Basic Care and Comfort: Practice Questions & Explanations

RANGE-OF-MOTION EXERCISES maintain joint flexibility, prevent contractures, maintain muscle tone, improve circulation, and prevent complications of immobility.

Types: PASSIVE ROM — nurse moves the client's joints through the range; used when client cannot participate (unconscious, complete paralysis, very weak); ACTIVE-ASSISTED ROM — nurse assists the client who can do some movement; ACTIVE ROM — client performs exercises independently; nurse provides instruction and encouragement.

Correct technique:

Support: hold the limb at the joint (above AND below) to stabilize and support the weight.

Smooth and slow: no jerky or rapid movements.

Full available range: move the joint as far as it will comfortably go.

Stop for pain: pain indicates possible injury or joint problem; stop, document, and report; WARMTH helps muscles and joints move more freely; some facilities encourage warm soaks prior to ROM.

Sequence: start at head and work down, or from proximal (closer to body) to distal (farther from body).

Frequency: typically 2-4 times per day; each joint 5-10 repetitions. ROM MOVEMENTS by joint type: HINGE JOINTS (elbow, knee) — flexion and extension; BALL-AND-SOCKET (shoulder, hip) — flexion, extension, abduction, adduction, rotation, circumduction; PIVOT (neck) — rotation; SADDLE (thumb) — wide variety of movements.

Contractures: fixed joint deformity from muscle shortening due to prolonged immobility; prevention is key — far harder to reverse than to prevent; foot drop (plantar flexion contracture) prevented with foot board or splints and dorsiflexion ROM.

Pn role: perform passive ROM, active-assisted ROM; document tolerance; report any pain, redness, swelling, decreased range; reinforce PT/OT instructions; educate family on ROM techniques.

PRESSURE INJURIES (formerly called pressure ulcers or decubitus ulcers) are localized areas of injury to the skin and/or underlying tissue, usually over a bony prominence, resulting from sustained pressure, shear, or friction.

Pathophysiology: pressure compresses capillaries, reducing blood flow; ischemia leads to tissue death; prolonged pressure (even low pressure over time) causes injury; highest-risk areas: sacrum/coccyx, heels, greater trochanter, ischial tuberosities, occiput, medial and lateral malleoli, elbows, scapulae. STAGING (NPUAP/EPUAP):

Stage 1: non-blanchable erythema of intact skin — early warning sign.

Stage 2: partial-thickness skin loss, shallow open ulcer with red/pink wound bed.

Stage 3: full-thickness skin loss, subcutaneous fat visible.

Stage 4: full-thickness tissue loss, bone, tendon, or muscle visible.

Unstageable: full-thickness but covered by slough/eschar.

Deep tissue injury: intact skin with discoloration/blood-filled blister.

Primary interventions: REPOSITIONING every 2 hours (or per individualized schedule based on tissue tolerance and patient condition); documentation of position changes; SKIN INSPECTION with each repositioning (especially bony prominences).

Keep skin clean and dry: moisture (incontinence, sweat) dramatically increases skin breakdown; use moisture barriers (zinc oxide).

Minimize friction and shear: use lift sheets for repositioning, not dragging.

Pressure redistribution: specialty mattresses (foam, air-fluidized, low-air-loss); heel protectors.

Nutrition and hydration: protein critical for tissue repair (target adequate protein intake); adequate fluids; nutritional supplements if needed.

Braden scale: most common standardized risk assessment tool (scores sensory perception, moisture, activity, mobility, nutrition, friction/shear; score ≤18 indicates risk).

CATHETER-ASSOCIATED URINARY TRACT INFECTION (CAUTI) is the most common healthcare-associated infection (HAI) in hospitals. Every day an indwelling urinary catheter is in place increases infection risk by 3-7%. CAUTI PREVENTION is a major patient safety priority. APPROPRIATE INDICATIONS FOR INDWELLING URINARY CATHETERS: urinary retention that doesn't respond to other management; accurate I&O monitoring in critically ill clients; perioperative use for specific surgeries; wound healing in sacral/perineal wounds where urine would compromise healing; hospice/end-of-life comfort; urological procedures; neurogenic bladder (selected cases). NOT APPROPRIATE indications: incontinence for CONVENIENCE (of staff or client); prolonged post-operative use without clinical need; avoiding repositioning. ALTERNATIVES TO CATHETERIZATION FOR INCONTINENCE: SCHEDULED TOILETING (every 2-4 hours); PROMPTED VOIDING; BLADDER TRAINING; EXTERNAL CONDOM CATHETER (for male patients); ABSORBENT PADS/BRIEFS; SKIN PROTECTION (moisture barriers to prevent skin breakdown from moisture — valid concern but doesn't require catheter); PELVIC FLOOR EXERCISES (Kegel exercises, though less applicable in acute illness).

If catheter is genuinely indicated: use SMALLEST POSSIBLE CATHETER (less trauma); maintain CLOSED STERILE DRAINAGE SYSTEM; keep urine drainage bag BELOW BLADDER LEVEL (prevents reflux); empty bag when 2/3 full; assess daily for continued need; REMOVE AS SOON AS POSSIBLE (each additional day increases risk).

Cauti signs: fever without other source, suprapubic tenderness, cloudy or foul-smelling urine (though these alone don't diagnose CAUTI), burning urination when catheter is removed.

CHRONIC PAIN management has evolved significantly with recognition that pain is complex — involving biological, psychological, and social factors (the biopsychosocial model). EVIDENCE-BASED NON-PHARMACOLOGICAL APPROACHES: COGNITIVE-BEHAVIORAL THERAPY (CBT) for pain: most evidence-based psychological approach; addresses catastrophizing, maladaptive thoughts, pain behaviors; improves functioning and quality of life even when pain intensity doesn't fully resolve; MINDFULNESS-BASED STRESS REDUCTION (MBSR): meditation-based approach; reduces pain-related distress;

Physical therapy and exercise: counterintuitive but movement is generally beneficial for most chronic pain (including low back pain); reduces deconditioning and muscle atrophy.

Heat therapy: increases blood flow, relaxes muscles; for chronic muscle pain; not for acute inflammation; COLD THERAPY (CRYOTHERAPY): reduces inflammation and acute pain; numbs area; for acute injuries or inflammatory conditions; TENS (Transcutaneous Electrical Nerve Stimulation): low-level electrical current modulates pain signals; evidence moderate; useful adjunct.

Massage: reduces muscle tension; improves mood; evidence for some chronic pain types.

Biofeedback: teaches physiological self-regulation.

Acupuncture: evidence for some pain conditions (low back pain, osteoarthritis, headache).

Distraction: music therapy, guided imagery, virtual reality (newer, emerging evidence).

Positioning and assistive devices: proper positioning, orthotic devices for joint pain.

Multimodal analgesia: the current standard of care combines multiple approaches (pharmacological and non-pharmacological) at lower doses to achieve pain control while minimizing side effects of any single approach.

Pn role: teach and implement non-pharmacological measures; assess pain with validated tools (0-10 numeric, FACES, FLACC for children); document pain assessment and response to interventions; advocate for adequate pain management; avoid stigmatizing chronic pain patients.

TOTAL HIP REPLACEMENT (THR) PRECAUTIONS are critical for preventing prosthetic hip dislocation — a serious complication requiring surgical revision. HIP PRECAUTIONS — THE THREE PROHIBITIONS: (1) NO HIP FLEXION GREATER THAN 90 DEGREES: Do not bend the hip past a right angle; no leaning forward in a chair; use a raised toilet seat; no low chairs or couches; (2) NO ADDUCTION (crossing the legs): No crossing legs at knees or ankles; use an abduction pillow between legs when lying in bed; (3) NO INTERNAL ROTATION: No turning toes inward; no lying on the operative side without pillow support;

Practical applications: Dressing: use long-handled adaptive equipment; do not bend to put on socks/shoes.

Sit to stand: Keep operated leg straight; use chair arm rests to push up; do not lean forward.

Toilet: Use elevated toilet seat or bedside commode.

Sleeping: Abduction pillow between legs; avoid lying on operative side initially.

Driving: No driving until cleared by surgeon (usually 4-8 weeks); these movements require hip flexion beyond 90 degrees; ANTERIOR vs POSTERIOR APPROACH: Hip precautions are traditionally associated with POSTERIOR approach; ANTERIOR approach has fewer or modified precautions — always follow the surgeon's specific orders.

Pn role: Reinforce precautions with every interaction; set up environment to support compliance; document teaching; report any signs of dislocation (sudden severe pain, leg in shortened and internally rotated position).

NG TUBE PLACEMENT VERIFICATION — CRITICAL SAFETY ISSUE: Feeding through a misplaced NG tube (especially one accidentally in the lung) can cause aspiration pneumonia and death. VERIFICATION METHODS (from most to least reliable):

Aspiration and ph testing: Aspirate stomach contents; pH of 5.5 or below suggests gastric placement; if pH is above 6, tube may be in small intestine or respiratory tract.

X-ray: Gold standard for confirming initial placement; required for initial placement confirmation before first use in most facilities.

Measurement marking: Verify that the external tube marking at the naris matches the documented insertion measurement — migration of the tube is detected this way.

Visual inspection: Aspirate color (gastric = cloudy/yellow-green; respiratory = clear/white).

Outdated method: Auscultation ('whoosh' test) — injecting air and listening for sound — is NO LONGER RECOMMENDED as a primary verification method; it has caused deaths when air sound was heard from a tube in the respiratory tract.

Pn scope: Verify before each feeding or medication; document verification method and results.

Hemiplegia positioning: The AFFECTED SIDE requires special protection because: reduced or absent sensation (cannot feel pain from poor positioning); reduced motor function (cannot shift weight normally); increased muscle tone in abnormal patterns (spasticity); RISKS OF IMPROPER POSITIONING ON AFFECTED SIDE:

Shoulder subluxation: Shoulder joint may partially dislocate under the weight of the flaccid arm without support; use arm supports in sitting.

Contractures: Without proper positioning and ranging, affected limbs contract in abnormal positions.

Pressure injuries: Bony prominences on the affected side are at highest risk — use pressure-redistributing surfaces.

Correct positioning: Affected side up: use pillows to support arm in 90-degree shoulder abduction with elbow extended, wrist neutral; Affected side down (possible if turning): brief; requires full padding of shoulder, arm, knee, ankle.

General principles: Neutral joint alignment; no dependent positioning of affected extremities; regular 2-hour repositioning; passive ROM; splints/positioning devices as ordered.

Aspiration precautions:

Positioning: 90° upright (not just slightly elevated) during and 30-45 min after meals — gravity assists swallowing and reduces reflux/aspiration risk.

Thickened liquids: Thin liquids are the most dangerous for dysphagia — thickening agents (nectar, honey, pudding consistency) as ordered by speech therapy.

Pace: Small bites, allow full swallow before next bite, no rushing.

Suction: Available at bedside in case of aspiration.

Monitoring: Watch for coughing, choking, wet/gurgly voice quality after swallowing (sign of aspiration).

Speech therapy: Dysphagia evaluation and specific dietary texture orders should be coordinated with SLP.

Pn scope: Implement and monitor aspiration precautions; report changes to RN; do not independently modify diet consistency orders.

PRESSURE INJURY STAGING AND DRESSING SELECTION:

Stage 2: Partial thickness skin loss — epidermis and part of dermis; wound appears as shallow open ulcer with red-pink wound bed.

Moist wound healing: Evidence consistently shows moist wound healing accelerates epithelialisation compared to dry.

Dry gauze: Creates a dry environment, adheres to wound bed, traumatises healing tissue on removal — NOT appropriate for stage 2.

Wet-to-dry: Appropriate for debridement of necrotic tissue (stage 3-4) — mechanically removes tissue including viable; contraindicated for clean, healing wounds.

Hydrocolloid: Contains moisture, promotes healing, self-adhesive — appropriate for stage 2 without infection.

Hydrofiber/alginate: For highly exudative wounds.

Silver-containing: For infected wounds.

Pn scope: Perform wound assessment, apply ordered dressings, report changes in wound status to RN; do not independently change wound care orders.

Chest tube management during transport:

Drainage system positioning: Must remain upright to maintain the water seal; the water seal prevents air from entering the pleural space.

System tipped: Priority is to return to upright position quickly; if water seal is disrupted (water spilled), notify RN immediately — the seal must be maintained.

Clamping controversy: Chest tubes should NOT be routinely clamped during transport (risk: tension pneumothorax if air is entering and tube is clamped).

Exceptions: Clamp briefly only if the system must be changed, or per specific physician order.

During transport: Keep system below chest level; prevent pulling on the tubing; have clamps available (not applied) in case system disconnects; if tube disconnects, submerge the end in sterile water to restore water seal until replacement system can be set up.

Pn scope: Monitor the drainage system; report changes; do not independently clamp without RN/provider direction.

Tracheostomy tube safety during coughing:

Tube displacement risk: Coughing generates significant intrathoracic pressure — a tracheostomy tube, especially one within the first 7-10 days of placement (before the stoma tract is established), can be expelled from the stoma; if this happens, the airway may close rapidly.

Nursing action: Pause the procedure; SECURE the tube — place a hand on the tube or hold the flanges to prevent accidental decannulation; allow the cough to complete naturally; suction if secretions are in the airway after coughing.

Decannulation emergency supplies: An extra tracheostomy tube of the same size and one size smaller should be at the bedside at all times; tracheal dilators should be available.

After coughing: Assess breath sounds; assess tube placement (air movement through the tube); assess skin colour and SpO2; resume procedure only when stable.

Pn scope: Perform routine tracheostomy care per protocol; report any concerns about tube placement or client distress to RN immediately.

Oral care for unconscious clients:

Aspiration risk: Unconscious clients have no protective gag reflex — fluid, secretions, or debris can enter the airway.

Positioning: Side-lying is ideal — gravity drains secretions away from the airway; if patient cannot be turned, turn the head to the side.

Technique: Use minimal fluid (moistened swabs rather than rinse); suction available and ready to use; small, controlled applications; avoid over-suctioning (mucosal trauma).

Frequency: Every 2-4 hours in mechanically ventilated patients (oral care reduces VAP — ventilator-associated pneumonia).

Supplies: Oral swabs, dilute chlorhexidine rinse (ICU/ventilated patients per evidence), lip moisturiser, suction.

Evidence-based: Regular oral care in ICU patients reduces VAP incidence by approximately 40%.

Pn scope: Perform routine oral care; assess oral mucosa; report signs of infection or breakdown; ensure suction equipment is functioning before providing care to unconscious patients.

Dysphagia aspiration prevention:

Positioning: High Fowler's (90 degrees upright) during meals.

Chin tuck: Slightly tucking the chin toward the chest narrows the airway entrance and directs food toward the esophagus — reduces aspiration.

Remain upright: 30-60 minutes after eating prevents reflux and aspiration.

Additional measures: Thickened liquids (per speech therapy/swallow evaluation — thin liquids are most easily aspirated); small bites; alternate solids and liquids; have suction available; feed slowly; assess for pocketing food in cheeks.

Aspiration signs: Coughing during/after eating, wet/gurgly voice, throat clearing, watery eyes.

Aspiration pneumonia risk: Aspiration of food/fluid into lungs causes pneumonia — a leading cause of post-stroke death.

Speech therapy: Conducts formal swallow evaluation and determines diet texture; LPN follows the established swallowing precautions.

Colostomy care teaching: CORRECT statements (no further teaching needed): Empty pouch at 1/3 to 1/2 full (prevents weight pulling appliance off and leakage); Stoma should be PINK/RED and MOIST (healthy perfusion — report pale, dusky, purple, or black stoma immediately = ischemia); Odor management with diet awareness (eggs, fish, garlic, onions increase odor); INCORRECT statement (needs teaching): Applying barrier to moist/weepy skin — the skin MUST be clean and completely DRY for the skin barrier (wafer) to adhere; moisture prevents adhesion and causes leakage and skin breakdown.

Stoma assessment: Healthy = pink/red, moist, slightly raised; CONCERNING = pale (anemia/poor perfusion), dark/dusky/purple/black (ischemia/necrosis - EMERGENCY).

Peristomal skin: Should be intact; protect from effluent with proper barrier fit; report excoriation; LPN role: reinforce ostomy teaching, assess stoma, support client adjustment.

PRESSURE INJURY PREVENTION — REPOSITIONING: Reposition bedbound clients at least every 2 hours (chair-bound: every 1 hour or teach weight shifts every 15 minutes);

Why: Pressure over bony prominences (sacrum, heels, hips, elbows, occiput) compresses capillaries, causing tissue ischemia; unrelieved pressure for as little as 2 hours can begin tissue damage.

Prevention bundle: Repositioning schedule; pressure-redistributing surfaces (specialty mattress); keep skin clean and dry; manage moisture (incontinence); adequate nutrition and hydration (protein for tissue integrity); float heels off the bed; avoid friction and shear (lift, don't drag); use the Braden Scale to assess risk.

Pressure injury stages: Stage 1 (non-blanchable erythema, intact skin) through Stage 4 (full thickness with exposed bone/muscle), plus unstageable and deep tissue injury; LPN role: reposition per schedule, assess skin every shift, document, report any skin changes (early Stage 1 is reversible with intervention).

Fluid restriction management: Distribute the daily allotment to match the client's activity and needs — more during waking/meal hours, less at night. TYPICAL DISTRIBUTION (1,500 mL example): Day (7a-3p): ~800 mL (breakfast, lunch, morning/noon meds, most active); Evening (3p-11p): ~500 mL (dinner, evening meds); Night (11p-7a): ~200 mL (minimal, just for night meds if needed).

Rationale: Accommodates meals and medications; respects the client's normal drinking patterns; prevents the client from using the entire allotment early and being thirsty all evening/night.

Practical measures: Use smaller cups (perception of more fluid); ice chips (count as 1/2 their volume); frequent oral care for thirst; sugar-free hard candy or gum to stimulate saliva; involve the client in planning; track ALL intake (IV, meds, foods that are liquid at room temp like gelatin and ice cream); CONDITIONS requiring fluid restriction: heart failure, SIADH, renal failure, hyponatremia; LPN role: distribute and track fluids, educate the client, manage thirst.