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Zorluk: ZorBasic Care and Comfort

A clinical nurse preceptor is reviewing the care plan drafted by a newly licensed nurse for an 82-year-old client. The client is bedbound with right-sided hemiplegia following an ischemic stroke, receives continuous enteral nutrition via a nasogastric (NG) tube, and has recently developed urinary incontinence. Which of the following planned interventions should the preceptor identify as correct and appropriate for the client's basic care and comfort? Select all that apply.

  1. Maintain the head of the bed elevated at a 30- to 45-degree angle while providing the client's daily bed bath.Cevap
  2. B
    Position the client in a flat, supine position for 30 minutes every shift while the continuous feeding is infusing to prevent hip flexion contractures.
  3. Incorporate passive range-of-motion (ROM) exercises for the client's right-sided extremities during hygiene care.Cevap
  4. D
    Delegate the initial assessment of the client's oral mucosa and swallowing capability to the unlicensed assistive personnel (UAP) prior to mouth care.
  5. Apply a moisture barrier ointment to the client's perineal and sacral skin after cleansing incontinent episodes.Cevap
  6. F
    Explain to the client's family that the new onset of urinary incontinence is a normal, expected consequence of the physiological aging process.

Cevap

The correct interventions are maintaining the head of the bed elevated during the bed bath, incorporating passive range-of-motion exercises for the affected extremities, and applying a moisture barrier ointment to the perineal area.
The correct interventions prioritize client safety and physiological integrity. Maintaining the head of the bed at an elevated angle during a bed bath prevents reflux and aspiration of the continuous enteral feeding. Passive range-of-motion exercises preserve joint mobility in the hemiplegic limbs and prevent debilitating contractures. Applying a moisture barrier cream effectively protects the perineal and sacral skin from the corrosive effects of urinary incontinence, reducing the risk of pressure injuries and dermatitis.

Adım Adım Çözüm

1
Analyze the client's clinical profile and risk factors.
The client is at high risk for aspiration (continuous NG feed, stroke), immobility complications (hemiplegia, bedbound), and skin breakdown (incontinence).
Identifying physiological risks dictates which basic care interventions are safe and necessary.
2
Evaluate interventions related to airway safety and enteral feeding.
Keeping the head of the bed elevated during a bath is correct to prevent aspiration. Laying the client flat while the feeding runs is highly contraindicated.
Standard aspiration precautions must be maintained continuously unless the feeding is paused.
3
Evaluate interventions for mobility and skin integrity.
Passive ROM and moisture barrier applications are correct nursing actions to prevent contractures and skin breakdown.
These interventions directly address the client's deficits without causing harm.
4
Assess the appropriateness of delegation and patient education.
Delegating an assessment to a UAP is unsafe. Normalizing new-onset incontinence as 'normal aging' is a clinical error.
The RN retains responsibility for all assessments, and pathological changes must not be dismissed as age-related.

Anahtar Kavram

Basic care for clients with complex deficits requires maintaining aspiration precautions during ADLs, prioritizing skin and joint preservation, and distinguishing between normal aging and pathological changes.
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Basic Care and Comfort

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