions, aspiration prevention, and restraint alternatives.
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Topics

Basic Care and Comfort

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