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Study guide · Physiological Integrity

Basic Care and Comfort

7 to 13% of the exam · 16 activity statements

Basic Care and Comfort covers the everyday care the practical nurse gives to keep a client comfortable, nourished, mobile, clean, rested and safe: tube site care and feedings, mobility, elimination, skin, sleep, pain relief without drugs, intake and output, sensory support and care after death. NCLEX-PN items test whether you carry out this care correctly, notice the finding that means something is going wrong, know what you may assign to assistive personnel and report to the RN or provider what is outside your scope.

A study feature written by ExamDragon, not part of the real exam. Each heading is one of the Related Activity Statements NCSBN lists for this category (16 of them), in our words; NCSBN's wording is in its Test Plan.

At a glance

Physiological Integrity
7 to 13%

of the exam (NCSBN's range)

Activity statements
16
Key terms
12

What this guide covers, statement by statement

  1. Care for the insertion site of a client's feeding tube
  2. Support complementary therapies, such as music or pet therapy, in client care
  3. Meet mobility needs, such as walking, range of motion, transfers, repositioning and adaptive equipment
  4. Give tube feedings through a client's enteral tube
  5. Monitor and meet the client's nutrition needs
  6. Relieve pain without drugs, for example with imagery, massage or repositioning
  7. Help clients with daily self-care activities
  8. Follow bowel or bladder management protocols in client care
  9. Rate pain with standard scales
  10. Help the client sleep and rest
  11. Protect and improve the client's skin and tissue
  12. Care for the body after death
  13. Irrigate catheters, the bladder, wounds, ears, nose or eyes
  14. Help care for and comfort a client with vision or hearing loss
  15. Monitor the client's intake and output
  16. Give an immobilized client care that fits their needs

1Care for the insertion site of a client's feeding tube

  • Look at the skin around a gastrostomy or jejunostomy tube at least daily: redness, warmth, swelling, drainage, odor or leakage of feeding are findings to report.
  • Clean the site with mild soap and water or normal saline as policy states, rinse, dry well and leave it open to air or under a light split gauze; avoid tight dressings that trap moisture.
  • Check the external length mark or the position of the external bumper each shift; a tube that has moved in or out is reported before the next feeding.
  • For a nasogastric or nasointestinal tube, check the nostril for pressure injury, keep the securing device clean and dry, and give mouth and nose care often because the client breathes through the mouth.
  • A dislodged new gastrostomy tube (a tract younger than about 4 to 6 weeks) is reported to the RN or provider at once; the practical nurse does not reinsert it.
  • Assistive personnel may help with hygiene around the tube, but checking the site and its position stays with the nurse.
  1. In practiceA resident in long-term care has a gastrostomy tube placed three months ago. The practical nurse finds a ring of redness 3 cm wide, warmth and thick yellow drainage at the site. The nurse cleans and dries the site, continues the feeding unless placement is in doubt, documents the findings and reports them to the RN, because these are signs of a site infection that needs evaluation.
  2. Where questions turnCovering a moist, red tube site with an occlusive dressing instead of keeping it clean, dry and reporting the signs of infection.
Practise this activity

2Support complementary therapies, such as music or pet therapy, in client care

  • Complementary therapies such as music, guided imagery, aromatherapy, massage, prayer or pet visits are used alongside prescribed treatment, never instead of it.
  • Ask what the client already uses at home, including herbal products, and pass that information to the RN and provider because some products interact with medications.
  • Choose what fits the client's own preferences and culture: music the client likes, not what staff like, and pet visits only when the client wants them and has no allergy or fear.
  • Pet therapy follows facility policy: a screened animal, hand hygiene before and after, and no visits for a client in isolation or with an open wound the animal could reach.
  • Observe and document the response (calmer, less pain, better sleep, or agitation) so the team can keep or change the therapy.
  • Reinforcing a therapy the care plan includes is within the practical nurse's role; starting a new herbal product is not.
  1. In practiceA client with dementia becomes restless every afternoon. The care plan includes music therapy, and the daughter says her mother loved hymns. The practical nurse plays the hymns at a low volume before the usual restless time, watches the response and documents that the client sat calmly for 40 minutes.
  2. Where questions turnTelling a client to stop a prescribed treatment in favor of a complementary one, or ignoring an herbal product the client mentions instead of reporting it.
Practise this activity

3Meet mobility needs, such as walking, range of motion, transfers, repositioning and adaptive equipment

  • Check the care plan and the client's current ability before moving anyone: weight-bearing status, strength, balance, orientation, orthostatic symptoms and pain.
  • Use a gait belt for ambulation of any client who needs help; walk on the weaker side, slightly behind, and lower the client to the floor if a fall starts rather than trying to hold the full weight.
  • Cane: held on the stronger side, moved forward with the weaker leg. Walker: move the walker, then the weaker leg, then the stronger leg; never pull up on the walker to stand.
  • Crutch gait and adaptive equipment are taught by the RN or physical therapist; the practical nurse reinforces the technique and reports unsafe use.
  • Range of motion: active for a client who can move, passive for one who cannot; move each joint smoothly to the point of resistance, never to the point of pain.
  • Lock the bed and wheelchair, raise the bed to working height, and use mechanical lifts and enough staff as the safe handling policy requires.
  1. In practiceA client recovering from a stroke with right-sided weakness is ready to walk with a quad cane. The practical nurse applies a gait belt, has the client hold the cane in the left hand and stands on the client's right side, slightly behind. The cane belongs on the strong side so it supports the weak leg as it moves.
  2. Where questions turnPlacing the cane on the weak side, or standing on the client's strong side, because the weak side is where support and falls happen.
Practise this activity

4Give tube feedings through a client's enteral tube

  • Before every intermittent feeding and at least every 4 to 6 hours for a continuous one, confirm the tube is where it should be: check the external length mark and, where policy uses it, the aspirate's appearance and pH; an X-ray is the only reliable confirmation of initial placement.
  • Keep the head of the bed at least 30 degrees (30 to 45 is usual) during the feeding and for at least 30 to 60 minutes after an intermittent feeding to lower aspiration risk.
  • Check gastric residual volume when policy or the prescription requires it; report a residual above the limit the facility sets, and do not discard or return it except as policy says.
  • Flush with water before and after each feeding and each medication, using the volume prescribed (often 30 mL for an adult); a 60 mL syringe gives low pressure and protects the tube.
  • Give the feeding at room temperature, by the prescribed formula, rate and method; label open systems and hang no more than policy allows (open formula commonly 4 to 8 hours).
  • Stop the feeding and report coughing, choking, vomiting, abdominal distension or a sudden drop in oxygen saturation, because they suggest aspiration or intolerance.
  1. In practiceDuring a continuous feeding at 55 mL/h, a client begins coughing and the oxygen saturation drops from 96% to 89%. The practical nurse stops the feeding, raises the head of the bed, suctions the mouth if needed and reports at once to the RN, because these are signs of possible aspiration.
  2. Where questions turnLowering the head of the bed flat to change the linens or reposition the client while a continuous feeding is still running.
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5Monitor and meet the client's nutrition needs

  • Collect data on intake: the percentage of each meal eaten, fluids taken, chewing or swallowing difficulty, appetite, food preferences and cultural or religious food practices.
  • Weigh the client at the same time of day, on the same scale, in similar clothing; report a trend such as an unplanned loss of 5% in a month.
  • Signs of a swallowing problem include coughing or a wet, gurgly voice during meals, pocketing food and drooling; keep the client upright and report so a swallowing evaluation can be arranged.
  • Serve the prescribed diet and texture (for example pureed, thickened liquids, low sodium, carbohydrate-consistent); check every tray against the order before serving it.
  • Help with set-up and feeding: sit at eye level, offer small bites, give time, and provide adaptive utensils when the plan includes them.
  • Watch laboratory values the provider orders, such as albumin, prealbumin and blood glucose, and report results outside the range.
  1. In practiceA resident on a mechanical soft diet with thin liquids coughs and clears her throat after each sip of water at lunch. The practical nurse stops giving liquids, sits her fully upright, and reports to the RN that she shows signs of aspiration with thin liquids so a swallowing evaluation can be requested.
  2. Where questions turnEncouraging the client to drink more water to wash down food when the coughing with liquids is itself the warning sign.
Practise this activity

6Relieve pain without drugs, for example with imagery, massage or repositioning

  • Nonpharmacological measures include repositioning, support with pillows, heat or cold as prescribed, massage, guided imagery, distraction, relaxation breathing and a quiet, dim room.
  • They work best alongside medication, not in place of it, and are often started before pain becomes severe.
  • Cold is used in the first 24 to 48 hours after an injury to reduce swelling; heat later to relax muscle; protect the skin with a cover and limit each application to about 20 minutes.
  • Avoid massage over a calf that could have a deep vein thrombosis, over open or reddened skin, and over any bony prominence, red or not.
  • Use the client's own preferences and culture: some prefer prayer, a family member present, or music.
  • Rate the pain again after the measure, using the same scale, and document the response.
  1. In practiceA client two days after knee replacement rates pain 5 of 10 an hour before the next dose is due. The practical nurse repositions the leg in alignment, applies the prescribed cold pack over a towel for 20 minutes and coaches slow breathing, then rechecks the pain score and documents a drop to 3 of 10.
  2. Where questions turnMassaging a warm, swollen, tender calf to ease a cramp, when those findings can mean a deep vein thrombosis that must be reported.
Practise this activity

7Help clients with daily self-care activities

  • Encourage the client to do as much as safely possible: independence in bathing, dressing, grooming, eating and toileting supports dignity and function.
  • Provide privacy, warmth and the client's own routine and products; respect cultural practices about modesty and the gender of the caregiver.
  • Give oral care at least twice daily; for an unconscious client, position on the side, use a small amount of liquid and have suction ready.
  • Use bathing time to collect data on skin, mobility and mood, and report new findings.
  • Assistive personnel can give routine hygiene and help with activities of daily living for a stable client; the practical nurse assigns, monitors and checks the results.
  • For dressing a client with weakness, dress the weak side first and undress the strong side first.
  1. In practiceA client with left-sided weakness asks for help putting on a shirt. The practical nurse guides the left arm into the sleeve first, then the right, and lets the client button the shirt with the strong hand, praising the effort.
  2. Where questions turnDoing every task for the client to save time, which takes away independence the care plan is trying to build.
Practise this activity

8Follow bowel or bladder management protocols in client care

  • A bladder training program schedules voiding at set intervals (for example every 2 hours), then lengthens the interval slowly as continence improves.
  • Prompted or timed toileting suits clients with cognitive impairment: offer the toilet on a schedule and praise success.
  • A bowel program sets a regular time, often 30 minutes after a meal to use the gastrocolic reflex, with fluids, fiber, activity and any prescribed suppository or digital stimulation.
  • For a client with a spinal cord injury at T6 or above, bowel or bladder distension can set off autonomic dysreflexia: sit the client up, look for the cause (a kinked catheter, a full bladder or rectum) and report at once.
  • Track continence and voids on a diary or flow sheet so the team can judge progress.
  • Pelvic floor (Kegel) exercises are reinforced as taught: tighten the muscles used to stop urine, hold, relax, several times a day.
  1. In practiceA resident with stress and urge incontinence starts a bladder training program. The practical nurse offers the bathroom every 2 hours while awake, records each void and each episode of incontinence, and reports to the RN after a week that dry intervals are now reaching 3 hours.
  2. Where questions turnRestricting the client's fluids to prevent incontinence, which concentrates urine, irritates the bladder and raises the risk of dehydration and infection.
Practise this activity

9Rate pain with standard scales

  • Use a scale that fits the client: a 0 to 10 numeric scale for an adult who can rate pain, the Wong-Baker FACES scale for children from about age 3 or for clients who prefer pictures.
  • FLACC (face, legs, activity, cry, consolability) is used for infants and young children; PAINAD for adults with advanced dementia who cannot report pain.
  • The client's own report is the most reliable measure; vital signs and behavior support it but do not replace it.
  • Ask about location, quality, onset, duration, what makes it better or worse and the client's acceptable pain goal.
  • Use the same scale every time for the same client so scores can be compared, and reassess after each intervention (commonly 30 to 60 minutes after an oral dose).
  • A sudden change in pain, new chest pain or pain far above the usual level is reported to the RN or provider.
  1. In practiceA resident with advanced dementia cannot rate pain but is groaning, frowning, and resisting care when turned. The practical nurse uses the PAINAD scale, scores the behaviors, reports the score to the RN and documents it so the response to treatment can be compared later.
  2. Where questions turnDeciding a client is not in pain because the heart rate and blood pressure are normal or because the client is asleep.
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10Help the client sleep and rest

  • Collect data on sleep: usual bedtime and routine, hours slept, waking at night, snoring or pauses in breathing, daytime sleepiness and what the client says helps.
  • Keep the client's own routine where possible: a light snack, a warm drink without caffeine, reading, or prayer before bed.
  • Group care at night to limit waking, dim the lights, reduce noise and alarms, and keep the room at a comfortable temperature.
  • Encourage daytime activity and light exposure and limit long naps, caffeine and heavy meals in the evening.
  • Older adults are at higher risk of falls and confusion from sedating sleep medications; nonpharmacological measures come first.
  • Report loud snoring with pauses in breathing, because it may mean sleep apnea that needs evaluation.
  1. In practiceA client on a medical unit says she has slept only three hours a night because of noise. The practical nurse plans vital signs and medications for the same visit, closes the door, dims the hall light, offers a warm blanket and earplugs, and documents her report of sleep the next morning.
  2. Where questions turnWaking a stable client every hour for separate tasks that could have been grouped.
Practise this activity

11Protect and improve the client's skin and tissue

  • Check the skin each shift, especially over bony prominences (sacrum, heels, hips, elbows, back of the head) and under devices such as tubes, splints and oxygen tubing.
  • Use a risk scale such as the Braden scale (a lower score means higher risk) to guide prevention, and report a falling score.
  • Reposition at least every 2 hours in bed, lift rather than drag, keep the head of the bed at 30 degrees or lower when possible, and float the heels off the mattress.
  • Keep skin clean and dry, use a barrier product after incontinence, and support nutrition and fluids because protein and hydration help skin stay intact.
  • Redness that does not blanch when pressed is a stage 1 pressure injury; report any new or worsening pressure injury to the RN.
  • Do not massage reddened bony prominences; it can damage tissue further.
  1. In practiceDuring morning care, the practical nurse finds a 3 cm area of nonblanchable redness on a client's sacrum. The nurse repositions the client off the area, uses a pressure redistribution surface per policy, documents the size and appearance and reports it to the RN as a new stage 1 pressure injury.
  2. Where questions turnRubbing a reddened sacrum to improve circulation, which injures the tissue it is meant to protect.
Practise this activity

12Care for the body after death

  • Follow facility policy and any cultural or religious practices the family requests; some faiths have specific rules for washing or touching the body.
  • Wear gloves and use standard precautions; place the body flat, with a small pillow under the head to prevent pooling of blood in the face.
  • Close the eyes, replace dentures if policy allows, and wash the body; remove tubes and lines only if no autopsy or coroner review is expected and policy allows.
  • Offer the family time with the body in a clean, quiet room before transfer; respect their wishes about being present.
  • Label the body, handle valuables as policy requires with a witness, and document who was notified and where belongings went.
  • Pronouncement of death and the request for organ donation follow the provider's and organization's process; the practical nurse reports and supports, not decides.
  1. In practiceA resident dies peacefully, and the family asks for a few minutes before the body is prepared. The practical nurse, following policy, closes the eyes, places the body flat with a small pillow, removes soiled linen and gives the family private time, then completes care and documents the family's wishes.
  2. Where questions turnRemoving all tubes and lines before checking whether the death will be reviewed by a coroner or an autopsy is planned.
Practise this activity

13Irrigate catheters, the bladder, wounds, ears, nose or eyes

  • Irrigation needs a prescription; check the solution, volume and frequency, and warm the solution to body temperature for ear and eye irrigation.
  • Wound irrigation: use sterile solution, irrigate from the cleanest area to the dirtiest, and use a pressure gentle enough not to damage tissue (a 35 mL syringe with a 19-gauge angiocath is a common choice).
  • Eye irrigation: tilt the head toward the affected side and flow from the inner corner outward so fluid does not run into the other eye.
  • Ear irrigation: for an adult, pull the pinna up and back; do not irrigate if the eardrum may be perforated or there is drainage, and report pain or dizziness.
  • Catheter or bladder irrigation uses sterile technique; never force the fluid, and subtract the irrigant from the output to find the true urine volume.
  • For a chemical splash in the eye, start flushing with water or saline at once and continue as the policy says while help is called.
  1. In practiceA client's continuous bladder irrigation shows 3,000 mL of output in 8 hours, and 2,400 mL of irrigant was infused. The practical nurse records true urine output as 600 mL, because the irrigant must be subtracted from the total in the drainage bag.
  2. Where questions turnRecording the full drainage bag volume as urine output during bladder irrigation, which hides a fall in kidney function.
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14Help care for and comfort a client with vision or hearing loss

  • For a client with low vision: identify yourself when entering, say when you leave, keep furniture and belongings in the same place and describe food on the plate by clock positions.
  • Guide a client who is blind by letting the client hold your arm just above the elbow and walk half a step behind.
  • For a client with hearing loss: face the client in good light, get attention first, speak clearly at a normal pace and slightly lower pitch, and do not shout.
  • Check that glasses are clean and hearing aids are in, working and have charged batteries; store them safely to prevent loss.
  • Use written notes, pictures or a qualified interpreter for sign language; family members are not used as interpreters for health information.
  • Report a new or sudden change in vision or hearing, which can be a sign of a serious condition.
  1. In practiceA resident with hearing loss seems confused and does not answer questions. The practical nurse checks the hearing aid, finds a dead battery, replaces it, then faces the resident in good light and repeats the questions; the resident answers appropriately.
  2. Where questions turnRaising your voice or speaking only to the family, instead of checking the hearing aid and facing the client.
Practise this activity

15Monitor the client's intake and output

  • Intake includes everything liquid at room temperature: oral fluids, ice chips (count as about half their volume), tube feedings and flushes, and IV fluids.
  • Output includes urine, emesis, liquid stool, drainage from tubes and wounds, and irrigant returns minus the irrigant given.
  • Measure urine in a graduated container, not by estimating from the bag; report urine output below 30 mL/h (or 0.5 mL/kg/h) for an adult.
  • Daily weight is the best sign of fluid change: a gain of 1 kg (2.2 lb) is about 1 liter of retained fluid.
  • Assistive personnel can measure and record intake and output; the practical nurse reviews totals, compares them with earlier shifts and reports trends.
  • Report an intake much larger than output with edema, crackles or weight gain, or an output much larger than intake with signs of dehydration.
  1. In practiceA client with heart failure has taken in 2,100 mL and put out 900 mL over 12 hours, and has gained 1.5 kg (3.3 lb) since yesterday with new ankle swelling. The practical nurse reports the imbalance and weight gain to the RN, because these findings suggest fluid retention.
  2. Where questions turnLeaving ice chips or tube flushes out of the intake total, which makes the balance look better than it is.
Practise this activity

16Give an immobilized client care that fits their needs

  • Immobility affects every system: pressure injury, contractures, muscle loss, constipation, urinary stasis and infection, pneumonia, deep vein thrombosis and low mood.
  • Turn and reposition at least every 2 hours, keep body alignment with pillows and devices, and use a trapeze when the client can help.
  • Encourage deep breathing, coughing and incentive spirometer use as prescribed; report crackles, fever or a falling oxygen saturation.
  • Give range of motion exercises, apply prescribed compression devices, and watch for calf pain, swelling or warmth in one leg.
  • Encourage fluids (unless restricted) and fiber, monitor bowel movements and voiding, and report constipation or retention.
  • For a client in traction or a cast, keep weights hanging freely, check circulation, movement and sensation of the limb and report the 5 Ps (pain, pallor, pulselessness, paresthesia, paralysis).
  1. In practiceA client in skeletal traction for a femur fracture has been in bed for five days. The practical nurse checks pin sites and the weights, gives ankle exercises on the unaffected leg, reminds the client to use the incentive spirometer hourly while awake and checks the injured leg's pulse, color and sensation each shift.
  2. Where questions turnLifting or resting traction weights on the bed or floor to make the client more comfortable during repositioning.
Practise this activity

Key terms

Gastric residual volume
The amount of feeding left in the stomach, measured by aspirating through the tube before or during a feeding.
Aspiration
Food, fluid or secretions entering the airway and lungs instead of the esophagus.
Range of motion
Moving each joint through its normal movement, by the client (active) or by the nurse (passive).
Gait belt
A belt fastened around the client's waist that the caregiver holds to steady the client while walking or transferring.
Braden scale
A pressure injury risk tool scoring sensation, moisture, activity, mobility, nutrition and friction; lower scores mean higher risk.
Stage 1 pressure injury
Intact skin with redness that does not blanch when pressed.
Bladder training
Voiding on a schedule and slowly lengthening the interval to regain continence.
Autonomic dysreflexia
A dangerous rise in blood pressure in a client with a high spinal cord injury, often set off by a full bladder or bowel.
PAINAD
A pain scale based on behavior for adults with advanced dementia who cannot report pain.
FLACC
A behavioral pain scale for infants and young children: face, legs, activity, cry, consolability.
Postmortem care
Care of the body after death, done with respect for the person and the family's wishes and practices.
Five Ps
Pain, pallor, pulselessness, paresthesia and paralysis: signs of poor circulation or nerve damage in a limb.

After this guide: After this guide you should be able to give basic care and comfort safely as a practical nurse, spot the finding that means a complication is starting, assign routine tasks correctly and know when to report to the RN or provider.

Practise Basic Care and Comfort