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Zorluk: Çok zorBasic Care and Comfort

A nurse is planning basic care for an 84-year-old client with advanced Alzheimer's disease who is receiving continuous enteral feedings via a percutaneous endoscopic gastrostomy (PEG) tube. The client has a stage 2 pressure injury on the left greater trochanter and has become acutely agitated during the shift, repeatedly attempting to pull at the feeding tube. Which of the following interventions represents the MOST appropriate evidence-based practice for this client?

  1. Conceal the feeding tube by securing it beneath a soft abdominal binder, and position the client in a 30-degree lateral tilt with the head of the bed elevated at 30 to 45 degrees.Cevap
  2. B
    Apply prescribed bilateral soft wrist restraints to prevent immediate tube dislodgement, and delegate the evaluation of the client's pressure injury healing progress to the unlicensed assistive personnel.
  3. C
    Turn the client to a 90-degree right lateral position to offload the left trochanter completely, and lower the head of the bed to a flat alignment to promote physical relaxation.
  4. D
    Attribute the sudden onset of agitation to the expected progression of advanced Alzheimer's disease, and dim the room lights while playing soft music to calm the client.

Cevap

Conceal the feeding tube by securing it beneath a soft abdominal binder, and position the client in a 30-degree lateral tilt with the head of the bed elevated at 30 to 45 degrees.
The correct intervention safely synthesizes multiple aspects of basic care and comfort. Securing the PEG tube under a soft abdominal binder is an evidence-based, less restrictive alternative to physical restraints that protects the medical device from an agitated client. Positioning the client in a 30-degree lateral tilt effectively relieves pressure on the sacrum and trochanter without placing excessive weight on the opposite hip. Most importantly, maintaining the head of the bed at an elevation of 30 to 45 degrees is a mandatory safety measure to prevent life-threatening aspiration in any client receiving continuous enteral feedings.

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1
Analyze the client's clinical presentation and identify priority risks.
The client has a continuous enteral feeding (aspiration risk), a trochanteric pressure injury (skin breakdown risk), and acute agitation (risk for device removal).
Identifying physiological and safety priorities determines which nursing interventions are safe and effective.
2
Evaluate interventions for protecting the medical device.
An abdominal binder safely conceals the tube without restricting limb movement.
Physical restraints are a last resort and should be avoided if less restrictive alternatives are available.
3
Determine the optimal positioning strategy.
The client must be positioned in a 30-degree lateral tilt with the head of the bed elevated at 30 to 45 degrees.
A 30-degree tilt avoids direct pressure on either trochanter, while head elevation is a critical requirement to prevent aspiration during continuous tube feedings.
4
Review scope of practice and delegation principles.
Evaluating the healing progress of a pressure injury cannot be delegated.
Assessments and clinical evaluations are strictly within the scope of practice of the Registered Nurse.

Anahtar Kavram

Complex Basic Care and Comfort Synthesis: Positioning, Device Safety, and Delegation
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Konular

Basic Care and Comfort

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