An older adult client is admitted to the medical-surgical unit with generalized weakness, poor oral intake, and frequent episodes of fecal incontinence. The client occasionally exhibits periods of confusion and is currently bed-bound. Which interventions should the nurse include in the client's plan of care to promote comfort and prevent skin breakdown? Select all that apply.
- Place a pillow under the client's calves to suspend the heels entirely off the mattress.Answer
- Reposition the client at least every two hours utilizing a 30-degree lateral inclined position.Answer
- Gently cleanse the perineal area and apply a moisture barrier cream after each episode of incontinence.Answer
- DMaintain the head of the bed continuously elevated at 60 to 90 degrees to decrease aspiration risk.
- EDirect the unlicensed assistive personnel to perform the initial comprehensive skin assessment.
- FApply bilateral soft wrist restraints immediately if the confused client begins scratching their fragile skin.
Answer
The correct interventions are placing a pillow under the calves to suspend the heels, repositioning every two hours using a 30-degree lateral position, and applying a moisture barrier cream after incontinence.
Proper basic care and comfort for an immobile, incontinent client focuses on relieving pressure and protecting the skin barrier. Suspending the heels completely off the mattress eliminates pressure on the vulnerable heel area. Repositioning every two hours using a 30-degree lateral position avoids placing direct pressure on the trochanter (hip bone) while effectively relieving sacral pressure. Applying a moisture barrier cream after gently cleaning the area protects the epidermis from the corrosive effects of stool and urine, preventing moisture-associated skin damage.
Step-by-Step Solution
Key Concept
Basic Care and Comfort for Skin Integrity