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Difficulty: HardBasic Care and Comfort

A 78-year-old client with moderate cognitive impairment is receiving intravenous therapy for a respiratory infection. The client is agitated, repeatedly picks at the venous access site, and exhibits new-onset urinary incontinence. Which basic care and comfort interventions should the nurse include in the plan of care? Select all that apply.

  1. Cover the intravenous insertion site loosely with a continuous stockinette bandage.Answer
  2. Cleanse the perineal region with a pH-balanced, no-rinse cleanser after each incontinent episode.Answer
  3. Provide the client with a textured sensory blanket to fold and manipulate with their hands.Answer
  4. D
    Document the new-onset urinary incontinence as a normal age-related change in the elimination pattern.
  5. E
    Direct the unlicensed assistive personnel to determine the client's pressure injury risk score during hygiene care.
  6. F
    Position the client in a continuous 90-degree high-Fowler's alignment during nighttime sleep to optimize oxygenation.

Answer

The appropriate basic care and comfort interventions include covering the intravenous site with a stockinette, providing prompt perineal cleansing with a pH-balanced cleanser, and offering a sensory blanket for diversional activity.
The correct basic care interventions prioritize client comfort, safety, and skin integrity without resorting to restrictive measures. Concealing the IV site with a stockinette and providing a textured sensory blanket are highly effective non-pharmacologic comfort strategies and restraint alternatives for agitated or cognitively impaired clients. Promptly cleansing the perineum with a pH-balanced, no-rinse cleanser is a fundamental hygiene practice that prevents moisture-associated skin breakdown following incontinent episodes.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has moderate cognitive impairment, agitation with picking at the IV site, and new-onset urinary incontinence.
Identifying all active clinical issues ensures a comprehensive approach to the client's basic care and safety needs.
2
Identify safe, non-pharmacologic comfort measures to protect the IV site.
Covering the site with a stockinette and providing diversional activities (like a sensory blanket) are selected.
These interventions are effective restraint alternatives that maintain therapy access while prioritizing client comfort.
3
Address the hygiene and skin integrity needs related to new-onset incontinence.
Prompt perineal cleansing with a pH-balanced, no-rinse cleanser is selected as a priority intervention.
Urine is irritating to the skin; appropriate cleansing prevents moisture-associated dermatitis and breakdown.
4
Evaluate the remaining options against nursing scope of practice and physiological safety.
The options involving normalizing new incontinence, delegating risk assessment, and continuous high-Fowler's positioning are rejected.
New incontinence requires medical evaluation, clinical risk assessments cannot be delegated, and 90-degree positioning increases shearing forces.

Key Concept

Implementing non-pharmacologic comfort measures, maintaining skin integrity, and prioritizing safe basic care for cognitively impaired clients.
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Topics

Basic Care and Comfort

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