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Zorluk: ZorBasic Care and Comfort

A night shift nurse evaluates an older adult client who is unable to sleep due to severe, burning discomfort in both feet. The client has a documented medical history of advanced peripheral arterial disease (PAD). Which nursing intervention provides the safest and most effective comfort measure for this condition?

  1. Assist the client to sit on the edge of the mattress and allow their legs to hang downward.Cevap
  2. B
    Support the client's lower legs with pillows to elevate the feet above the level of the heart.
  3. C
    Direct the unlicensed assistive personnel to firmly massage the calf muscles to reduce cramping.
  4. D
    Reassure the client that these sensory changes are an expected part of aging and administer a prescribed sleep aid.

Cevap

Assist the client to sit on the edge of the mattress and allow their legs to hang downward.
In advanced peripheral arterial disease (PAD), severe narrowing of the arteries restricts oxygenated blood from reaching the distal extremities, leading to ischemic rest pain that often worsens at night when the client is supine. Placing the client in a dependent position (such as dangling the legs over the edge of the bed) leverages gravity to assist arterial perfusion, thereby increasing oxygen delivery to the tissues and effectively relieving the discomfort.

Adım Adım Çözüm

1
Analyze the client's symptoms and medical history.
The client is experiencing severe, burning foot pain at night, combined with a history of advanced PAD.
Identifying the etiology of the pain (ischemic rest pain) is required before implementing a comfort measure.
2
Determine the pathophysiological principle of PAD.
Arterial narrowing restricts oxygenated blood flow to the distal extremities.
Understanding the compromised blood flow guides the nurse to select interventions that enhance arterial perfusion.
3
Evaluate the positioning options based on gravitational effects on blood flow.
Dependent positioning (dangling) utilizes gravity to pull blood down to the feet, improving perfusion and relieving ischemic pain.
This directly counters the arterial insufficiency, providing immediate non-pharmacologic comfort.

Anahtar Kavram

Dependent positioning for Peripheral Arterial Disease (PAD)
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Konular

Basic Care and Comfort

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