Skip to content

Get the app

Study guide · Physiological Integrity

Basic Care and Comfort

6 to 12% of the exam · 16 activity statements

Basic Care and Comfort covers the everyday physical care that keeps a client comfortable, nourished, mobile and safe: hygiene and ADLs, nutrition and tube feeding, elimination, skin, mobility devices, sleep, pain and comfort measures. NCLEX items test the correct, safe way to perform this care, what to assess before and after, and when a finding means the care must stop or be escalated.

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
6 to 12%

of the exam (NCSBN's range)

Activity statements
16
Key terms
14

What this guide covers, statement by statement

  1. Assess how the client manages daily self care and help as needed
  2. Feed the client through a feeding tube
  3. Give care to the body after death
  4. Carry out irrigations, for example of the eye, ear or bladder
  5. Help the client offset a physical or sensory deficit, for example with aids
  6. Assess the skin and act to keep skin and tissue intact
  7. Assess and manage problems with bowel or bladder function
  8. Put on, look after or take off orthopaedic devices
  9. Protect the client's dignity and privacy during care
  10. Use comfort measures that do not involve medication
  11. Assess how well nourished the client is and act as needed
  12. Assess how the client sleeps and rests and act as needed
  13. Assess fluid intake and output and act as needed
  14. Promote blood flow through movement, range of motion and positioning
  15. Assess the client's pain and act on it
  16. Know complementary therapies, their possible benefits and when to avoid them

1Assess how the client manages daily self care and help as needed

  • ADLs are bathing, dressing, toileting, transferring, continence and feeding; instrumental ADLs include shopping, cooking, managing money and medications.
  • Assess what the client can do alone, with help, or not at all, and encourage the client to do as much as safely possible.
  • Give only the help needed and allow extra time; doing everything for the client increases dependence.
  • Assisting with ADLs can be delegated to assistive personnel (AP); assessing the client's ability and evaluating progress stays with the RN.
  • A sudden decline in ADL ability is a change in condition (infection, stroke, delirium) and needs assessment.
  • Involve occupational therapy for adaptive equipment such as long-handled sponges, button hooks and plate guards.
  1. In practiceA client recovering from a right-sided stroke can wash her face but struggles to button her blouse. The nurse sets up her supplies within reach on her stronger side, lets her dress herself with extra time and a button hook, and helps only with the buttons she cannot manage, because promoting independence aids rehabilitation.
  2. Where questions turnCompleting the whole task for the client to save time, which undermines independence and rehabilitation.
Practise this activity

2Feed the client through a feeding tube

  • Confirm initial placement of a blind-inserted feeding tube by X-ray before the first feeding or medication.
  • Before each feeding or medication, check that the external tube marking has not moved, and test the pH of aspirate if your agency uses it (gastric aspirate is usually acidic, 5 or less); auscultating an air bolus alone is not reliable.
  • Keep the head of the bed raised at least 30 degrees (30 to 45) during feeding and for a period afterward, or at all times with continuous feeding, to reduce aspiration.
  • Flush the tube with water before and after each medication and per protocol during continuous feeding; give medications one at a time and never add them to the formula.
  • Follow agency policy for residual volumes, formula hang time and changing the bag and tubing, and label the bag with the date and time.
  • Stop the feeding and assess if the client coughs, becomes short of breath, vomits or has abdominal distension.
  1. In practiceA client receiving continuous nasogastric feeding is found lying flat after a bed change and is now coughing. The nurse stops the feeding, raises the head of the bed, assesses breathing and oxygen saturation and checks tube placement before restarting, because coughing in a flat position suggests aspiration.
  2. Where questions turnRelying on hearing air in the stomach to confirm tube placement, or giving a feeding to a client lying flat.
Practise this activity

3Give care to the body after death

  • Confirm that death has been pronounced per agency policy and law, and check for organ or tissue donation requirements and whether the case goes to the medical examiner or coroner.
  • If an autopsy or medical examiner review is required, leave tubes, lines and devices in place per policy.
  • Otherwise remove tubes and devices, clean the body, place it supine with the head raised on a pillow to reduce facial discoloration, close the eyes and replace dentures.
  • Offer the family private time with the body, and respect cultural and religious rituals such as who may touch or wash the body.
  • Use standard precautions, label the body and belongings per policy, and document the time of death, who was notified and where belongings went.
  1. In practiceA client dies on the unit after a fall at home that is under investigation, and his wife wants to see him. The nurse leaves the lines and tubes in place because the case is referred to the coroner, makes him clean and presentable, and gives his wife private time with him.
  2. Where questions turnRemoving all tubes and lines from a client whose death must be reviewed by the medical examiner or coroner.
Practise this activity

4Carry out irrigations, for example of the eye, ear or bladder

  • Eye irrigation: tilt the head toward the affected side and flow the solution from the inner canthus to the outer canthus so it drains away from the other eye and the tear duct; for a chemical splash, irrigate **immediately** with large volumes.
  • Ear irrigation: use solution at body temperature to prevent dizziness, straighten the canal (adult: pinna up and back; child under 3: down and back), and direct the stream gently toward the top of the canal.
  • Do not irrigate an ear with a perforated eardrum, or with a foreign body that swells with water, such as a bean or seed.
  • Continuous bladder irrigation after prostate surgery: adjust the flow to keep urine light pink to clear and free of clots; true urine output equals total drainage minus irrigant infused.
  • If irrigation outflow stops, or the client has bladder distension or severe spasms, check the catheter for kinks or clots and follow the irrigation protocol or notify the provider.
  • Use sterile technique for bladder irrigation and clean technique for the ear.
  1. In practiceA client on continuous bladder irrigation after a prostate resection has bright red drainage with clots, little outflow, and says his bladder feels full. The nurse stops the irrigation inflow, checks the tubing for kinks, irrigates the catheter by hand with sterile saline as prescribed to clear the clot, resumes the irrigation once outflow is restored at a rate that keeps the drainage light pink, and notifies the surgeon if bleeding or the blockage persists, because adding fluid to a blocked bladder causes over-distension.
  2. Where questions turnCounting the whole drainage bag as urine output instead of subtracting the irrigant infused.
Practise this activity

5Help the client offset a physical or sensory deficit, for example with aids

  • Cane: hold it on the stronger side and advance it with the weaker leg.
  • Walker: move the walker forward first, then step into it with the weaker leg, then the stronger leg; do not carry it on stairs.
  • Crutches: keep the pads about two to three finger widths below the armpit and bear weight on the hands; on stairs, the strong leg goes up first and the weak leg and crutches go down first.
  • Use a gait belt and nonslip footwear for ambulation and transfers, and transfer toward the client's stronger side.
  • Position a client with hemiplegia to support the weak side and prevent contractures, and keep the call light and items on the side the client can reach and see.
  • Make sure glasses, hearing aids and prostheses are clean, in good repair and in use.
  1. In practiceA client with left leg weakness after knee surgery is learning to use a cane. The nurse checks that he holds it in his right hand and moves it forward together with his left leg, because the cane on the strong side widens the base of support and takes weight off the weak leg.
  2. Where questions turnTeaching the client to hold the cane on the weak side, which reduces stability.
Practise this activity

6Assess the skin and act to keep skin and tissue intact

  • Assess skin on admission and regularly with a risk scale such as the Braden Scale; a lower Braden score means higher risk.
  • Pressure injury stages: Stage 1 intact skin with nonblanchable redness; Stage 2 partial-thickness loss with exposed dermis; Stage 3 full-thickness loss with fat visible; Stage 4 full-thickness loss with bone, tendon or muscle exposed.
  • Unstageable means the base is hidden by slough or eschar; a deep tissue pressure injury is intact or nonintact skin with persistent deep red, maroon or purple discoloration; a healing injury keeps its highest stage and is not reverse-staged.
  • Prevent: reposition on an individualized schedule (commonly at least every 2 hours in bed), offload the heels, keep the head of bed at 30 degrees or lower when allowed, and use lift sheets to avoid shear.
  • Keep skin clean and dry, manage incontinence promptly, give adequate protein and fluids, and do not massage reddened bony prominences.
  1. In practiceA client on bed rest has an open area on the sacrum with a pink, moist wound bed and no slough, with no fat visible. The nurse documents it as a Stage 2 pressure injury, relieves pressure with a turning schedule and support surface, manages moisture and reports it, because partial-thickness loss with exposed dermis defines Stage 2.
  2. Where questions turnMassaging a reddened bony prominence, which damages tissue, or calling a healing Stage 3 injury a Stage 2.
Practise this activity

7Assess and manage problems with bowel or bladder function

  • Assess bowel and bladder patterns, intake, mobility and medications that affect elimination (opioids, anticholinergics, diuretics).
  • Use a bladder scanner to check for retention; prevent catheter-associated urinary tract infection by removing catheters as soon as possible, keeping the bag below the bladder and the tubing unkinked.
  • Constipation care: fluids, fiber, activity and a regular time to defecate; give a cleansing enema with the client on the left side.
  • Digital removal of impacted stool can stimulate the vagus nerve; stop if the heart rate drops or the client feels faint.
  • A healthy stoma is moist and pink to red; a pale, dusky or black stoma needs **immediate** reporting.
  • Bladder training uses scheduled voiding at set intervals that are lengthened gradually.
  1. In practiceA client two days after hip surgery who takes an opioid has not voided in 8 hours and has lower abdominal discomfort. The nurse scans the bladder, finds a large volume and follows the protocol or prescription for catheterization, because opioids and immobility cause urinary retention and a distended bladder can be damaged.
  2. Where questions turnAsking a client with suspected retention to drink more fluid, instead of assessing bladder volume first.
Practise this activity

8Put on, look after or take off orthopaedic devices

  • Check neurovascular status distal to a cast, splint or traction: color, warmth, capillary refill, pulses, sensation, movement and pain.
  • Elevate a new cast on pillows and apply ice for the first day or two to reduce swelling; handle a wet plaster cast with the palms, not the fingertips.
  • Pain out of proportion to the injury, pain on passive stretch, numbness or tingling, or a tight cast suggests compartment syndrome: notify the provider **immediately** and keep the limb at heart level rather than elevated.
  • In traction, keep weights hanging freely and the ropes in their pulleys; never remove the weights of skeletal traction; give pin care per policy.
  • Teach the client not to put objects inside the cast and to report a foul smell, drainage or a hot spot.
  1. In practiceA client with a new forearm cast says the pain is now severe despite the analgesic and his fingers feel numb, and the pain worsens when the nurse gently extends his fingers. The nurse lowers the arm to heart level, loosens any wrapping and notifies the provider **immediately**, because these signs suggest compartment syndrome, which can cause permanent damage within hours.
  2. Where questions turnGiving more pain medication and elevating the limb higher when the findings point to compartment syndrome.
Practise this activity

9Protect the client's dignity and privacy during care

  • Knock, introduce yourself and explain care before you begin.
  • Close the door or curtain and expose only the part of the body being cared for.
  • Address the client by the name the client prefers and include the client in decisions about care.
  • Discuss health information only with the client and people the client has authorized, and never in public areas.
  • Respect requests for a same-gender caregiver or a chaperone when possible.
  1. In practiceA client is to have a bed bath while his visitors are in the room. The nurse asks whether he would like his visitors to step out, closes the curtain and keeps him covered with a bath blanket except for the area being washed, because privacy and control preserve his dignity.
  2. Where questions turnStarting care with the curtain open, or discussing the client's condition at the nurses' station where others can hear.
Practise this activity

10Use comfort measures that do not involve medication

  • Nonpharmacological measures include positioning, heat or cold, massage, relaxation and breathing, guided imagery, music and distraction; they add to analgesics but do not replace them for moderate or severe pain.
  • Cold reduces swelling and pain in the first 24 to 48 hours after an injury; heat relaxes muscles and increases blood flow afterward.
  • Limit heat or cold to about 15 to 20 minutes, place a barrier between the device and the skin, and check the skin often, especially with reduced sensation.
  • Do not apply heat over active bleeding or acute swelling, or cold in clients with poor circulation such as Raynaud phenomenon; do not massage a leg with a suspected deep vein thrombosis.
  • TENS is not placed over the chest of a client with a pacemaker or over the front of the neck.
  1. In practiceA client with diabetes and peripheral neuropathy asks for a heating pad for back pain. The nurse wraps the pack, limits the time, checks the skin frequently and offers repositioning and relaxation breathing as well, because reduced sensation increases the risk of burns.
  2. Where questions turnApplying a heating pad without a barrier or time limit for a client with reduced sensation.
Practise this activity

11Assess how well nourished the client is and act as needed

  • Weight change over time is one of the most useful signs of nutritional status; weigh at the same time on the same scale.
  • Albumin and prealbumin are affected by inflammation and fluid status, so they are read with the whole picture; prealbumin changes faster than albumin.
  • Signs of a swallowing problem include coughing or a wet voice during meals and pocketing food; request a swallowing evaluation by a speech-language pathologist.
  • For dysphagia: sit the client upright at 90 degrees, use the prescribed diet and liquid consistency, give small bites, and teach a chin tuck if prescribed.
  • When starting nutrition after a long period of poor intake, watch for refeeding syndrome (low phosphate, potassium and magnesium).
  • Match the diet to the condition, culture and preferences: for example sodium limits in heart failure and potassium and phosphorus limits in kidney failure.
  1. In practiceAn older client after a stroke coughs and her voice sounds wet after sips of water. The nurse stops oral intake, keeps her upright and requests a swallowing evaluation before more food or fluid is given, because these signs point to aspiration.
  2. Where questions turnGiving thin water to a client who coughs while swallowing because it seems harmless.
Practise this activity

12Assess how the client sleeps and rests and act as needed

  • Ask about usual sleep times, quality, daytime sleepiness, snoring and pauses in breathing, and medications or substances that affect sleep.
  • Sleep hygiene: a regular schedule, a dark and quiet room, limited caffeine, alcohol and screens before bed, and daytime activity.
  • In hospital, cluster care to allow long stretches of rest and reduce noise and lights at night.
  • Loud snoring, witnessed pauses in breathing and daytime sleepiness suggest obstructive sleep apnea; report them.
  • Sedative-hypnotics raise the risk of falls and confusion in older adults; try nonpharmacological measures first.
  1. In practiceAn older client in hospital says he cannot sleep because of noise and night vital signs. The nurse coordinates with the team to group assessments and medications, dims the lights and offers earplugs and a warm drink without caffeine, because uninterrupted sleep supports recovery without the fall risk of a sedative.
  2. Where questions turnRequesting a sleeping pill for an older adult before trying to fix the environment and routine.
Practise this activity

13Assess fluid intake and output and act as needed

  • Intake includes oral fluids, tube feeding, IV fluids and flushes; output includes urine, vomit, liquid stool, drainage and suction.
  • Adult urine output below about 0.5 mL/kg/h (roughly 30 mL/h for most adults) needs prompt assessment and reporting.
  • A gain of 1 kg (2.2 lb) in a day reflects about 1 liter of retained fluid; weigh daily at the same time, on the same scale, in similar clothing.
  • Compare intake with output and weight trends, and look for signs of fluid deficit (thirst, dry mucosa, tachycardia, concentrated urine) or excess (edema, crackles, rising weight).
  • Teach the client and AP to record every intake and output, and check that the measuring is accurate.
  1. In practiceA client with heart failure weighs 2 kg (4.4 lb) more than yesterday, and output has been less than intake for 24 hours. The nurse assesses lung sounds and edema and reports the gain to the provider, because rapid weight gain shows fluid retention before symptoms become severe.
  2. Where questions turnRelying on intake and output totals alone when daily weight is the more reliable measure of fluid balance.
Practise this activity

14Promote blood flow through movement, range of motion and positioning

  • Active range of motion is done by the client; passive range of motion is done by the caregiver for a client who cannot move a joint, moving each joint gently only to the point of resistance or pain.
  • Change position regularly, get the client moving early as allowed, and teach ankle pumps and leg exercises to prevent venous stasis.
  • Apply sequential compression devices and graduated compression stockings as prescribed, correctly sized and removed for skin checks.
  • Avoid pillows under the knees, crossing the legs, and tight clothing that restricts blood flow.
  • Before standing, have the client sit and dangle the legs to reduce orthostatic hypotension.
  • Stop and report calf pain, swelling, warmth or redness, which may signal a deep vein thrombosis.
  1. In practiceA client the morning after abdominal surgery is to walk for the first time. The nurse has him sit at the edge of the bed with his feet dangling, checks for dizziness and blood pressure change, then walks him with a gait belt, because early mobilization promotes circulation and dangling first prevents a fall from orthostatic hypotension.
  2. Where questions turnContinuing range of motion or massage on a leg with signs of a deep vein thrombosis.
Practise this activity

15Assess the client's pain and act on it

  • Pain is what the client says it is; the client's self-report is the most reliable measure.
  • Assess onset, location, duration, character, aggravating and relieving factors, and intensity with a scale the client can use: a 0 to 10 numeric scale, a faces scale for young children, or a behavioral scale such as FLACC or PAINAD for clients who cannot self-report.
  • Reassess after every intervention at the time the drug or measure should take effect (sooner for IV, later for oral) and document the response.
  • With opioids, sedation increases before respiratory depression; assess sedation level and breathing rate, and hold the dose and report increasing sedation.
  • New, sudden or very different pain can signal a complication and needs assessment, not just another dose.
  • Expression of pain varies; a calm client or one who is sleeping can still have pain.
  1. In practiceA client after a knee replacement rates pain 8 of 10 and received an oral opioid 45 minutes ago. The nurse reassesses intensity, sedation and breathing, repositions the leg and applies ice as prescribed, and reports to the provider if pain stays high, because reassessment at peak effect shows whether the plan works.
  2. Where questions turnDoubting the client's report of pain because the client is laughing with visitors or vital signs are normal.
Practise this activity

16Know complementary therapies, their possible benefits and when to avoid them

  • Ask every client about herbs, supplements, oils and other therapies, because clients often do not mention them unless asked.
  • St. John's wort can cause serotonin syndrome with antidepressants and reduces the effect of many drugs, including oral contraceptives, warfarin and some transplant drugs.
  • Ginkgo, garlic, ginger and ginseng can increase bleeding risk with anticoagulants and antiplatelet drugs; the surgeon may ask the client to stop them before surgery.
  • Kava has been linked to liver injury, and valerian adds to the effect of sedatives and alcohol.
  • Aromatherapy oils are not swallowed, are diluted for skin use and can trigger asthma; acupressure is avoided over wounds, bruises and varicose veins and certain points during pregnancy.
  • Supplements are not tested for effectiveness like prescription drugs, and their content can vary; support the client's choice while sharing safety information.
  1. In practiceA client taking warfarin mentions she started ginkgo for her memory. The nurse informs the provider, teaches her to watch for bruising and bleeding and explains that ginkgo can increase the effect, because the combination raises the risk of bleeding.
  2. Where questions turnAssuming a natural product is harmless and not reporting it when the client takes an interacting medication.
Practise this activity

Key terms

Activities of daily living (ADLs)
Basic self-care tasks: bathing, dressing, toileting, transferring, continence and feeding.
Braden Scale
A pressure injury risk scale; lower scores mean higher risk.
Deep tissue pressure injury
Persistent, nonblanchable deep red, maroon or purple discoloration from pressure damage to underlying tissue.
Unstageable pressure injury
Full-thickness tissue loss whose depth is hidden by slough or eschar.
Shear
Force from skin and underlying tissue sliding in opposite directions, such as when a client slides down in bed.
Compartment syndrome
Rising pressure in a muscle compartment that cuts off blood flow and threatens the limb.
Neurovascular check
Assessment of color, warmth, pulses, capillary refill, sensation, movement and pain distal to an injury or device.
Continuous bladder irrigation
Constant flow of sterile solution through a three-way catheter to prevent clots after urologic surgery.
Dysphagia
Difficulty swallowing, which raises the risk of aspiration.
Refeeding syndrome
Dangerous shifts in phosphate, potassium and magnesium when nutrition restarts after starvation.
Orthostatic hypotension
A drop in blood pressure on standing that causes dizziness and falls.
FLACC
A behavioral pain scale (face, legs, activity, cry, consolability) for children or clients who cannot self-report.
PAINAD
A behavioral pain scale for clients with advanced dementia.
Postmortem care
Care of the body after death, with respect for the family and legal requirements.

After this guide: After this guide you should be able to carry out and evaluate basic physical care safely, from feeding tubes and irrigations to skin, mobility, elimination, sleep and pain, and recognize when a finding means you must stop and escalate.

Practise Basic Care and Comfort