This episode breaks down one of the most underestimated sections of the NCLEX: Basic Care and Comfort, worth a solid 6–12% of your exam. Brooke Wallace, a 20-year ICU nurse, walks you through the essential skills that protect patient dignity, prevent secondary complications, and anchor safe clinical practice every shift. You’ll learn mobility safety, assistive device sizing, crutch and stair rules, immobility complications, aspiration prevention, end-of-life comfort care, nutrition and elimination priorities, skin integrity protection, and the subtle clinical decisions that separate novice thinking from true nurse judgment. By the end, you'll understand why "basic" care is anything but basic—and how mastering these fundamentals boosts both your patient outcomes and your NCLEX score.
Canes
Handle height: aligns with greater trochanter.
Elbow slightly flexed (15–30 degrees).
Too high → shrugging; too low → stooping → fall risk.
Walkers
Height at wrist crease with arms relaxed.
Promotes upright posture and stability.
Crutches (major safety trap)
Two to three finger widths between axilla and crutch pad.
Weight on hands only, never in armpits (brachial plexus injury risk).
Stairs mnemonic: Up with the good, down with the bad.
Up: good leg → crutches + bad leg.
Down: crutches + bad leg → good leg.
MRI Precautions
Remove hearing aids (metal components heat or pull).
Verify prosthetics for compatibility.
Prosthetic Limb Care
Daily skin checks.
Liner must be smooth to prevent pressure injuries.
Tissue injury develops in as little as 2 hours of unrelieved pressure.
#1 priority for bedbound patient: reposition every 2 hours (more vital than specialty mattress).
Tools:
Trochanter roll → prevents external rotation.
Footboard → prevents foot drop.
Trapeze bar → increases independence and reduces shear.
Compression Devices (SCDs/TEDs)
Remove each shift for skin checks.
Contraindicated in arterial insufficiency (risk of ischemia, gangrene).
Safety First Scenario
Bedbound patient trying to get up: activate bed alarm and lower bed before anything else.
Cold therapy: avoid in Raynaud’s (vasoconstriction).
Heat: avoid on acute injuries or areas without sensation.
Distraction vs. guided imagery:
Distraction = short, procedural pain.
Guided imagery = chronic or long-duration pain.
Terminal secretions (“death rattle”)
Appropriate: reposition, elevate head, possible scopolamine.
Avoid: deep suctioning (causes distress, minimal benefit).
Family concern: “Morphine will hasten death.”
Explain the principle of double effect: medication is used solely for comfort, not to shorten life.
Post-mortem priorities
Support family first.
Prepare body: dentures in, eyes closed, clean gown, tidy room.
Remove jewelry unless family requests otherwise (document carefully).
Aspiration Risk
Red flag: coughing after thin liquids.
Progression: nectar → honey → pudding thick.
Chin tuck recommended for safe swallowing.
Tube Feeding
High gastric residual (ex: above 350): stop feeding and notify provider.
Hydration Assessment
Most accurate: daily weights.
One kilogram change equals one liter of fluid.
Ostomy Teaching
Higher in the GI tract = more liquid output (ileostomy).
Lower in the GI tract = more formed stool (sigmoid).
Catheter Balloon Safety
Inflate only with the exact printed volume.
Overfilling → balloon rupture or trauma.
Ventilated patients require chlorhexidine oral care every 2 hours.
Includes brushing, suctioning, and mouth care bundle steps.
UAP can reposition, but nurse must assess skin.
Understanding basic care enables correct prioritization and safe delegation.
Patient taking ginkgo biloba before surgery → MUST notify surgeon due to bleeding risk.
Sleep hygiene & clustering care dramatically improve recovery.
Basic care supports physiological healing in every system.
Welcome to Think Like a Nurse, the conversation that's all about sharpening your clinical mind so you can walk into any situation prepared. If you're a student feeling uh a little buried in textbooks, or maybe you're a working nurse who just wants a really high impact refresher, you are in exactly the right place. Today, we're digging into material from the incredible Brooke Wallace. She's a 20-year ICU nurse and organ transplant coordinator, a clinical instructor, and a published author. I mean, her experience is really the backbone of everything we do here. That's right. And our mission is well, it's pretty simple. We take these huge complex nursing topics and we just break them down, make them easier to understand so you can actually think like a nurse.
Before we jump in, we just want to invite you to visit think like a nurse.org. There's so many more resources and materials there. All right. So, our focus today is a core, I mean a really non-negotiable area of the enkle xn physiological integrity, specifically basic care and comfort.
And that might sound simple, but it accounts for a solid 6 to 12% of your exam,
which is huge.
Yeah.
These are the skills that, you know, they really define competent, compassionate care.
It's the stuff we do every single shift. It's about dignity, infection control, safety, and preventing those awful secondary complications. If you get this stuff right, everything else kind of falls into place.
Okay, let's unpack this category then. I think we should start with mobility and assisted devices, right? That's where safety is just so paramount.
Exactly. I think students sometimes see thesevices devices as just generic equipment, but the sizing is so specific, get it wrong, and you could cause long-term damage.
So, let's take a cane for instance. How do you know it's the right fit?
Okay, so you have the patient stand up tall and the top of the cane should hit right at the greater trochapter.
And what does that do for the patient's posture and uh their arm position?
It ensures their elbow has a slight bend about 15 to 30°. That little bit of flexion is what absorbs the shock and prevents shoulder strain.
So, if it's too high, they're shrugging. And if it's too low, they're stooping. Either way, it's a fall risk.
Precisely. And for a walker, it's a similar idea. You want the height to be right at the wrist crease when their arms are just hanging relaxed at their sides.
Okay, let's talk about the biggest safety trap for students, which has to be crutches.
Oh, absolutely. The rules for crutches are non-negotiable, and it's all about protecting the nerves. You need two to three finger widths of space between the armpit, the axilla, and the crutch pad.
And the weight has to be on their hands, not in the our armpits,
not in the armpits. If they lean there, we're risking brachial plexus injury, you know, crutch paralysis.
Wow. So, that nerve network that controls the whole arm and hand can be damaged just by leaning incorrectly on a crutch.
It can. Sustained pressure can cause weakness, even paralysis. It turns a simple mobility aid into a well, a huge clinical risk.
That really drives home why the assessment is so important. Yeah.
Okay, let's get to that crucial pneummonic for students, teaching a patient how to use stairs.
Right. This is a must know. Oh, it's simply up with the good, down with the bad.
So, when you're going upstairs, the good or unaffected leg goes first.
Yep. Followed by the crutches and the affected leg. When you're going downstairs, the crutches and the bad leg go first, then the good leg follows to stabilize.
The strong leg does the heavy lifting up and it provides the stable base on the way down. Simple as that.
Exactly. You're always pushing off the strong side.
Okay. Quick sidebar before we move on. Critical care items. Your patient is going for an MRI. What are you immediately checking for?
Hearing es they have to come out. They have metal components that can heat up or get pulled by the magnet.
And what about prosthetic limbs?
Daily skin inspection is key. You teach the patient to check their limb every single day and make sure the liner or sock is completely smooth. A wrinkle is basically a guaranteed pressure injury.
Okay, here's where things get uh really interesting for me. How fast the body declines with immobility.
It is shockingly fast. I mean, a pressure injury over a bony spot can develop in as little as 2 hours.
2 hours. That's it.
That's all it takes for the blood flow to be cut off and for that tissue to start dying.
So, if you get an EN Kleex question asking for the number one priority intervention for a bedbound patient, what's the answer?
Repositioning them every 2 hours. That's it. Even before a fancy air mattress.
Why is that? Why is the turning more important?
Because even the best mattress can't eliminate sheer forces. Only physically turning the patient can redistribute that pressure and get blood flowing back to the tissue.
We also use specific tools, right? Like troanter rolls and footboards. Could you quickly break those down?
Sure. A troanter roll goes by the hip to stop the leg from rotating outward. A footboard is at the end of the bed to prevent foot drop. Keeps the ankle in a neutral position.
And the trapeze bar,
that's for patient independence. It lets them use their upper body strength to shift themselves around, which is huge for preventing skin breakdown.
Okay, let's talk about SEDDS and Tedos. Vital for preventing clots. But there are some big risks,
right? You can't just leave them on. They have to come off at least once a shift for a full skin check. And you know, the big contraindication is arterial insufficiency.
So if the problem is getting blood to the leg, compressing it will only make things worse.
Way worse. You could cause eskeeia, even gangrine, you have to know if it's a Venus or an arterial problem.
Okay, a little priority challenge. You walk into a room, your patient has two leg casts, they're on bed rest, and they're trying to get out of bed.
What is your very first action? Safety. Always safety first. You activate the bed alarm and you lower the bed to the floor
before anything else.
Before anything else, you stop the fall. Then you can do your other assessments.
Perfect. Okay. Let's shift from physical safety to comfort, specifically non-farmacological interventions.
Right? Things like heat, cold, massage, distraction. But we have to know when not to use them.
Let's talk about cold therapy. When is that a bad idea?
Well, think about a patient with Reo's phenomenon. They already have intense vasoc constriction, poor blood flow, adding cold would just make it worse.
And what about heat?
Heat is a nogo for an acute injury like a fresh sprain because it just increases swelling.
And you never put it on an area where the patient has impaired sensation. They could get a serious burn and not even feel it.
And when you're tailoring the intervention, say distraction versus guided imagery, how do you choose?
It's really about duration. Distraction like music or just talking is great for short, sharp pain like during a procedure. Guided imagery is much better for chronic pain. Helps them achieve a deeper, more sustained relaxation.
Let's transition to a really sensitive topic.
Yeah,
end of life care in a paliotative or hospice setting.
Here, comfort is everything. We're managing pain, shortness of breath, nausea, anxiety. One of the things that's most distressing for families is terminal secretions.
The death rattle. What's the right way to manage that and what's the wrong way?
The right way is simple comfort measures. Repositioning the patient on their side, elevating the head of the bed, maybe a scopalamine patch to help dry up secretions,
and which we absolutely avoid,
deep aggressive suctioning. It's incredibly distressing for the patient. It doesn't provide much relief, and it just causes agitation. It goes against the goal, which is comfort.
This often leads to that really tough conversation about using opioids at the end of life.
A family member is worried that morphine will hasten death. How do you respond?
You have to be very clear and empathetic. You explain explain the principle of double effect. You say something like the morphine is only for comfort to ease the pain or shortness of breath. When it's used appropriately, it will not hasten death.
So, the intent is to treat the symptom.
The intent is everything. And explaining that can really alleviate the family's distress.
Okay, let's shift gears again to nutrition and elimination. Starting with aspiration risk, what's the number one clinical sign that tells you a client needs thickened liquids?
It's a cough. A client who coughs immediately after swallowing a thin liquid like water is at the highest risk. That cough is their body trying to tell you something is going down the wrong pipe.
So once we see that, we move to thickened liquids. Can you just quickly run through the different levels?
Sure. It goes from least to most thick, nectar thick, which is kind of like a thick juice, then honey thick, and finally pudding thick, which you need a spoon for.
And there's a simple maneuver we can teach patients to help, right?
The chin tuck. Just having them tuck their chin toward their chest when they swallow physically help. close off the airway and guide the food down the esophagus. It's so simple but so effective.
What about for patients on tube feeds? When you do a gastric residual check, what's the critical action if you pull back a large volume?
You hold the feeding immediately and you notify the provider. A high residual, say over 350 mill, means the stomach isn't emptying. Continuing the feed would be a huge aspiration risk.
And for tracking hydration, what's our single most accurate measure?
Daily weights. Period. 1 kilogram of weight change is one liter of fluid. It's the gold standard.
Okay, let's hit some quick facts on elimination osttomy care. How does the location change the output?
The further down the intestine the otomy is, the more formed the stool will be. So an ilostomy in the small intestine will have liquid output. A sigmoid colostomy way down at the end will eventually have formed stool. That's a huge teaching point for patients.
And for catheter insertion, a critical safety back on the balloon.
There's zero room for error here. You inject the exact volume printed on the port. If it says 5 ml, you use 5 ml. No more, no less.
Using more could rupture the balloon.
Or cause trauma on removal. You just have to trust the manufacturer's spec on that one.
Finally, personal hygiene, which is so much more than just comfort, especially in the ICU.
Oh, yeah. Oral care for a ventilated patient is a core part of the ventilator associated pneumonia or VAP prevention bundle.
And what does that involve?
It's material. Ridiculous. You're using a chlorhexodine rinse, a soft toothbrush, suctioning after, and you are doing this entire routine at least every two hours.
Every two hours. That's relentless.
It's what it takes to prevent a serious lung infection.
Okay, moving to the final steps. After a death has been pronounced, and assuming it's not a coroner's case, what is the nurse's immediate priority?
The family. Human needs come first. You notify the family. You offer them support, emotional, spiritual, whatever they need. You care for the living first. And once that's done, when you're preparing the body for viewing, what are the key actions for dignity?
We place the dentures back in, gently close the eyes, apply a clean gown, and tidy the room. And with jewelry, the rule is to remove it unless the family specifically asks for a wedding ring or something to stay on.
And you document that request carefully,
meticulously.
So, how do all these basic tasks tie back to bigger critical thinking principles like delegation?
Well, they're the foundation. Knowing these facts helps you prioritize. It helps you know what you can delegate. A UAP can turn the patient, but the nurse has to assess the skin. Every single task is an opportunity to respect the patients autonomy.
Let's touch on one more emerging topic, complimentary and alternative therapies or CAM.
Yes, our role here is to assess and report. A classic example. Your patient is scheduled for surgery and tells you they take benkoalloba every day
and you have to notify the surgeon immediately. Why is ginko though such a big deal
because it has significant anti-coagulant properties. It dramatically increases the bleeding risk. That one little question about supplements can prevent a massive posttop hemorrhage.
Wow. That's clinical safety right there in a single conversation.
Exactly. Safety is always in the details.
This has been an incredibly focused review. As our listeners are studying, what's one final thought you can leave them with that connects all this foundational material back to high level patient recovery?
I'd say consider the mass a physiological impact of simple things like sleep hygiene and clustering care. You know, organizing your tasks so your patient gets long uninterrupted blocks of rest
because that's when the real healing happens.
That's when the body does its most complex work. So, you see, basic care isn't basic at all. It profoundly directs the entire recovery trajectory.
That is a powerful connection. We've covered so much today. The specifics of crutch sizing, up with the good, down with the bad, aspiration prevention with the chin tuck, that non-negotiable two-hour turning rule, post-mortem priorities and all those critical safety rules for feeding tubes and catheterss.
The hope is you now have these foundational nuggets for basic care and comfort clarified and uh ready to go.
Thank you so much for joining us for this high impact review. We invite you to check in for more conversations each week to help you think like a nurse. And please be sure to visit think like a nurse.org for more resources. We'll see you next time.