An older adult client with advanced dementia and impaired physical mobility is admitted to an acute care unit. The client has poor nutritional intake and is at high risk for skin breakdown. Which interventions should the nurse include in the plan of care to promote basic care and comfort? Select all that apply.
- Suspend the client's heels completely off the surface of the bed using pillows.Answer
- Apply a moisture barrier ointment to the perineal area following each episode of incontinence.Answer
- Provide oral hygiene using a soft-bristled toothbrush before meals to stimulate appetite.Answer
- DMaintain the client's upper body in a continuous high-Fowler's position to minimize the risk of aspiration.
- EDirect the assistive personnel to conduct the primary evaluation of the client's swallowing coordination.
- FDocument any sudden onset of acute confusion as a normal physiological change of aging.
Answer
The correct interventions are suspending the client's heels off the bed, applying a moisture barrier after incontinence, and providing oral hygiene prior to meals.
Suspending the heels, applying perineal moisture barriers, and performing pre-meal oral hygiene are evidence-based basic care interventions that protect skin integrity, improve hygiene, and promote nutritional intake for high-risk immobile clients.
Step-by-Step Solution
Key Concept
Basic care and comfort for immobile older adults involves vigilant skin protection, oral hygiene to promote nutrition, appropriate positioning to prevent shearing, and recognizing acute clinical changes.