Physiological Integrity: Basic Care and Comfort
Basic Care and Comfort
This domain tests hygiene, mobility, positioning, skin integrity, nutrition, elimination, sleep, and pain. The exam asks which comfort measure is safe and appropriate for the client's specific limitation.
Core rules
- Reposition at-risk clients at least every 2 hours; use pressure-redistribution surfaces and offload heels. Do not massage reddened bony prominences.
- Use the Braden scale to identify pressure injury risk; nutrition and moisture management matter.
- For dysphagia, position upright at 90 degrees, chin tuck, small bites, and thickened liquids as ordered; assess swallow and provide oral care.
- Pain is what the client reports. Use age-appropriate scales and reassess after intervention.
- Apply heat and cold with a barrier, limit duration, and check skin; clients with neuropathy, poor circulation, or impaired cognition are at high risk for burns.
- Catheter care includes perineal hygiene, keeping the bag below bladder level, and avoiding routine irrigation.
Worked example
A client with a new stroke has coughing and a wet voice after swallowing water. Stop oral intake, keep the client upright, notify the provider, and request a swallow evaluation. Do not simply encourage more fluids or switch to a straw; both can worsen aspiration risk. The reasoning is that coughing during swallowing signals possible aspiration, and the nurse's first action is to protect the airway.
Traps that cost marks
Massaging a reddened pressure area; using a hot pack on insensate skin; relying on vital signs to judge pain; routine catheter irrigation; feeding a coughing client to 'try again.'