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Difficulty: MediumBasic Care and Comfort

A client who recently experienced a cerebrovascular accident has dense left-sided hemiplegia. The nursing team is establishing a schedule to maintain body alignment, prevent joint deformities, and ensure skin integrity. Which action is the most appropriate to include in this client's daily care?

  1. Place a trochanter roll alongside the lateral aspect of the client's left thigh.Answer
  2. B
    Elevate the affected left arm on a pillow with the shoulder in internal rotation.
  3. C
    Maintain the client in a left lateral lying position for at least four hours at a time.
  4. D
    Direct the care assistant to evaluate the integrity of the skin over the client's sacrum.

Answer

The most appropriate action is to place a trochanter roll alongside the lateral aspect of the client's left thigh.
Placing a trochanter roll along the lateral aspect of the paralyzed leg prevents external rotation of the hip, which is a common and debilitating complication in clients with hemiplegia. This intervention maintains proper anatomical alignment, protects the joint capsule, and promotes overall comfort as part of basic care.

Step-by-Step Solution

1
Analyze the client's condition and the goals of care.
The client has left-sided hemiplegia (paralysis) and needs interventions for joint alignment and skin integrity.
Understanding the deficits guides the selection of safe and therapeutic comfort measures.
2
Evaluate the physiological impact of hemiplegia on the lower extremities.
A paralyzed leg naturally tends to roll outward (external rotation) due to gravity and lack of muscle tone.
Identifying the natural pathological tendency highlights the need for a mechanical counter-measure.
3
Determine the correct positioning intervention.
A trochanter roll placed laterally along the thigh physically prevents the hip from rotating outward.
This maintains neutral anatomical alignment, preventing permanent joint deformities and promoting comfort.

Key Concept

Therapeutic Positioning and Alignment for Hemiplegia
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Topics

Basic Care and Comfort

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