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Difficulty: Very hardBasic Care and Comfort

An older adult client with right-sided hemiparesis and a history of severe gastroesophageal reflux disease (GERD) is bedbound and receiving continuous enteral tube feedings. During the shift assessment, the nurse notes a non-blanchable, localized area of deep red skin over the client's sacrum and right greater trochanter. To simultaneously address the client's nutritional needs, airway safety, and impaired skin integrity, which comprehensive positioning and care strategy should the nurse implement?

  1. Place the client in a 30-degree left lateral incline, maintain the head of the bed at exactly 30 degrees, and support the right extremities with pillows.Answer
  2. B
    Position the client completely supine with the head of the bed elevated to 60 degrees, and apply a specialized donut-shaped cushion under the sacrum.
  3. C
    Turn the client to a 90-degree left lateral decubitus position, elevate the head of the bed to 45 degrees, and gently massage the reddened bony prominences.
  4. D
    Maintain the client in a semi-Fowler's position, turn the client to the right side every 2 hours, and apply a prophylactic hydrocolloid dressing to the sacrum.

Answer

Place the client in a 30-degree left lateral incline, maintain the head of the bed at exactly 30 degrees, and support the right extremities with pillows.
The client requires head elevation to prevent aspiration from the continuous enteral feeding and GERD, but high elevation increases shearing forces on the sacrum. Elevating the head of the bed to exactly 30 degrees provides the optimal balance between airway protection and minimizing shear. The 30-degree left lateral incline effectively offloads pressure from both the sacrum and the right greater trochanter without placing excessive pressure on the left trochanter (which occurs in a full 90-degree lateral position). Supporting the hemiparetic right extremities with pillows prevents subluxation and dependent edema.

Step-by-Step Solution

1
Analyze the client's airway and nutritional requirements.
The client has GERD and is receiving continuous enteral feedings.
The head of the bed must be elevated to prevent aspiration, but high elevation causes dangerous shearing forces on the sacrum.
2
Evaluate the client's skin integrity and pressure injury locations.
The client has non-blanchable erythema on the sacrum and right greater trochanter.
These specific areas must be completely offloaded to prevent further tissue necrosis, ruling out supine and right-sided positioning.
3
Identify the safest position to balance airway protection, hemiparesis care, and pressure offloading.
A 30-degree left lateral incline with the head of the bed at 30 degrees is selected.
This offloads the sacrum and right trochanter, avoids extreme pressure on the left trochanter, supports the hemiparetic side, and provides the minimum safe head elevation for tube feeding.

Key Concept

Complex Client Positioning and Pressure Injury Prevention
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Topics

Basic Care and Comfort

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