A nurse is planning morning hygiene and mobility care for an 80-year-old client who recently had a halo vest external fixator applied for a stable cervical spine fracture. Which of the following actions is the most appropriate for the nurse to include in the plan of care?
- Use a flashlight to inspect the skin beneath the vest for breakdown while keeping all vest straps securely fastened.Cevap
- BGrasp the vertical metal struts of the halo framework to securely support the client's head when logrolling them for a bed bath.
- CDelegate the daily aseptic cleaning of the cranial pin insertion sites to the unlicensed assistive personnel (UAP).
- DAttribute the client's sudden onset of severe confusion to expected age-related cognitive decline and continue with the routine bed bath.
Cevap
The most appropriate action is to use a flashlight to inspect the skin beneath the vest for breakdown while keeping all vest straps securely fastened.
Clients with a halo vest are at high risk for skin breakdown due to the friction of the hard vest edges and the inner sheepskin lining. The nurse must proactively assess the skin daily. Because the vest maintains life-saving cervical alignment, the straps must never be loosened or unfastened by the nurse for hygiene purposes. Using a flashlight to visually inspect underneath the edges of the secured vest represents the safest integration of basic hygiene care and physiological safety.
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Safe Provision of Basic Care with a Halo Vest