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Difficulty: EasyBasic Care and Comfort

A nurse is planning care for an older adult client who is completely bedridden following an ischemic stroke. The plan includes interventions to maintain skin integrity, promote comfort, and ensure proper body alignment. Which of the following nursing actions are appropriate to include in the client's care plan? Select all that apply.

  1. Float the client's heels off the mattress by placing a supportive pillow under the lower legs.Answer
  2. Utilize a draw sheet to lift rather than drag the client when moving them up in bed.Answer
  3. C
    Maintain the head of the bed at a 60- to 90-degree angle for extended periods to prevent respiratory complications.
  4. D
    Delegate the daily assessment of the client's skin status over bony prominences to the unlicensed assistive personnel (UAP).
  5. Place a trochanter roll alongside the client's outer thigh and hip to prevent external hip rotation.Answer

Answer

The appropriate actions are floating the heels off the mattress, utilizing a draw sheet to lift the client, and placing a trochanter roll alongside the outer thigh and hip.
Floating the heels prevents pressure injuries on highly vulnerable bony prominences. Using a draw sheet prevents shearing and friction forces that damage the epidermis during repositioning. Placing a trochanter roll prevents abnormal external rotation of the hip joint, maintaining functional body alignment for the immobile client.

Step-by-Step Solution

1
Identify the client's primary risks related to being completely bedridden.
The client is at high risk for pressure injuries (due to immobility, friction, and shear) and musculoskeletal complications like contractures or abnormal joint rotation.
Understanding the physiological impacts of immobility directs the selection of appropriate basic care interventions.
2
Evaluate the interventions aimed at protecting skin integrity.
Floating heels and using a draw sheet correctly mitigate pressure, friction, and shear. Maintaining a high head-of-bed angle incorrectly increases sacral shear.
Direct pressure and shearing forces are the primary causes of pressure injuries in bedridden clients.
3
Evaluate the intervention for body alignment.
Using a trochanter roll is an effective mechanical support to prevent external hip rotation.
Immobile clients lose muscle tone that normally keeps joints aligned, requiring mechanical aids.
4
Evaluate the delegation intervention.
Delegating skin assessment is identified as an unsafe action.
Assessments fall strictly within the Registered Nurse's scope of practice.

Key Concept

Immobility Management and Pressure Injury Prevention
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Topics

Basic Care and Comfort

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