Basic Care

and
Comfort

© USMLE Galaxy LLC

Basic Care and Comfort
1. Positioning → Watch positioning video
2. Mobility/Immobility
3. Assistive Devices→ Watch assistive devices video
4. Non-Pharmacological Comfort Interventions
5. Nutrition
6. Elimination
7. Postmortem Care
Positioning
Positions
Watch positioning video!

● Supine
● Prone
● Fowler’s
● Right lateral
● Left lateral
● Trendelenburg
● Reverse Trendelenburg
● Sims
● Knee-to-chest
Traction Positioning
Uses a pulling force to realign a bone

● Skeletal
○ Uses screws/pins into the bone
○ 15 - 30 lbs of pulling force
○ Example: Halo Traction
● Skin
○ Decreases muscles spasms
○ 5- 10 lbs of pulling force
○ Example: Buck Traction
Bucks Traction

Buck’s traction image

Traction Nursing Actions
● Do NOT adjust weights unless specifically ordered by the PHCP
● Weights should be free hanging
● Ensure no fraying of ropes/pulleys
● Monitor circulation hourly for the first 24 hours then every 4 hours
● Pin site care:
○ Use of saline/Vaseline Dressings (facility protocol may differ)
○ Done every 8 - 12 hours
● Signs of pin site Infection:
○ Loose pins
○ Purulent drainage from pins (clear is an expected finding)
○ Odor
○ Fever
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: BMAT - Bedside Mobility Assessment Tool
○ 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
Assistive Devices
Watch assistive devices video!

● Walker
● Cane
● Crutches
○ Fit
○ Gaits
■ 2 point
■ 3 point
■ 4 point
■ Swing through
○ Up the stairs
○ Down the stairs
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
○ e.g. Braden scale
● Open sores can lead to infection

Example of a nursing diagnosis:

“At risk for pressure ulcers related to immobility”

Shear & Friction
Pressure injury stages
Ways to reduce pressure
● Assess the source of the pressure and reduce it!!
● Turn every 2 hours
● Reposition every 2 hours
● HOB < 30 degrees
● Padding on bony prominences
● Float the heels off the bed
● Specialty mattresses
● NO donut-shaped pillow
NGN Question
The supervising nurse watches a newly hired nurse take care of a client who is at risk of developing a
pressure ulcer. Which of the following interventions by the newly hired nurse requires follow-up?

Select all that apply.

A. Applies zinc oxide to the client’s perineal skin

B. Provides a donut pillow while the client is sitting in the chair
C. Maintain the head of the client’s bed at 90 degrees
D. Encourages the client to consume foods rich in carbohydrates
E. Uses a pillow to float the client’s heels
Promoting venous return
● Venous stasis = blood isn’t flowing!
● Blood that’s not flowing is at increased risk for clots
○ We want to prevent that!
● Devices that promote venous return
○ TED hose
○ Compression stockings
○ Sequential compression devices (SCDs)
Range of Motion
● Prolonged immobility causes decreased range of motion
● Totally immobile?
○ Help your client with passive range of motion activities!
● Able to do some movement?
○ Teach them about active range of motion activities!
Contractures
● Permanent muscle shortening caused by muscle spasticity
○ Often occurs due to prolonged immobility
● Foot drop
○ Plantar flexion contracture
○ Prevent with boots!

Image Source: Pagemaker787, Foot drop, CC BY-SA 4.0

Non-pharmacological Comfort
Interventions
Nonverbal Signs of Pain
● Grimacing
● Flinching
● Guarding an area of the body
● Moaning
● Restlessness
● Change in vital signs
Body
● Massage
● Reiki
● Acupuncture
● Acupressure
● Progressive muscle relaxation
● Biofeedback
● Electrical stimulation
Mind
● Meditation
● Prayer
● Guided imagery
● Hypnosis
● Mind/body exercises
● Distraction
● Deep breathing
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 57 kg and is 1.52 meters tall. Are they at risk for
impaired nutritional status?
Answer: No!
BMI = 57 kg ➗ (1.52m)² = 24.68

<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
○ Nutrition provided intravenously

Monitor fluid and electrolytes!!!

Daily weights! I’s & O’s!
Nasogastric tube
● Tube inserted in the nare
that terminates in the
stomach
● Uses
○ Enteral nutrition
○ Gastric decompression
○ Medication administration
○ Removal of stomach contents
after an overdose
Placement verification
● Gold standard is x-ray visualization
● Other methods
○ 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

James Heilman, MD, ETTubeandNGtubeMarked, CC BY-SA 4.0

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
○ Electrolyte imbalances
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
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.
Colostomy and 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
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
○ 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!
NGN Question
The nurse observes a student inserting an indwelling urinary catheter into a female client. Which action by the
student requires follow-up by the nurse? The student

(Select all that apply)

A. applies clean gloves to clean the perineal area with soap and water.
B. asks the client to bear down gently and slowly insert the catheter through the urethral meatus.
C. separates the labia with the fingers of the dominant hand when cleaning with antiseptic solution.
D. secures the catheter tubing to the inner thigh.
E. attaches the drainage bag to the side rails of bed.
Postmortem Care
Postmortem Care
● Be respectful
○ Close door/curtains
○ Communicate with family
● Lines/Tubes
○ Autopsy
■ Keep all lines/tubes in place
○ No autopsy
■ Remove all lines/tubes
● Client care
○ Place pillow under head
○ Put in dentures
○ Close eyes
○ Assess for specific religious/cultural practices