A nurse is developing a care plan focusing on basic care and comfort for a client admitted with acute decompensated heart failure. The client is experiencing severe orthopnea, fatigue, and marked dependent pitting edema in the lower extremities. Which nursing interventions should be included in the plan of care? Select all that apply.
- Position the client in a high Fowler's alignment while allowing the arms to rest on a padded overbed table.Answer
- BElevate the client's legs significantly above the level of the heart to facilitate rapid reduction of peripheral swelling.
- Supply frequent oral hygiene along with sugar-free hard candies to alleviate dry mouth associated with prescribed fluid restrictions.Answer
- DDelegate the task of evaluating any changes in the severity of the sacral edema to the nursing assistant during morning care.
- Establish a strict repositioning schedule every two hours that includes thorough inspection of dependent skin surfaces.Answer
Answer
The correct interventions are positioning the client upright while leaning over a bedside table, providing oral care with hard candies, and ensuring strict repositioning every two hours.
Clients with acute decompensated heart failure and orthopnea benefit from an orthopneic position (upright, leaning forward on an overbed table) to maximize chest expansion and decrease venous return. Frequent oral hygiene and hard candies promote comfort for dry mouth, a common issue due to fluid restrictions and mouth breathing. Edematous skin is highly susceptible to breakdown due to poor tissue perfusion, making a strict turning and inspection schedule essential.
Step-by-Step Solution
Key Concept
Basic care interventions in acute decompensated heart failure focus on maximizing respiratory function through positioning, preventing skin breakdown in edematous areas, and providing comfort measures while adhering to fluid restrictions.