A nurse is creating a plan of care for an older adult client admitted with acute decompensated heart failure. The client has severe peripheral edema, is experiencing orthopnea, and has become restless, frequently picking at their continuous intravenous (IV) infusion line. Which of the following nursing interventions should be included in the client's basic care and comfort plan? Select all that apply.
- Maintain the head of the bed elevated at 45 to 60 degrees.Answer
- BPlace the client in a flat, supine position for two hours every shift to promote venous return.
- Apply a protective moisture barrier cream to the perineal area following routine hygiene care.Answer
- DInstruct the unlicensed assistive personnel (UAP) to conduct the initial admission assessment of the client's sacral skin integrity.
- EApply bilateral soft wrist restraints immediately to prevent the client from dislodging the intravenous line.
- Implement non-pharmacological interventions such as reducing room noise and dimming the lights to address restlessness.Answer
Answer
The correct interventions are maintaining the head of the bed elevated at 45 to 60 degrees, applying a protective moisture barrier cream to the perineal area, and implementing non-pharmacological interventions to reduce environmental stimuli.
The correct nursing actions prioritize respiratory function, skin integrity, and safe comfort measures. Elevating the head of the bed utilizes gravity to pull the diaphragm downward, expanding the lungs and relieving orthopnea. Protecting the skin with a barrier cream is a fundamental hygiene measure that prevents breakdown in edematous tissue. Utilizing environmental modifications, such as dimming lights, addresses restlessness safely without resorting to restrictive measures.
Step-by-Step Solution
Key Concept
Basic Care and Comfort in Acute Decompensated Heart Failure