The nursing team is providing morning hygiene care for a client who recently sustained a right-sided cerebrovascular accident (CVA). The client presents with left-sided hemiplegia and left homonymous hemianopsia, and is receiving continuous enteral nutrition via a nasogastric (NG) tube. The registered nurse (RN) is providing specific parameters to the unlicensed assistive personnel (UAP) regarding the care routine. Which directive from the RN represents the safest and most comprehensive approach to this client's basic care and comfort?
- ALower the head of the bed completely flat to minimize shearing forces when rolling the client to their left side to wash their back, then immediately elevate it.
- BIf the client becomes restless and attempts to pull at the feeding tube during the bath, apply bilateral soft wrist restraints to protect the tube and notify me.
- CWhile providing incontinence care, recognize that sudden, acute episodes of disorientation are a normal age-related physiological change and continue with the bath.
- Maintain the head of the bed at a 30- to 45-degree angle during oral hygiene, and approach the client from their right side to explain the procedure before touching them.Cevap
Cevap
Maintain the head of the bed at a 30- to 45-degree angle during oral hygiene, and approach the client from their right side to explain the procedure before touching them.
The correct answer properly addresses both the risk of aspiration and the client's sensory deficit. Continuous enteral nutrition requires keeping the head of the bed elevated at 30 to 45 degrees to prevent aspiration, even during oral hygiene. Additionally, because a right-sided CVA causes left homonymous hemianopsia (blindness in the left half of both visual fields), approaching the client from their intact right side prevents startling them and promotes psychological comfort.
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Anahtar Kavram
Basic care modifications for neurological deficits and continuous enteral nutrition