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Soru

Zorluk: ZorBasic Care and Comfort

A nurse is directing the care of an 80-year-old client who is 48 hours post-operative following a right total hip arthroplasty (posterior approach). The client, who has no history of cognitive impairment, has become increasingly restless, is pulling at their indwelling urinary catheter, and has had two episodes of bowel incontinence. Which intervention is most appropriate for the nurse to include in the client's basic care and comfort plan?

  1. Secure an abduction pillow between the client's lower extremities before turning them onto their left side to perform perineal care.Cevap
  2. B
    Delegate the initial evaluation of the sacral skin integrity to the unlicensed assistive personnel (UAP) during the linen change.
  3. C
    Request a prescription for soft wrist restraints to prevent the client from prematurely discontinuing the urinary catheter.
  4. D
    Reassure the family that the new onset of confusion and restlessness is an expected age-related change during hospitalization.

Cevap

Secure an abduction pillow between the client's lower extremities before turning them onto their left side to perform perineal care.
For a client recovering from a total hip arthroplasty via a posterior approach, maintaining abduction of the affected extremity is critical to prevent dislocation of the new joint. When the nurse must turn the client to provide basic hygiene, such as perineal care after bowel incontinence, securing an abduction pillow between the legs ensures the operative hip does not fall into adduction or internal rotation when the client is rolled onto their unaffected side.

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1
Analyze the client's surgical history and current basic care needs.
The client is 48 hours post-operative for a right total hip arthroplasty (posterior approach) and requires perineal care and linen changes due to bowel incontinence.
Identifying the surgical approach determines the necessary movement precautions to prevent hip dislocation during care.
2
Identify the positional constraints for a posterior approach total hip arthroplasty.
The client must avoid hip flexion greater than 90 degrees, adduction across the midline, and internal rotation.
These movements put excessive stress on the posterior joint capsule and can lead to immediate dislocation of the femoral head.
3
Evaluate the proposed nursing actions against safe practice standards for basic care.
Turning the client onto their unaffected (left) side while using an abduction pillow to keep the right leg from adducting is the correct and safe method to access the perineal area.
The abduction pillow maintains alignment and prevents the operative right leg from crossing the midline under the pull of gravity during the turn.
4
Critique the alternative interventions for safety and scope of practice violations.
Delegating assessment to a UAP, using restraints without trying alternatives, and ignoring new-onset confusion all violate standard nursing protocols.
Eliminating unsafe or inappropriate actions confirms the correct positioning intervention is the priority.

Anahtar Kavram

Basic care and positioning for clients following total hip arthroplasty (posterior approach), integrating safe delegation and complication recognition.
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Konular

Basic Care and Comfort

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