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Zorluk: Çok zorBasic Care and Comfort

An 81-year-old client with bulbar amyotrophic lateral sclerosis (ALS) is admitted for treatment of aspiration pneumonia. The client has a newly inserted percutaneous endoscopic gastrostomy (PEG) tube for continuous enteral feeding, a Stage II sacral pressure injury, and exhibits intermittent periods of profound disorientation. Which nursing interventions are appropriate for this client's basic care and comfort? Select all that apply.

  1. Ensure the upper body remains inclined at a 30-degree to 45-degree angle during active administration of the prescribed enteral nutrition.Cevap
  2. B
    Direct the assistive personnel to evaluate the peristomal skin integrity around the gastrostomy site while performing the morning bed bath.
  3. C
    Secure bilateral soft limb restraints to the movable portion of the bed frame to prevent inadvertent removal of the enteral feeding device during agitated states.
  4. D
    Record the episodes of disorientation in the health record as an anticipated cognitive alteration associated with the normal aging process.
  5. Position the client using a 30-degree lateral tilt, alternating between the left and right sides, to alleviate direct mechanical pressure on the sacral region.Cevap
  6. F
    Lower the bed to a completely horizontal position while the enteral pump continues infusing to facilitate optimal nurse body mechanics during lower body hygiene.

Cevap

The correct interventions are maintaining the upper body at a 30-to-45-degree angle during feedings and utilizing a 30-degree lateral tilt to offload sacral pressure.
Clients receiving continuous enteral nutrition are highly susceptible to aspiration; keeping the upper body elevated at 30 to 45 degrees utilizes gravity to reduce this risk. Furthermore, for clients with existing sacral pressure injuries, a 30-degree lateral tilt is the optimal, evidence-based position to offload direct pressure from the bony prominences of the coccyx while avoiding the excessive trochanteric pressure caused by full 90-degree side-lying.

Adım Adım Çözüm

1
Analyze the client's clinical profile and associated risks.
The client has a high risk for aspiration (bulbar ALS, previous aspiration pneumonia, continuous PEG feeding), impaired tissue integrity (Stage II sacral injury), and acute confusion.
Identifying overlapping acute and chronic issues dictates the prioritization of safe basic care interventions.
2
Evaluate interventions related to enteral feeding safety.
Positioning the client at a 30-45 degree angle is standard safe practice to prevent aspiration. Lowering the bed to a flat position without stopping the continuous infusion is highly contraindicated.
Gravity is necessary to prevent reflux of enteral formula from the stomach into the esophagus and airway.
3
Determine the appropriate intervention for the sacral pressure injury.
A 30-degree lateral tilt alternates pressure off the sacrum without causing new pressure injuries on the hip bones, making it the optimal evidence-based positioning strategy.
Traditional 90-degree side-lying positions create intense pressure over the trochanter, exacerbating skin breakdown rather than preventing it.
4
Critique the remaining options regarding delegation, safety, and cognitive assessment.
UAP cannot evaluate wounds, restraints are a last resort (not an immediate solution), and sudden confusion is a pathological symptom, not normal aging.
Nursing care must adhere to legal scopes of practice, prioritize least-restrictive safety environments, and accurately distinguish between senescence and acute disease processes.

Anahtar Kavram

Basic Care and Comfort: Positioning, Skin Integrity, and Safe Care Environment
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Basic Care and Comfort

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