Basic Care

and Comfort
Archer Review

Basic Care and Comfort

1. Positioning
2. Non-Pharmacological Comfort Interventions
3. Mobility/Immobility
4. Assistive Devices
5. Nutrition
6. Elimination
 Positioning

Low Fowler’s
Semi-Fowler’s

Fowler’s
High Fowler’s

Orthopneic Position
Supine

Prone
Right Lateral Recumbent

Left Lateral Recumbent

Trendelenburg

Reverse Trendelenburg
Sims

NCLEX Question
Which of the following interventions is helpful in reducing the effects of GERD?

A. Lie down after eating.

B. Wear a girdle.
C. Elevate the head of the bed on 4-6 inch blocks.
D. Increase fluid intake just before bedtime.
Answer: C
GERD occurs when stomach acid slips into the esophagus. Any position that hinders or slows the
movement of food from the stomach should be avoided.

C is correct. Patients should be encouraged to elevate the head of the bed to allow food to move
out of the stomach before lying flat.

A is incorrect. I was lying down after eating causes the movement of food out of the stomach to
slow, which could aggravate symptoms.

B is incorrect. The compression of the stomach reduces its volume, and those who wear girdles or
waist training find that overeating gives them indigestion and heartburn.

D is incorrect. When a patient lies in bed shortly after eating or drinking, gravity is not as quickly
keeping digestive juices in the stomach. Eating or drinking more than three to four hours before
bed reduces the risk of nighttime heartburn.

Non-pharmacological
Comfort Interventions
Relieving pain without meds!
● Different types of interventions work for different clients
● This is the least invasive way to address pasin
○ Nonpharmacological
○ Non-opioid analgesics
○ Opioid analgesics

Body
● Massage
● Reiki
● Acupuncture
● Acupressure
● Progressive muscle relaxation
● Biofeedback
Mind
● Meditation
● Prayer
● Guided imagery
● Hypnosis
● Mind/Body exercises
● Distraction
● Deep breathing
 Mobility/
Immobility

Mobility assessment
● Many different tools available
● You may score your client with a tool, which determines the amount of
assistance they need.
● Common methods of assessing
○ Sit and shake
■ How is their trunk strength, seated balance, and cognition?
○ Stretch and point
■ How is their lower extremity stability and strength?
○ Stand
■ Can they stand? Strength from sitting to standing?
○ Walk
■ How is their standing balance? Assess their gait while walking.
Complications of immobility
● Skin breakdown
○ Pressure ulcers
● Contractures
● Muscular weakness
● Muscular atrophy
● Loss of calcium from the bones
○ Osteoporosis
○ Hypercalcemia
○ Renal calculi
● Atelectasis
○ Pneumonia
● Venous stasis
○ DVT -- > Can lead to a clot anywhere in the body!

Skin breakdown
● Always assess your client’s skin!
● Use a risk score
○ Ex - Braden scale
● Open sores can lead to infection

Example of a nursing diagnosis:

“At risk for pressure ulcers related to immobility”

Pressure injury stages
Ways to reduce pressure
● Assess the source of the pressure + reduce it!!
● Turn
● Reposition
● HOB < 30 degrees
● Padding on bony prominences
● Float the heels off the bed
● Specialty mattresses
● NO donut-shaped pillow

Promoting venous return

● Venous stasis = blood isn’t flowing!
● Blood that’s not flowing clots. We want to prevent that!
● Devices that promote venous return
○ Ted hose
○ Compression stockings
○ Sequential compression devices (SCDs)
Range of Motion
● Prolonged immobility caused decreased range of motion
● Totally immoble?
○ Help your client with passive range of motion activities?
● Able to do some movement?
○ Teach them about active range of motion activities?

Contractures
● Foot drop
○ Plantar flexion contracture
○ Prevent with boots!
 Assistive Devices

Assistive Devices
● Walker
● Cane
● Wheelchair
● Crutches
Walker
● Stand in the center of the walker
● Slide walker forward 6-8 inches
● Keep all 4 feet of walker on ground
● Step forward with affected side
○ Keep weight on the walker and unaffected leg
● Bring unaffected leg up to walker
Crutches: Fit
● Don’t rest on armpits
● Use shoulders and arms for strength
● Slight bend through the elbows

Three-Point Gait
● For partial weight bearing
● Crutches are advanced with
the affected leg
● Unaffected leg brought
forward
Swing-Through Gait
● For non-weight bearing clients
● Stand on the unaffected leg
● Move both crutches forward
about a foot
● Brace the hand grips for support
● Swing both legs through the
crutches
Cane
● Cane goes on the unaffected side
● Slight bend at the elbow
● Cane moves forward 6-10 inches
● Affected leg moves forward with
cane
● Unaffected leg then moves past
the cane
 Nutrition

Assessment
● Any unintentional weight loss
○ If present in the past three months, client at risk
● How is their appetite
○ Reduced dietary intake in the last week puts the client at risk
● Body Mass Index
○ <18.5 is underweight
● Elderly clients at higher risk
● Assess skin turgor and mucous membranes - are they hydrated?
● What is their appearance?
● Energy level
Calculating BMI

Example: Your client weight 60 kg and is 1.52 meters tall. Are they at risk for
imparied nutritional status?

Answer: No!
BMI = 60 kg ➗ (1.52m)² = 25.96

<18.5 - Underweight

18.5-24.9 - Normal weight

25.0-29.9 - Overweight

>30 - Obese
Interventions
● Oral nutrition
○ High calories
○ High protein
● Enteral nutrition
○ Feeding delivered via a nasogastric tube
● Parenteral nutrition
○ Feeding delivered intravenously.

Monitor fluid and electrolytes!!!

Daily weights! I’s & O’s!
 NG Tubes

What is a nasogastric tube?

● Tube inserted in the nare
that terminates in the
stomach
● Uses:
○ Enteral nutrition
○ Decompression
○ Medication administration
○ Removal of stomach contents
after an overdose
Insertion
1. Perform hand hygiene
2. Explain the procedure to the client
3. Measure from the earlobe of the client to the nose, then to the xiphoid
process. This is how deep you will insert the NG tube.
4. Mark the depth of insertion on the NG tube
5. Lubricate the tip of the tube.
6. Insert the tube to the nasopharynx, and ask the client to swallow and tuck
their chin to their chest.
7. Continue advancing the tube to the predetermined depth.
8. Secure the tube.
9. Verify placement of the NG tube.

Measurement
Placement verification
● Gold standard - x-ray visualization
● Aspiration of gastric contents
● Auscultation of air over the epigastrium
● Residuals
○ The amount of feeding that remains in the
stomach at the time of your assessment
○ Typically checked as you are preparing to start
the next feed
○ If it is greater than 500 mL, the feed should be
held.

TPN
● Nutrition delivered intravenously
● Central line is preferred
● Complications
○ Big infection risk….. Scrub that hub! Wash your hands!! Gloves!!!
■ Tubing is changed every day
○ Fluid overload
○ Hyper OR hypoglycemia
 Elimination

Assessment
● Assess your client for alterations in elimination
○ Bowel
○ Bladder
● Incontinence
○ May need intervention to promote elimination
○ At high risk of skin breakdown
At risk clients
● Altered level of consciousness
● Developmental level
● Advanced age
● Poor muscular tone
● Urinary tract infection

Interventions
● Maintain skin integrity
○ Keep skin clean and dry
○ Check and change bedding/pad/diaper etc. often
● Medications
○ Diuretics → Promote urinary elimination
○ Laxatives/stool softeners → Promote bowel elimination
○ Enemas
● Colostomy or ileostomy
● Urinary catheter
Colostomy & Ileostomy
● Colostomy
○ Opening in the large intestine brought to the surface
○ Stool will be formed
● Ileostomy
○ Opening created in the small intestine brought to the surface
○ Higher risk for dehydration
○ Stool will be liquidy

Monitor their fluid & electrolytes closely!!

Nursing Care of the Ostomy

● Empty the pouch when ⅓-½ full
● Change pouch every 3-5 days
● Keep stoma clean and dry
● Assess peristomal skin closely for breakdown
Enemas
● Supplies needed: enema bag and solution, lubricant, gloves, clamp,
towel/bed pads
● Ideal position for the client - left side with knees drawn up or Sims position
● Always warm the solution
● Smart to put a towel or pads under the client first!
● Administration steps:
1. Fill enema bag, prime, and clamp tubing
2. Lubricate the tip of the enema applicator.
3. Insert into client’s rectum
4. Release clamp
5. Remove applicator after solution has infused.
What is a foley catheter?
● Catheter placed into the urethra and up to the client's bladder
● Foley catheters are ‘indwelling’ or left for an extended period of time
● Urine drains into a drainage bag

Inserting a foley catheter

1. Wash your hands and don sterile gloves
2. Place the tip of the catheter in lubricant
3. Clean with betadine
a. Females: Use the non-dominant hand to spread the labia. Use three swabs: one on the left,
one on the right, and the last one down the middle.
b. Male: Clean the peri-urethral opening with three swabs.
4. Using the dominant hand, insert the catheter into the urethral opening
5. Once urine is observed, advance the catheter another one to two inches
6. Attach the pre-filled syringe to the port and inflate the balloon
7. Connect the drainage system to the catheter and secure per facility protocol.
Nursing Must Know
● There should never be dependent loops in the tubing. This can lead to urine
backing up in the bladder.
● Inserting a foley catheter requires sterile technique to prevent infection.
● CAUTIS (catheter acquired urinary tract infections) are UTIs caused by a
catheter. The hospital is not reimbursed for these infections, so there is a lot
of emphasis on preventing them.
○ Most facilities use a bundle to prevent CAUTIS
■ Always remove as soon as possible
■ Daily cleaning and care
● You can collect a urine sample directly from the port on the foley!

Collecting a urine sample

1. Collect supplies.
2. Wash hands, put on gloves.
3. Wipe genitals with a towelette
4. Allow urine for flow for two seconds, then place sterile container to collect
sample.
5. Client can finish urinating.
6. Replace lid on specimen container and label according to policy. Place in a
specimen bag.
7. Remove gloves, wash hands.
 Archerreview.com | @archernclex
Next live review:
July 12th + 13th

Instructors:
Lexie Garber: lexie@archerreview.com
Lauren Korth: lauren@archerreview.com
Rachel Taylor: rachel@archerreview.com
Cait Capablanca: cait.capa@archerreview.com
Katelyn Moring: katelyn.moring@archerreview.com
Morgan Taylor: morgan@archerreview.com