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Difficulty: MediumBasic Care and Comfort

A nurse is developing a plan of care for an older adult client who is bedbound, has a continuous peripheral IV infusion, and occasionally experiences urinary incontinence. The client's family reports that the client has suddenly become much more confused over the past 24 hours. Which of the following nursing actions should the nurse include in the plan of care? Select all that apply.

  1. Implement a turning schedule to reposition the client at least every 2 hours using pillows for support.Answer
  2. B
    Keep the head of the bed elevated to 60 degrees at all times to promote optimal lung expansion.
  3. C
    Delegate the evaluation of the client's skin status and pressure injury risk to the unlicensed assistive personnel (UAP).
  4. Apply a moisture-repellent barrier cream to the perineal skin after cleansing the area following incontinent episodes.Answer
  5. E
    Reassure the family that the client's recent onset of increased confusion is an expected physiological change associated with aging.
  6. F
    Apply bilateral soft wrist restraints immediately to prevent the client from pulling at the peripheral IV site due to confusion.

Answer

The correct nursing actions are implementing a 2-hour turning schedule with pillows for support and applying a moisture-repellent barrier cream to the perineal skin after incontinent episodes.
The correct nursing actions focus on maintaining skin integrity and promoting comfort through established, evidence-based practices. Implementing a turning schedule every 2 hours with pillow support effectively offloads pressure from vulnerable bony prominences. Additionally, applying a moisture-repellent barrier cream after cleansing incontinent episodes protects the epidermal layer from the caustic effects of urine and feces, preventing incontinence-associated dermatitis.

Step-by-Step Solution

1
Analyze the client's clinical presentation and identify primary risk factors.
The client is an older adult, bedbound, incontinent, with a peripheral IV, and experiencing a sudden onset of acute confusion. The main risks are skin breakdown, potential infection or delirium, and safety hazards.
Identifying the client's specific vulnerabilities is essential to prioritize safe and effective basic care interventions.
2
Evaluate the proposed interventions for maintaining skin integrity.
Repositioning every 2 hours and using barrier creams are correct, evidence-based practices. Delegating skin assessment and keeping the head of the bed at 60 degrees are incorrect and potentially harmful actions.
Assessment remains strictly an RN responsibility. A 60-degree elevation significantly increases sacral shearing forces, whereas the recommended angle is 30 degrees or less for resting.
3
Evaluate the proposed interventions for managing the client's confusion and safety.
Applying immediate restraints and attributing sudden confusion to normal aging are incorrect actions.
Sudden confusion indicates an acute pathological process (like an infection or delirium), not normal aging. Restraints are strictly a last resort after all other less restrictive measures have failed.

Key Concept

Basic care and comfort for the bedbound older adult involves prioritizing skin integrity through proper positioning and hygiene, using the least restrictive safety measures, recognizing acute cognitive changes as abnormal, and understanding the legal scope of practice for delegation.
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Topics

Basic Care and Comfort

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