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Zorluk: OrtaBasic Care and Comfort

An older adult client with moderate Alzheimer's disease is admitted to the medical unit for treatment of bacterial pneumonia. The client is receiving continuous intravenous (IV) fluids. Throughout the morning, the client becomes repeatedly incontinent of urine, appears increasingly restless, and continuously picks at the IV dressing. Which action by the nurse is most appropriate?

  1. A
    Apply bilateral soft wrist restraints to prevent the client from dislodging the IV catheter and disrupting therapy.
  2. B
    Assign the unlicensed assistive personnel (UAP) to evaluate the client's perineal skin for signs of breakdown during each brief change.
  3. Apply a protective moisture barrier cream to the perineal area and camouflage the IV tubing using a long-sleeved hospital gown.Cevap
  4. D
    Document the frequent urinary incontinence as an expected cognitive decline associated with the client's advancing age and Alzheimer's disease.

Cevap

The correct intervention is to apply a moisture barrier cream to protect the skin and conceal the IV site using a long-sleeved gown as a restraint alternative.
The correct answer addresses the client's physiological needs while utilizing the least restrictive interventions. Applying a moisture barrier cream protects the client's skin from moisture-associated skin damage caused by incontinence. Concealing the IV site with a long-sleeved gown or tubular bandage is an effective, non-restrictive alternative to prevent the client from picking at the line.

Adım Adım Çözüm

1
Identify the client's primary needs based on the clinical presentation.
The client requires immediate skin protection due to incontinence and an IV protection strategy due to restlessness.
Frequent incontinence increases the risk of skin breakdown, and pulling at the IV line risks interrupting essential prescribed therapy.
2
Evaluate the proposed interventions for safety and adherence to the nursing scope of practice.
Restraints are too restrictive for an initial intervention, and delegating assessment to a UAP is unsafe.
Least restrictive measures must be used first to promote safety, and registered nurses cannot delegate nursing assessments.
3
Select the intervention that promotes comfort and safety using the least restrictive means.
Applying barrier cream and camouflaging the IV site is the best choice.
This comprehensively addresses both hygiene and safety by protecting the skin and distracting the client without using physical restraints.

Anahtar Kavram

Prioritizing least restrictive safety measures and maintaining skin integrity in cognitively impaired older adults.
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Basic Care and Comfort

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