Page 586 - Saunders Comprehensive Review For NCLEX-RN

Dyspnea

Elevate the head of the bed or position the client on his or her side.
Administer supplemental oxygen for comfort.
Suction fluids from the airway as needed.
Administer medications as prescribed.

Skin

Assess color and temperature.
Assess for breakdown.
Implement measures to prevent breakdown.

Dehydration

Maintain regular oral care.
Encourage taking ice chips and sips of fluid.
Do not force the client to eat or drink.
Use moist cloths to provide moisture to the mouth.
Apply lubricant to the lips and oral mucous membranes.

Anorexia, Nausea, and Vomiting

Provide antiemetics before meals.
Have family members provide the client’s favorite foods.
Provide frequent small portions of favorite foods.

Elimination

Monitor urinary and bowel elimination.
Place absorbent pads under the client and check frequently.

Weakness and Fatigue

Provide rest periods.
Assess tolerance for activities.
Provide assistance and support as needed for maintaining bed or chair
positions.

Restlessness

Maintain a calm, soothing environment.
Do not restrain.
Limit the number of visitors at the client’s bedside (consider cultural practices).
Allow a family member to stay with the client.

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