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Difficulty: EasyBasic Care and Comfort

A nurse is planning basic care and comfort measures for an older adult client who is restricted to bed rest. Which of the following actions should the nurse include in the plan of care? Select all that apply.

  1. Elevate the head of the bed to 30 degrees or less when the client is resting.Answer
  2. Place a pillow under the client's lower legs to suspend the heels off the mattress.Answer
  3. C
    Delegate the initial assessment of the client's skin integrity to the unlicensed assistive personnel (UAP).
  4. D
    Maintain the client exclusively in a supine position to ensure proper spinal alignment.
  5. Use a friction-reducing device, such as a draw sheet, when moving the client up in bed.Answer
  6. F
    Apply physical restraints to prevent the client from repeatedly scratching dry, itchy skin.

Answer

The correct interventions are elevating the head of the bed to 30 degrees or less, placing a pillow under the lower legs to suspend the heels, and using a friction-reducing device when moving the client.
Appropriate basic care for an immobile client involves interventions that proactively minimize pressure, friction, and shear. Elevating the head of the bed to 30 degrees or less reduces shearing forces on the sacrum. Suspending the heels with a pillow relieves all pressure on the heels. Using a draw sheet or slider board prevents friction injuries when repositioning the client.

Step-by-Step Solution

1
Identify the client's primary risk factor based on the scenario.
The client is on bed rest and is at high risk for complications of immobility, specifically pressure injuries and skin breakdown.
Recognizing the risks of immobility guides the selection of appropriate basic care and comfort interventions.
2
Evaluate each intervention for its effectiveness in promoting skin integrity and safety.
Elevating the head of the bed to 30 degrees or less, floating the heels, and using friction-reducing devices are all evidence-based practices.
These actions directly minimize pressure, friction, and shearing forces on vulnerable skin.
3
Evaluate the incorrect interventions for scope of practice and safety contraindications.
Delegating initial assessments to a UAP, maintaining a continuous supine position, and using restraints for itching are inappropriate and unsafe actions.
The RN must perform assessments; clients must be repositioned frequently to restore circulation; and restraints are a last resort for severe safety risks.

Key Concept

Immobility Management and Pressure Injury Prevention
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Topics

Basic Care and Comfort

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