Physiological Integrity: Basic Care and Comfort
Basic Care and Comfort tests the PN's ability to maintain hygiene, mobility, skin integrity, nutrition, elimination, rest, and pain relief.
Core care
- Reposition immobile clients at least every 2 hours; offload heels; keep skin clean and dry; use pressure-redistribution surfaces; do not massage reddened areas.
- Assist with ADLs while promoting independence; use gait belts and proper body mechanics; keep the call light and personal items within reach.
- For dysphagia, place the client upright, use chin tuck and small bites, follow thickened-liquid orders, and keep the client upright about 30 minutes after meals.
- Pain is what the client says it is; use a valid scale, reassess after intervention, and combine nonpharmacologic measures with prescribed analgesia.
Worked example
An older client who is immobile has a reddened area over the sacrum that does not blanch when pressed. The PN documents a stage 1 pressure injury, keeps the client off the area, repositions every 2 hours, keeps the skin clean and dry, and requests a nutrition consult. Reasoning: nonblanchable erythema is early pressure injury; massage would increase tissue damage. Offloading and moisture control prevent progression.
Elimination and comfort
Prevent constipation with fluids, fiber, and mobility; avoid routine indwelling catheters; provide perineal and catheter care per policy; use heat and cold carefully with a barrier and time limits; protect bony areas from pressure and friction.
Traps
Massaging a reddened area; using a donut cushion; leaving a dysphagia client supine after eating; inserting a Foley without an indication; documenting pain as zero because the client is quiet; applying heat directly to skin.