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Zorluk: Çok zorBasic Care and Comfort

A 78-year-old client with advanced Alzheimer's disease, severe kyphosis, and a recent right hemispheric stroke resulting in right homonymous hemianopsia and dysphagia is admitted to a palliative care unit. The client is completely bedbound, non-verbal, and grimaces frequently when turned. When planning the client's basic care and comfort interventions, which of the following actions should the nurse include in the plan of care? (Select all that apply.)

  1. Position the overbed table and initiate communication primarily from the client's left side to accommodate the visual field deficit.Cevap
  2. B
    Delegate the administration of pureed meals to the unlicensed assistive personnel (UAP) using a feeding syringe to ensure adequate intake.
  3. C
    Attribute the client's grimacing during repositioning to expected age-related osteoarthritic joint changes and continue standard turning schedules without additional analgesia.
  4. Support the client's head, neck, and upper shoulders with customized pillow placement when lying supine to accommodate the altered spinal curvature.Cevap
  5. E
    Utilize a ring-shaped hydrocolloid device (donut cushion) directly beneath the client's sacrum during semi-Fowler's positioning to offload bony prominences.
  6. Perform oral hygiene using a soft suction toothbrush, carefully inspecting the buccal mucosa for pocketed food after every meal.Cevap

Cevap

The correct basic care interventions include approaching the client from their unaffected visual field (the left side), supporting their kyphotic spinal curvature with customized pillows, and performing meticulous oral care with buccal inspections to clear pocketed food.
For a client with right homonymous hemianopsia, the right half of the visual field is absent; therefore, the nurse must approach and place objects on the unaffected left side to prevent startling the client. Severe kyphosis alters the spine's natural alignment; forcing the client flat can cause severe discomfort and compromise the airway, requiring the head and neck to be supported with pillows. Dysphagia following a stroke often leads to food pocketing in the cheeks on the affected side, requiring meticulous oral care with a suction toothbrush to prevent the delayed aspiration of residual food.

Adım Adım Çözüm

1
Analyze the neurological deficits (right homonymous hemianopsia and dysphagia) to determine safe interaction and hygiene practices.
The nurse must approach from the left side where vision is intact, and use a suction toothbrush to clear pocketed food, preventing aspiration.
Neurological deficits directly impact how a client interacts with their environment and their ability to swallow safely.
2
Evaluate the musculoskeletal status (severe kyphosis) to guide positioning.
The head and neck must be supported with pillows when supine to maintain the kyphotic curvature.
Forcing a kyphotic spine flat against a bed causes severe musculoskeletal pain and airway compromise due to extreme neck extension.
3
Assess the behavioral indicators of pain in the context of dementia.
Grimacing must be recognized as acute pain requiring intervention, not dismissed as normal aging.
Clients with advanced Alzheimer's cannot verbalize pain; behavioral cues are reliable indicators of distress.
4
Review skin integrity guidelines and delegation rules for high-risk clients.
Donut cushions are contraindicated for pressure relief, and feeding a dysphagic stroke client cannot be delegated to a UAP.
Donut cushions cause tissue ischemia. UAPs lack the clinical judgment to assess swallowing mechanisms and early signs of aspiration.

Anahtar Kavram

Complex Synthesis of Basic Care and Comfort in Geriatric Neurological Clients
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Konular

Basic Care and Comfort

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