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Difficulty: HardBasic Care and Comfort

An 78-year-old client with a history of mild dementia is 24 hours post-operative following a right total hip arthroplasty (posterior approach). During morning rounds, the client becomes acutely agitated and continuously attempts to pull at their indwelling urinary catheter. Which basic care and comfort intervention should the nurse implement?

  1. A
    Delegate the unlicensed assistive personnel to assess the client's pain level and inspect the skin integrity around the catheter meatus.
  2. Conceal the catheter tubing beneath the client's gown using a stabilization device and provide a gentle hand massage to promote relaxation.Answer
  3. C
    Apply bilateral soft wrist restraints to protect the catheter and turn the client onto their right side to perform perineal care.
  4. D
    Document the acute agitation as a normal physiological manifestation of the aging process exacerbated by the client's baseline dementia.

Answer

The most appropriate intervention is to visually conceal the catheter tubing beneath the gown using a stabilization device and provide a gentle hand massage to promote relaxation.
The most appropriate basic care and comfort strategy uses non-pharmacological interventions as a first-line approach. Visually concealing medical devices and securing them properly reduces the sensory triggers that cause confused clients to pull at them. A gentle hand massage provides tactile comfort and diverts the client's attention, promoting relaxation safely without the use of physical restraints.

Step-by-Step Solution

1
Analyze the client's clinical presentation and identify the primary safety and comfort needs.
The client is 24 hours post-right THA, has mild dementia, and is experiencing acute agitation while pulling at an invasive device.
Understanding the surgical precautions and the root cause of the behavior is essential for planning safe, effective basic care.
2
Evaluate the appropriateness of non-pharmacological comfort measures versus physical restraints.
Concealing the device and offering tactile diversion (massage) is selected as the safest, least restrictive intervention.
Standard nursing guidelines require the use of less restrictive, non-pharmacological alternatives before applying physical restraints to prevent injury and promote dignity.
3
Identify contraindicated actions based on the client's recent surgical procedure and nursing scope of practice.
Positioning the client on the operative right hip and delegating assessments to the UAP are ruled out as unsafe and inappropriate.
Post-THA precautions strictly prohibit positioning on the operative side to prevent dislocation, and RNs cannot delegate clinical assessments to UAP.

Key Concept

Non-pharmacological comfort interventions and restraint alternatives
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Topics

Basic Care and Comfort

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