Examkin

Question

Difficulty: MediumBasic Care and Comfort

An older adult client with advanced dementia and frequent urinary incontinence is confined to bed. The nurse notes new, non-blanchable erythema on the client's sacrum. The client has also been frequently scratching at the perineal area. Which nursing intervention is the most appropriate to promote comfort and protect the client's skin integrity?

  1. Cleanse the perineal region with a pH-balanced, no-rinse cleanser and apply a moisture barrier ointment.Answer
  2. B
    Maintain the head of the bed at a 60-degree angle to prevent the client from sliding down in bed.
  3. C
    Instruct the unlicensed assistive personnel (UAP) to evaluate the sacral erythema during the next incontinence change.
  4. D
    Apply bilateral soft wrist restraints to prevent the client from further scratching the perineal skin.

Answer

The most appropriate intervention is to cleanse the perineal region with a pH-balanced, no-rinse cleanser and apply a moisture barrier ointment.
Cleansing with a pH-balanced, no-rinse cleanser and applying a moisture barrier ointment protects the epidermis from moisture-associated skin damage (MASD), reduces the irritating effects of urine, and soothes the skin. This non-invasive hygiene measure directly addresses the cause of the client's discomfort without introducing new risks, aligning with standard basic care and comfort protocols.

Step-by-Step Solution

1
Analyze the client's current clinical presentation and identify primary risk factors.
The client has urinary incontinence causing perineal irritation (manifested by scratching) and sacral erythema, which indicates an early-stage pressure injury.
Identifying the root cause of the discomfort and skin breakdown is necessary to select a targeted, non-harmful intervention.
2
Evaluate the proposed interventions against safety standards, scope of practice, and evidence-based skin care guidelines.
Cleansing and applying barrier cream safely treats the moisture issue; elevating the head of the bed causes harmful shear; delegating assessment violates the RN scope of practice; and restraints are excessively restrictive.
Prioritizing non-invasive, evidence-based hygiene measures protects the client while adhering to legal and safety standards.

Key Concept

Prevention of Moisture-Associated Skin Damage and Pressure Injuries
Rate this question

Topics

Basic Care and Comfort

More questions from this topic