A nurse is planning care for an older adult client who is on strict bed rest due to severe generalized weakness. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.
- Place a pillow between the client's knees and ankles when turning them to a side-lying positionAnswer
- Apply a moisture-barrier ointment to the perineal skin after cleansing following an incontinence episodeAnswer
- CDirect the unlicensed assistive personnel (UAP) to evaluate the client's skin for signs of breakdown during the bed bath
- DKeep the client exclusively in a supine position to minimize energy expenditure and reduce fatigue
- ERequest a prescription for physical restraints if the client becomes mildly restless during the night
Answer
The correct interventions are placing a pillow between the knees and ankles when side-lying, and applying a moisture-barrier ointment to the perineal skin.
Appropriate basic care for an immobile older adult prioritizes the prevention of pressure injuries and the maintenance of skin integrity. Placing a pillow between the knees and ankles when the client is side-lying prevents bony prominences from rubbing together, which reduces friction and pressure. Applying a moisture-barrier ointment after incontinence protects the epidermis from maceration and chemical irritation.
Step-by-Step Solution
Key Concept
Basic care and comfort principles for immobile clients focus on maintaining skin integrity, preventing pressure injuries, and promoting proper body alignment.
Estimated Time:1m 0s