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Difficulty: MediumBasic Care and Comfort

A nurse is caring for a 75-year-old client who underwent a lumbar puncture two hours ago. The client is frail, has a history of osteoarthritis, and is experiencing episodes of urinary incontinence. Which nursing actions are appropriate to promote basic care and comfort while ensuring client safety? Select all that apply.

  1. Place a fracture bedpan under the client for elimination needs to minimize spinal flexion.Answer
  2. Encourage the intake of oral fluids by offering a cup with a straw while the client remains flat.Answer
  3. C
    Elevate the head of the bed to a 60-degree angle to assist the client in eating a meal more comfortably.
  4. D
    Delegate the evaluation of the lumbar puncture dressing for signs of bleeding to the unlicensed assistive personnel (UAP).
  5. Apply a moisture barrier ointment to the perineal area after cleansing following an incontinence episode.Answer
  6. F
    Reassure the family that the client's sudden onset of severe confusion is an expected physiological change associated with normal aging.

Answer

The correct interventions are to place a fracture bedpan under the client, encourage fluids using a straw, and apply a moisture barrier ointment to the perineal area.
The correct options involve interventions that promote basic care while strictly adhering to post-procedure safety constraints. A fracture bedpan allows for elimination without requiring the client to lift their hips significantly, which minimizes spinal flexion. Offering fluids through a straw maintains hydration and replaces cerebrospinal fluid without breaking the flat-bedrest requirement. Applying a moisture barrier ointment protects the frail skin from breakdown due to urinary incontinence.

Step-by-Step Solution

1
Analyze the client's current status and recent procedure.
The client is a frail older adult, 2 hours post-lumbar puncture, experiencing urinary incontinence.
Identifying these factors highlights the primary constraints: a strict flat bedrest requirement, risk of skin breakdown, and risk for post-procedure complications.
2
Evaluate each intervention for safety and appropriateness.
Interventions must support nutrition, elimination, and hygiene without violating the flat bedrest prescription or scope of practice.
Basic care must be adapted to fit within medical and procedural constraints.
3
Select the actions that promote comfort and hygiene safely.
Using a fracture pan, offering fluids via a straw, and applying barrier cream are selected as the appropriate actions.
These specific actions maintain the required supine position and protect skin integrity without causing harm.

Key Concept

Basic Care and Comfort: Adapting Interventions to Procedural Constraints
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Topics

Basic Care and Comfort

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