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Zorluk: Çok zorBasic Care and Comfort

A nurse is creating a comprehensive basic care and comfort plan for an older adult client with advanced dementia who is bedbound, has a history of sacral pressure injuries, and is receiving continuous enteral tube feedings. Which of the following nursing interventions should be included in the client's plan of care? Select all that apply.

  1. Maintain the head of the bed elevated between 30 and 45 degrees to balance aspiration precautions with the prevention of sacral shearing forces.Cevap
  2. B
    Delegate the evaluation of the client's sacral and perineal skin condition to the unlicensed assistive personnel (UAP) during routine hygiene care.
  3. Reposition the client using a 30-degree lateral inclined position, alternating between the right and left sides to minimize pressure on the greater trochanters.Cevap
  4. D
    Document the client's newly developed severe urinary incontinence as an expected physiological change associated with the normal aging process.
  5. E
    Place the client in a 90-degree high Fowler's position for extended periods throughout the day to maximize oxygenation and prevent enteral feeding reflux.
  6. Apply a protective moisture barrier cream to the client's perineal and sacral areas after cleansing following each episode of incontinence.Cevap

Cevap

The correct interventions are maintaining the head of the bed between 30 and 45 degrees, repositioning using a 30-degree lateral incline, and applying a moisture barrier cream after incontinence episodes.
The correct interventions directly address the client's competing physiological needs. Maintaining a 30 to 45-degree head-of-bed elevation prevents aspiration from the enteral feeding while minimizing sacral shearing forces. The 30-degree lateral inclined position effectively offloads pressure from the high-risk sacral and trochanteric areas. Applying a moisture barrier cream is an essential proactive measure to prevent incontinence-associated dermatitis and subsequent pressure injuries.

Adım Adım Çözüm

1
Analyze the client's clinical profile and risk factors.
The client is bedbound, has a history of sacral pressure injuries, receives continuous enteral feedings, and has advanced dementia.
Identifying overlapping risk factors (aspiration risk vs. skin breakdown risk) is necessary to prioritize conflicting interventions.
2
Evaluate positioning strategies for enteral feeding alongside pressure injury prevention.
A 30 to 45-degree head of bed elevation prevents aspiration while avoiding the severe sacral shearing forces caused by a 90-degree high Fowler's position. The 30-degree lateral incline is best for side-lying.
Evidence-based practice requires balancing respiratory/gastrointestinal safety with tissue integrity.
3
Assess delegation and age-related physiological principles.
Skin assessment cannot be delegated to UAP, and new-onset severe incontinence must be investigated as a pathological symptom, not dismissed as normal aging.
Maintaining scope of practice and accurate clinical judgment ensures safe care delivery.

Anahtar Kavram

Complex Care Coordination: Balancing Aspiration Precautions and Tissue Integrity in the Bedbound Client
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Konular

Basic Care and Comfort

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