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Difficulty: MediumBasic Care and Comfort

A nurse is creating a care plan for a client with an acute exacerbation of multiple sclerosis who has bilateral lower extremity paralysis and frequent bowel incontinence. Which interventions should the nurse include to maintain skin integrity and promote basic comfort? Select all that apply.

  1. Cleanse the perineal region with a pH-balanced no-rinse cleanser and apply a moisture barrier.Answer
  2. B
    Keep the backrest of the bed continuously raised to a 60-degree angle to optimize respiratory function.
  3. Employ a mechanical lift or a friction-reducing slide sheet when moving the client up in bed.Answer
  4. D
    Place a ring-shaped foam cushion under the client's buttocks when they are seated in a wheelchair.
  5. E
    Delegate the morning inspection and documentation of the client's skin status to the unlicensed assistive personnel (UAP).
  6. Position a supportive pad under the lower legs from the mid-calf to the ankle to suspend the heels.Answer

Answer

The appropriate interventions are: cleansing the perineum with a pH-balanced cleanser and applying a moisture barrier; employing a friction-reducing device for movement; and positioning a supportive pad under the calves to suspend the heels.
The correct interventions for maintaining skin integrity and promoting comfort in an immobile client include using a pH-balanced cleanser with a moisture barrier to prevent incontinence-associated dermatitis. Additionally, using friction-reducing devices during repositioning minimizes destructive shear forces on the skin. Suspending the heels by placing support under the lower legs completely offloads pressure from the vulnerable heel areas, preventing localized pressure injuries.

Step-by-Step Solution

1
Evaluate the client's specific risk factors for skin breakdown.
The client is identified as high risk due to immobility from paralysis and constant moisture exposure from bowel incontinence.
Identifying specific physiological risk factors allows the nurse to select targeted, evidence-based preventive measures.
2
Select interventions that manage moisture and protect the epidermal barrier.
Using a pH-balanced, no-rinse cleanser and applying a moisture barrier are chosen to protect the perineum.
Alkaline soaps can strip the skin's natural oils, while moisture barriers protect the epidermis from the corrosive, macerating effects of feces.
3
Select interventions that minimize shear, friction, and localized pressure on bony prominences.
Using a friction-reducing slide sheet and completely offloading the heels are appropriate. Donut cushions and continuous high Fowler's positioning are rejected as inherently harmful.
Shear and intense localized pressure are the primary mechanical causes of pressure injuries; ring cushions and high backrest angles exacerbate these destructive forces.
4
Determine appropriate delegation of care tasks for this high-risk client.
The task of assessing and documenting skin integrity is retained by the RN rather than being assigned to the UAP.
Initial assessment, ongoing evaluation, and clinical judgment are strictly within the scope of practice of the registered nurse.

Key Concept

Pressure Injury Prevention and Safe Delegation
Estimated Time:2m 0s
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Topics

Basic Care and Comfort

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