A client with multiple sclerosis is admitted with an acute exacerbation, experiencing severe lower extremity spasticity, profound weakness, and functional incontinence. The healthcare provider prescribes strict bed rest. The nurse is updating the plan of care to promote optimal basic care, comfort, and safety. Which of the following interventions should the nurse include? Select all that apply.
- Use a friction-reducing device for repositioning and place trochanter rolls along the client's hips.Answer
- BPlace a firm pillow directly under the client's popliteal spaces to relieve tension on the lower back.
- Establish a scheduled toileting program by offering the bedpan every 2 hours during waking hours.Answer
- DInstruct the unlicensed assistive personnel (UAP) to evaluate the client's bony prominences for nonblanchable erythema during daily hygiene.
- EApply soft bilateral wrist restraints at night to prevent the client from removing their incontinence garments while sleeping.
- Perform passive range-of-motion (ROM) exercises slowly, stopping temporarily if a muscle spasm occurs.Answer
Answer
The correct interventions are using a friction-reducing device with trochanter rolls, establishing a scheduled toileting program, and performing slow, passive range-of-motion exercises.
The correct interventions focus on safely maintaining skin integrity, promoting joint mobility, and ensuring safe elimination for an immobile client. Using a friction-reducing device with trochanter rolls prevents shearing and maintains neutral hip alignment. Establishing a scheduled toileting program manages functional incontinence proactively, protecting the skin from moisture-associated breakdown. Performing passive range-of-motion exercises slowly, while pausing during spasms, prevents contractures without causing muscle injury or severe pain.
Step-by-Step Solution
Key Concept
Basic Care and Comfort: Immobility Management