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Zorluk: ZorBasic Care and Comfort

A practical nurse is assisting a client who has a traumatic brain injury with right-sided weakness and moderate dysphagia. The client's dietary order specifies pureed foods and nectar-thick liquids. Which action is the most appropriate for the nurse to implement during the meal?

  1. Position the client upright at 90 degrees, instruct them to tilt the chin downward during swallowing, and place food on the left side of the oral cavity.Cevap
  2. B
    Maintain the head of the bed at a 45-degree angle and provide a flexible straw to help the client consume the nectar-thick liquids.
  3. C
    Offer small, alternating sips of unthickened water between bites of pureed food to ensure the throat remains clear of residue.
  4. D
    Delegate the feeding procedure to an unlicensed assistive personnel (UAP) after independently verifying the correct meal tray was delivered.

Cevap

Position the client upright at 90 degrees, instruct them to tilt the chin downward during swallowing, and place food on the left side of the oral cavity.
The correct answer demonstrates the most comprehensive and safe approach for a client with dysphagia and unilateral weakness. Positioning the client at 90 degrees utilizes gravity to assist swallowing, while the chin-down (chin-tuck) maneuver widens the valleculae and narrows the airway entrance, providing essential protection against aspiration. Placing the food on the left side (the unaffected, strong side) ensures the client can properly sense and manipulate the bolus before swallowing.

Adım Adım Çözüm

1
Analyze the client's physical deficits and dietary orders based on the clinical presentation.
Identifies that right-sided weakness leaves the left side of the mouth as the strong, unaffected side. Notes the strict requirement for pureed foods and nectar-thick liquids.
Understanding the anatomical deficits and dietary constraints is required to plan safe feeding interventions.
2
Evaluate the physiological risks associated with moderate dysphagia.
Recognizes that the primary risk during oral intake is airway compromise and aspiration pneumonia.
Prioritizing Airway, Breathing, and Circulation (ABCs) guides the selection of interventions that protect the respiratory tract.
3
Determine the optimal positioning and feeding technique to mitigate aspiration risk.
Concludes that sitting at a 90-degree angle with a chin-tuck maneuver mechanically protects the airway, and utilizing the strong (left) side of the mouth ensures the client can effectively control the food bolus.
Applying evidence-based dysphagia precautions ensures the maintenance of basic care, comfort, and physiological integrity.

Anahtar Kavram

Dysphagia Management and Airway Protection
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Konular

Basic Care and Comfort

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