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Difficulty: EasyBasic Care and Comfort

A night-shift nurse is caring for an older adult client with chronic obstructive pulmonary disease (COPD) who reports worsening shortness of breath and an inability to fall asleep. Which independent nursing interventions should be implemented to promote physical comfort and rest? (Select all that apply.)

  1. Assist the client into an orthopneic position by resting their arms on pillows placed on an overbed table.Answer
  2. Adjust the room environment by lowering the ambient temperature and turning on a bedside circulating fan.Answer
  3. Guide the client through relaxation strategies, including guided imagery and pursed-lip breathing exercises.Answer
  4. D
    Reposition the client into a completely flat, supine position to straighten the airway and promote lung expansion.
  5. E
    Direct the unlicensed assistive personnel (UAP) to conduct a respiratory assessment while the nurse gathers clean linens.
  6. F
    Apply bilateral soft wrist restraints to ensure the client does not accidentally dislodge their nasal cannula while sleeping.

Answer

The correct interventions are assisting the client into an orthopneic position, adjusting the room environment to be cool with circulating air, and guiding the client through relaxation and pursed-lip breathing exercises.
Clients with chronic respiratory conditions like COPD experience significant discomfort and anxiety when dyspneic. Independent nursing interventions focus on maximizing lung expansion, reducing the metabolic demand for oxygen, and decreasing the subjective feeling of air hunger. Assisting the client into the orthopneic position, promoting a cool environment with circulating air, and teaching pursed-lip breathing directly target these goals safely and effectively without the need for new pharmacological orders.

Step-by-Step Solution

1
Analyze the client's primary problem and needs.
The client has COPD and is experiencing dyspnea that is preventing them from resting.
Understanding the pathophysiology of COPD helps identify which interventions will safely relieve symptoms.
2
Evaluate the proposed positioning interventions.
The orthopneic position is selected because it facilitates lung expansion, while the supine position is rejected because it worsens breathing effort.
Positioning directly affects diaphragmatic excursion and the work of breathing.
3
Evaluate environmental and supportive measures.
Cool circulating air and relaxation techniques are selected.
These independent actions directly reduce the subjective sensation of dyspnea and decrease metabolic oxygen demand.
4
Apply safety and delegation principles to the remaining options.
UAP delegation for assessment and the use of restraints for oxygen tubing are rejected.
UAPs cannot perform clinical assessments, and physical restraints are contraindicated for simply maintaining a nasal cannula without prior indication of severe risk.

Key Concept

Non-pharmacological comfort and positioning for respiratory compromise
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Topics

Basic Care and Comfort

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