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Difficulty: MediumBasic Care and Comfort

An older adult client is restricted to bed rest on the surgical unit following a lumbar spinal fusion. When addressing the client's basic care, comfort, and mobility needs, which interventions should the nurse implement? Select all that apply.

  1. Use a logrolling technique with the assistance of at least one other staff member when turning the client.Answer
  2. Place a supportive pillow between the client's knees when turning them to a lateral recumbent position.Answer
  3. Apply a protective moisture barrier ointment to the sacral and perineal skin during hygiene care.Answer
  4. D
    Elevate the head of the bed to a 90-degree angle to promote comfort during meal times.
  5. E
    Delegate the evaluation of the surgical incision site for redness to the unlicensed assistive personnel (UAP) during the bed bath.
  6. F
    Reassure the client's family that the client's sudden onset of severe confusion is an expected change related to aging.

Answer

The correct interventions are using a logrolling technique with assistance, placing a pillow between the knees when in a lateral position, and applying a moisture barrier ointment to protect the skin.
Following a lumbar spinal fusion, the client's spine must be kept in straight alignment to prevent injury to the surgical site. Logrolling with multiple staff members ensures the spine moves as a single unit without twisting. Placing a pillow between the knees in a lateral position prevents inward rotation of the hip and pulling on the lower spine, thereby promoting proper alignment and comfort. Finally, applying a moisture barrier during hygiene is a fundamental basic care measure to prevent skin breakdown in vulnerable clients who are restricted to bed.

Step-by-Step Solution

1
Analyze the client's specific medical condition and activity restrictions.
The client has undergone a lumbar spinal fusion and requires interventions that maintain strict spinal alignment while on bed rest.
Preventing spinal twisting or acute flexion is critical to avoid surgical complications and promote healing.
2
Evaluate each intervention for safety, scope of practice, and physiological rationale.
Logrolling, using supportive pillows between the knees, and protecting skin integrity are safe basic care standards. Conversely, placing the client in high Fowler's, delegating clinical assessments, and ignoring sudden confusion are unsafe practices.
Nursing actions must maintain alignment, ensure proper RN oversight for clinical evaluation, and accurately recognize acute pathological changes versus normal aging.

Key Concept

Basic Care, Comfort, and Positioning for Post-Spinal Surgery
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Topics

Basic Care and Comfort

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