A clinical team is providing hygiene and mobility support for a bedfast client who exhibits new-onset urinary incontinence and a localized, non-blanchable redness over the sacral area. Which interventions are appropriate for this client? Select all that apply.
- Apply a zinc oxide-based moisture barrier cream to the perineum after cleansing.Answer
- BElevate the head of the bed to 90 degrees during periods of rest to minimize sacral pressure.
- Utilize a friction-reducing device, such as a lift sheet, when repositioning the client in bed.Answer
- DInstruct the unlicensed assistive personnel to assess the size and color of the sacral redness during morning care.
- EReassure the family that the new-onset urinary incontinence is an expected physiological change associated with aging.
- Establish an individualized turning schedule that rotates the client's position at least every two hours.Answer
Answer
The appropriate interventions include applying a moisture barrier cream to the perineum, utilizing a friction-reducing device during repositioning, and establishing a turning schedule of at least every two hours.
Maintaining basic care and comfort for a bedfast client with impaired skin integrity requires strategies that minimize pressure, shear, and moisture. Applying a zinc-oxide moisture barrier protects the skin from the corrosive effects of urine. Using a lift sheet minimizes friction and shearing forces that damage fragile epidermal layers during movement. Repositioning the client at least every two hours ensures that blood flow is restored to vulnerable tissues over bony prominences like the sacrum.
Step-by-Step Solution
Key Concept
Basic Care and Comfort: Skin Integrity and Mobility Interventions