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Zorluk: OrtaBasic Care and Comfort

A clinical nurse leader is evaluating the care plan for an older adult client who is essentially bedbound due to severe generalized deconditioning and has recently developed episodic urinary incontinence. Which interventions are appropriate for the client's basic care and comfort? Select all that apply.

  1. Use a specialized wedge cushion to float the heels completely off the mattress surface.Cevap
  2. Cleanse the perineal area and apply a moisture barrier cream immediately after each incontinent episode.Cevap
  3. Reposition the client using a 30-degree lateral tilt alternating side to side.Cevap
  4. D
    Place a rolled towel directly underneath the popliteal space to alleviate knee strain.
  5. E
    Instruct the assistive personnel to evaluate the skin over bony prominences for non-blanchable erythema.
  6. F
    Counsel the family that the recent onset of urinary incontinence is a standard consequence of the aging process.

Cevap

The appropriate interventions are using a wedge to float the heels, applying moisture barrier cream after incontinence, and utilizing a 30-degree lateral tilt for repositioning.
Appropriate basic care for a bedbound client requires meticulous attention to skin integrity and circulation. Floating the heels relieves pressure on highly susceptible bony prominences. Applying a moisture barrier cream protects the epidermis from maceration and chemical breakdown caused by urine exposure. The 30-degree lateral tilt is the evidence-based optimal position to relieve pressure on the sacrum and trochanters while minimizing dangerous shear forces.

Adım Adım Çözüm

1
Analyze the client's risk factors based on the clinical scenario.
The client is at exceptionally high risk for skin breakdown and pressure injuries due to immobility and moisture from new-onset urinary incontinence.
To identify necessary basic care interventions prioritizing skin protection and circulatory health.
2
Evaluate the positioning and hygiene interventions for safety and efficacy.
Floating the heels, using a 30-degree lateral tilt, and applying barrier cream are safe, evidence-based practices. Placing items in the popliteal space is unsafe as it restricts venous return.
To prevent shear, friction, and deep vein thrombosis.
3
Evaluate the delegation and pathophysiology statements.
Skin assessment cannot be delegated to assistive personnel. Furthermore, new-onset incontinence requires medical investigation as it is pathological, not a normal part of aging.
To ensure safe delegation according to the RN scope of practice and accurate clinical understanding.

Anahtar Kavram

Basic Care and Comfort: Immobility and Skin Integrity
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Konular

Basic Care and Comfort

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