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Difficulty: HardBasic Care and Comfort

An older adult client is bedbound and recovering from severe bacterial pneumonia when they develop sudden, acute agitation and confusion. The nursing team is establishing interventions to address the client's basic care, comfort, and safety needs. Which of the following actions should be included in the care plan? Select all that apply.

  1. Implement a scheduled turning and toileting routine every two hours to manage incontinence and protect skin integrity.Answer
  2. Provide a quiet environment with dim lighting and minimize unnecessary monitor alarms to reduce sensory overload.Answer
  3. C
    Position the client in a flat, supine position during periods of rest to maximize deep sleep and respiratory relaxation.
  4. D
    Instruct the unlicensed assistive personnel (UAP) to evaluate the severity of any perineal redness to determine which barrier cream to apply.
  5. E
    Reassure the client's family that the sudden onset of acute agitation is an expected physiological change associated with the aging process.
  6. F
    Request a prescription for soft bilateral wrist restraints to immediately secure the client's hands and protect the peripheral intravenous access.

Answer

The correct interventions are implementing a scheduled turning and toileting routine every two hours, and providing a quiet environment with dim lighting to reduce sensory overload.
Implementing a scheduled turning and toileting routine protects the client's skin integrity and proactively manages incontinence, which is a critical basic care standard for a bedbound client. Furthermore, providing a quiet, dimly lit environment with minimal alarms is an essential non-pharmacological comfort measure that actively reduces sensory stimulation and helps de-escalate acute agitation.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has bacterial pneumonia, is bedbound, and is experiencing sudden acute agitation (delirium).
Understanding the interplay of infection, immobility, and altered mental status guides the prioritization of airway protection, skin integrity, and non-pharmacological comfort.
2
Evaluate positioning and comfort needs based on the pathophysiology.
The client requires positioning that promotes lung expansion, routines that protect skin integrity, and an environment that prevents overstimulation.
Bacterial pneumonia necessitates head elevation; being bedbound demands strict turning schedules; agitation requires a calm, low-stimulus environment.
3
Differentiate between appropriate nursing actions and contraindicated practices.
Delegating skin assessments, attributing delirium to normal aging, using flat positioning during a respiratory illness, and prematurely utilizing physical restraints are identified as contraindicated.
Nurses must adhere to the scope of practice, differentiate pathology from normal aging, utilize evidence-based respiratory positioning, and apply restraints only as an absolute last resort.

Key Concept

Basic care and comfort for an agitated, bedbound client includes maintaining skin integrity, promoting optimal respiratory positioning, and utilizing non-pharmacological interventions to reduce sensory overload while strictly adhering to safety and delegation principles.
Estimated Time:2m 0s
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Topics

Basic Care and Comfort

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