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Difficulty: EasyBasic Care and Comfort

A nurse is planning basic care for an older adult client who is completely bedbound and requires assistance with all activities of daily living. Which interventions should the nurse include in the plan of care to maintain skin integrity and promote comfort? Select all that apply.

  1. Reposition the client at least every 2 hours using a structured turning schedule.Answer
  2. B
    Delegate the daily full-body skin assessment to the Unlicensed Assistive Personnel (UAP).
  3. C
    Elevate the head of the bed to a 90-degree angle for extended periods to prevent sliding.
  4. Utilize a draw sheet or friction-reducing device when moving the client up in bed.Answer
  5. E
    Attribute a sudden onset of urinary incontinence to the normal aging process and monitor.
  6. Cleanse the skin gently and apply a moisture barrier ointment promptly after any incontinent episode.Answer

Answer

The correct interventions include repositioning the client at least every 2 hours, utilizing a draw sheet for movement, and cleansing the skin while applying a moisture barrier after incontinent episodes.
Maintaining skin integrity for a bedbound client requires a multifaceted approach. Repositioning every two hours relieves continuous pressure on bony prominences. Using a draw sheet lifts rather than drags the client, preventing friction injuries. Promptly cleansing and applying a barrier cream protects the epidermis from moisture-associated skin damage caused by incontinence.

Step-by-Step Solution

1
Identify the client's primary risk factors from the scenario.
The client is an older adult, completely bedbound, and dependent for all ADLs, placing them at high risk for skin breakdown and pressure injuries.
Understanding the clinical risks guides the selection of appropriate preventive interventions.
2
Evaluate the evidence-based practices for maintaining skin integrity.
Standard practices include frequent turning, protecting the skin from moisture, and avoiding shear.
These standard practices form the basis of the correct answers.
3
Analyze each option against nursing scope of practice and safety standards.
Assessments cannot be delegated to UAP. High-Fowler's position increases shearing. Sudden incontinence is abnormal.
Eliminating options that violate delegation rules, cause harm, or misinterpret pathology leaves the safest and most effective nursing actions.

Key Concept

Basic care interventions for immobility and skin integrity maintenance
Estimated Time:1m 0s
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Topics

Basic Care and Comfort

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