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Zorluk: ZorBasic Care and Comfort

A nurse is formulating a basic care and comfort plan for an 82-year-old client who experienced a right hemispheric ischemic stroke 48 hours ago. The client exhibits left-sided hemiparesis, impulsive behavior, moderate dysphagia, and new-onset urinary incontinence. Which intervention is the most appropriate for the nurse to include in the plan of care?

  1. A
    Assign the unlicensed assistive personnel (UAP) to perform an initial bedside swallowing evaluation before providing the breakfast tray.
  2. B
    Inform the family that the client's new-onset urinary incontinence is an expected physiological change associated with advanced age.
  3. Elevate the head of the bed to a high-Fowler's position during meals and maintain this position for at least 30 minutes after oral intake.Cevap
  4. D
    Position the client continuously on the affected left side with the head of the bed flat to prevent sacral skin breakdown.

Cevap

The most appropriate intervention is to elevate the head of the bed to a high-Fowler's position during meals and maintain this position for at least 30 minutes after oral intake.
For a client with moderate dysphagia following a stroke, airway protection is the highest priority. Elevating the head of the bed to a high-Fowler's (90-degree) position during meals and keeping it elevated for 30 to 45 minutes afterward utilizes gravity to prevent aspiration of food or fluids into the lungs.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client has a recent stroke, left-sided hemiparesis, impulsive behavior, dysphagia, and new-onset incontinence.
Identifying the client's deficits helps prioritize basic care interventions, particularly those related to airway safety.
2
Evaluate the risk associated with moderate dysphagia.
Dysphagia places the client at a high risk for aspiration pneumonia, which is a life-threatening complication.
Airway protection is the highest priority in this scenario according to standard nursing guidelines.
3
Select the appropriate nursing intervention for dysphagia.
Positioning the client upright at 90 degrees (high-Fowler's) uses gravity to facilitate swallowing and prevent aspiration.
Maintaining the upright position during and after meals allows time for food to safely clear the esophagus.

Anahtar Kavram

Basic Care and Comfort: Dysphagia Management and Positioning
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Konular

Basic Care and Comfort

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