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Difficulty: HardBasic Care and Comfort

A nurse is planning basic care and comfort measures for an older adult client receiving palliative care who has severe cachexia, intractable bone pain, and a stage 3 sacral pressure injury. Which interventions should the nurse include in the plan of care? Select all that apply.

  1. Utilize a 30-degree lateral tilted position when turning the client in bed.Answer
  2. B
    Instruct the unlicensed assistive personnel (UAP) to evaluate the granulation tissue of the pressure injury during daily bathing.
  3. C
    Keep the backrest of the bed elevated between 60 and 90 degrees continuously to maximize lung expansion.
  4. Implement guided imagery and provide a preferred music playlist to serve as an adjunct to prescribed analgesics.Answer
  5. E
    Inform the family that the client's sudden onset of severe confusion and restlessness is a normal physiological expectation of advanced age.
  6. Cleanse the perineal area with a pH-balanced cleanser and apply a moisture barrier ointment after each incontinence episode.Answer

Answer

The correct interventions include utilizing a 30-degree lateral tilted position, implementing guided imagery and music therapy, and cleansing the perineal area while applying a moisture barrier after incontinence episodes.
The correct interventions prioritize skin preservation and holistic comfort. A 30-degree lateral tilt safely offloads the sacrum without shifting excessive pressure to the greater trochanter, which is crucial for a cachectic client. Guided imagery and music are evidence-based non-pharmacologic adjuncts for intractable pain. Prompt cleaning with pH-balanced cleansers and application of barrier ointments prevent moisture-associated skin damage, which is vital for preventing the deterioration of the existing pressure injury.

Step-by-Step Solution

1
Analyze the client's clinical profile and identified risks.
The client has severe cachexia, intractable pain, and an existing stage 3 sacral pressure injury, creating a high risk for further skin breakdown and discomfort.
To determine which basic care interventions are safe and effective for this specific presentation.
2
Evaluate the proposed positioning and hygiene strategies.
The 30-degree lateral tilt offloads the sacrum safely. Barrier creams protect compromised skin from moisture. Conversely, a continuous high Fowler's position is contraindicated due to sacral shearing forces.
To select interventions that promote skin integrity and reject those that cause harm.
3
Identify appropriate non-pharmacological comfort measures.
Guided imagery and familiar music are valid, evidence-based adjuncts for pain management in palliative care.
To provide holistic comfort alongside pharmacological treatments.
4
Assess the delegation and education interventions for safety and accuracy.
Wound assessment cannot be delegated to UAPs, and sudden confusion is acute delirium, not normal aging.
To eliminate unsafe delegation practices and incorrect clinical education.

Key Concept

Comprehensive basic care for clients with severe immobility and altered skin integrity involves specific offloading techniques (30-degree lateral tilt), non-pharmacologic pain adjuncts, and diligent moisture management, while avoiding contraindicated positioning and improper delegation.
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Topics

Basic Care and Comfort

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