A nurse is developing a plan of care for an older adult client who is receiving continuous enteral tube feedings and is on bedrest due to generalized weakness. Which of the following interventions should the nurse include in the client's plan of care to promote basic care, comfort, and safety? Select all that apply.
- Maintain the head of the bed at an elevation of 30 to 45 degrees at all times.Answer
- BInstruct the unlicensed assistive personnel (UAP) to assess the client's lung sounds for signs of aspiration.
- Provide comprehensive oral hygiene every 4 hours using a soft-bristled toothbrush.Answer
- DReposition the client into a completely flat, supine position every 2 hours to relieve sacral pressure.
- Apply a moisture barrier ointment to the perineal skin after each incontinent episode.Answer
- FReassure the family that the client's new onset of severe urinary incontinence is an expected part of the aging process.
Answer
The correct interventions are maintaining the head of the bed at an elevation of 30 to 45 degrees, providing comprehensive oral hygiene every 4 hours, and applying a moisture barrier ointment to the perineal skin.
Maintaining the head of the bed elevated prevents aspiration of continuous enteral feedings. Providing frequent oral hygiene keeps the mucosa moist and intact, while applying a moisture barrier protects the skin from breakdown due to incontinence. These actions directly support basic care, comfort, and physiological safety.
Step-by-Step Solution
Key Concept
Basic care and comfort for a client on continuous enteral feedings requires interventions that maintain skin integrity, promote oral health, and prevent aspiration without compromising safety or proper delegation.