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Difficulty: HardBasic Care and Comfort

A nurse is establishing a basic care regimen for an older adult client who is bedbound with right-sided flaccid paralysis and altered sensory perception due to a recent traumatic brain injury. To optimize comfort, prevent contractures, and protect skin integrity, which combination of nursing actions is most appropriate?

  1. Position the client in a 30-degree lateral incline, support the paralyzed right arm on a pillow, and place a trochanter roll alongside the right thigh.Answer
  2. B
    Elevate the head of the bed to 90 degrees to maximize lung expansion, allow the right arm to rest dependently, and vigorously massage any non-blanching erythema.
  3. C
    Maintain the client in a strictly supine position, use a donut-shaped cushion to relieve direct sacral pressure, and apply a rigid hand splint continuously.
  4. D
    Delegate the unlicensed assistive personnel (UAP) to perform initial evaluations of right-sided joint mobility during the bed bath and report any new spasticity.

Answer

The most appropriate combination is positioning the client in a 30-degree lateral incline, supporting the paralyzed arm on a pillow, and utilizing a trochanter roll alongside the thigh.
The 30-degree lateral position is the evidence-based standard for offloading pressure from the sacrum and greater trochanter, minimizing the risk of pressure injuries. Supporting the flaccid arm on a pillow maintains joint alignment and prevents shoulder subluxation, which is a significant risk due to the lack of muscle tone. A trochanter roll placed alongside the outer thigh prevents external rotation of the hip joint, maintaining functional anatomical alignment.

Step-by-Step Solution

1
Evaluate the risks associated with right-sided flaccid paralysis and immobility.
Identified high risk for pressure injuries, shoulder subluxation, and external hip rotation.
Flaccid muscles cannot provide structural support to joints, and immobility creates localized pressure points.
2
Determine the optimal position for pressure relief and joint alignment.
Selected the 30-degree lateral incline over a 90-degree side-lying or strict supine position.
The 30-degree lateral position avoids placing the client's body weight directly on the bony prominence of the greater trochanter or sacrum.
3
Identify specific supportive devices needed for the flaccid extremities.
Incorporated a pillow for the right arm and a trochanter roll for the right leg.
The pillow prevents gravity from dislocating the shoulder joint, and the trochanter roll prevents the weakened leg from rolling outward.

Key Concept

Basic Care and Comfort: Safe Positioning and Assistive Devices
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Topics

Basic Care and Comfort

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