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Zorluk: OrtaBasic Care and Comfort

An 82-year-old individual is receiving inpatient treatment for pneumonia. Due to profound fatigue, the healthcare provider has prescribed strict bed rest. The client requires total assistance with personal hygiene and mobility. Which nursing action is most appropriate to promote comfort and prevent complications of immobility?

  1. Elevate the head of the bed to 30 degrees and utilize a friction-reducing sheet when pulling the client upward.Cevap
  2. B
    Position a firm, rolled blanket directly underneath the client's knees to maintain alignment and prevent downward sliding.
  3. C
    Assign the unlicensed assistive personnel (UAP) to examine and document the staging of a red area on the client's sacrum.
  4. D
    Assure the family that the client's sudden onset of urinary incontinence is an expected, normal change associated with advanced age.

Cevap

The correct action is to elevate the head of the bed to 30 degrees and use a friction-reducing sheet when repositioning the client.
Elevating the head of the bed to no more than 30 degrees and using a friction-reducing device (like a draw sheet or slider board) significantly reduces shearing forces and friction against the skin. This protects skin integrity, prevents the client from constantly sliding downward, and promotes respiratory comfort for a bedbound individual with pneumonia.

Adım Adım Çözüm

1
Analyze the client's clinical status and specific risks.
The client is 82 years old, completely bedbound, and profoundly fatigued, placing them at high risk for skin breakdown, shearing injuries, and complications of immobility like deep vein thrombosis (DVT).
Identifying the primary risks of immobility determines the priority basic care and comfort interventions.
2
Evaluate the proposed positioning and mobility intervention.
Elevating the head of the bed to 30 degrees and using a friction-reducing sheet prevents the client from sliding down and eliminates skin shear during repositioning.
Shearing forces and friction are primary mechanical causes of pressure injuries in bedbound clients.
3
Assess the distractors for unsafe practices or incorrect assumptions.
Placing a blanket directly under the knees causes venous stasis; UAPs cannot perform clinical skin assessments; and sudden incontinence is an abnormal, acute symptom, not a normal part of aging.
Ruling out unsafe or incorrect actions ensures the selected intervention represents evidence-based, safe nursing practice.

Anahtar Kavram

Immobility Management and Skin Integrity
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Konular

Basic Care and Comfort

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