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Zorluk: ZorBasic Care and Comfort

A nurse is formulating a basic care and comfort plan for an 80-year-old client who is receiving continuous enteral nutrition via a nasogastric (NG) tube. The client has a history of gastroesophageal reflux disease (GERD), mobility impairments, and has recently developed urinary incontinence with mild confusion. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

  1. Pause the continuous enteral feeding pump whenever it is necessary to lower the head of the bed for repositioning or hygiene.Cevap
  2. Cleanse the perineal area with a pH-balanced, no-rinse skin cleanser and apply a moisture barrier ointment after each incontinent episode.Cevap
  3. C
    Lower the head of the bed to a flat, supine position for 15 minutes every 2 hours to relieve continuous pressure on the sacrum.
  4. D
    Delegate the aspiration of gastric residual volumes to the unlicensed assistive personnel (UAP) prior to morning care.
  5. Provide oral hygiene every 4 hours using a soft-bristled toothbrush and a non-alcohol-based rinse.Cevap
  6. F
    Reassure the client's family that the recent onset of confusion and urinary incontinence are expected physiological changes of advanced age.

Cevap

The correct interventions are: pausing the continuous feeding before lowering the head of the bed, providing oral hygiene every 4 hours, and applying moisture barrier ointment to the perineum after incontinence episodes.
Pausing the feeding before lowering the bed prevents pulmonary aspiration. Applying a moisture barrier after incontinent episodes protects skin integrity. Providing regular oral hygiene prevents mucous membrane breakdown and reduces the risk of aspiration pneumonia.

Adım Adım Çözüm

1
Analyze the client's risk factors and current interventions.
The client is older, immobilized, has GERD, and is receiving continuous enteral nutrition. New symptoms include incontinence and confusion.
Identifying these factors highlights the primary risks: aspiration, skin breakdown, and potential acute infection.
2
Evaluate the interventions related to enteral nutrition safety and comfort.
The head of the bed must remain elevated (30-45 degrees) to prevent aspiration. The feeding must be paused if lowering the bed is required. Frequent oral care is mandatory to maintain mucous membrane health.
Enteral feeding bypasses normal oral stimulation, causing dry mouth, and concurrent GERD increases regurgitation risk.
3
Evaluate interventions for skin integrity related to incontinence.
Prompt perineal cleansing with pH-balanced cleansers and the application of moisture barriers are required.
Moisture-associated skin damage (MASD) can quickly progress to pressure injuries in immobilized older adults.
4
Identify inappropriate or unsafe clinical actions among the choices.
Delegating residual assessment to a UAP is a legal scope-of-practice violation. Lowering the bed flat while feeds run is a safety hazard. Dismissing new confusion as 'normal aging' is a diagnostic error.
These represent common procedural, delegation, and pathological misconceptions.

Anahtar Kavram

Basic care and comfort for a client on continuous enteral feeding requires vigilant positioning to prevent aspiration, proactive oral and perineal hygiene to maintain tissue integrity, and the recognition that sudden cognitive or elimination changes in older adults warrant acute assessment.
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Basic Care and Comfort

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