An older adult client with advanced Alzheimer's disease is receiving acute care for pneumonia. The client becomes intensely agitated and physically combative during attempts to provide morning hygiene. Which actions should the nurse include in the client's care plan to safely promote basic hygiene and comfort? (Select all that apply.)
- Keep the client covered with a warm bath blanket and expose only the specific body part being washedAnswer
- BDocument the client's combative behavior as a normal, expected physiological change of aging
- Introduce a calm environment by playing the client's favorite soothing music during the procedureAnswer
- DDelegate the unlicensed assistive personnel (UAP) to perform a comprehensive skin assessment during the bath
- EApply bilateral soft wrist restraints temporarily to complete the hygiene care without staff injury
- Delay washing the client's hair until the end of the bath or schedule it for a completely separate timeAnswer
Answer
The correct actions are keeping the client covered with a warm bath blanket, playing soothing music, and delaying hair washing until the end of the bath or a separate time.
Clients with advanced dementia often experience sensory overload and fear during personal care. Promoting basic care and comfort involves reducing these stressors. Using a warm bath blanket and exposing only one area at a time prevents chilling and preserves dignity. Washing the hair is often highly distressing due to water on the face and manipulation of the head, so it should be done last or at a separate time to avoid escalating agitation early in the process. Playing familiar, soothing music provides a non-pharmacologic calming effect, distracting the client and creating a more therapeutic environment.
Step-by-Step Solution
Key Concept
Basic Care and Comfort for clients with cognitive impairment focuses on non-pharmacological interventions to reduce sensory overload, preserve dignity, and prevent defensive behaviors.