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Zorluk: ZorBasic Care and Comfort

A practical nurse is providing basic care for an older adult client who is completely immobile, has a high risk for pressure injuries, and is receiving continuous enteral tube feeding. The nurse is preparing to reposition the client to promote comfort and skin integrity. Which action is the most appropriate for the nurse to perform?

  1. Turn the client to a 30-degree lateral position and maintain the head of the bed elevated at 30 degrees.Cevap
  2. B
    Position the client in a 90-degree side-lying position to completely eliminate pressure on the sacrum.
  3. C
    Elevate the head of the bed to a high-Fowler's position to maximize airway protection during the feeding.
  4. D
    Place the client in a prone position for short intervals to actively relieve posterior tissue ischemia.

Cevap

The most appropriate action is to turn the client to a 30-degree lateral position while maintaining the head of the bed elevated at 30 degrees.
Turning the client to a 30-degree lateral position effectively offloads the sacrum without placing excessive pressure on the greater trochanter. Simultaneously maintaining the head of the bed at 30 degrees prevents gastric reflux and aspiration of the continuous enteral feeding, while keeping it low enough to prevent the severe shearing forces associated with higher Fowler's positions.

Adım Adım Çözüm

1
Analyze the client's clinical profile.
Identified dual risks: high risk for pressure injuries due to immobility, and high risk for aspiration due to continuous enteral feeding.
Understanding these competing risks is essential for determining a safe positioning strategy.
2
Evaluate positioning requirements for continuous enteral feeding.
Determined that the head of the bed must remain elevated to at least 30 degrees.
Gravity is required to prevent gastric reflux and subsequent pulmonary aspiration of the continuous feeding formula.
3
Evaluate positioning requirements for pressure injury prevention.
Determined that a 30-degree lateral tilt is optimal, and high-Fowler's must be avoided.
A 30-degree tilt offloads the sacrum without crushing the trochanter. Head elevation above 30 degrees causes the body to slide, resulting in excessive tissue shearing.
4
Select the intervention that safely addresses both clinical requirements.
The 30-degree lateral position combined with a 30-degree head of bed elevation is selected.
This precise combination protects the airway while simultaneously minimizing pressure and shear forces on vulnerable skin.

Anahtar Kavram

Safe positioning strategies for clients with simultaneous aspiration and pressure injury risks
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Konular

Basic Care and Comfort

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