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Zorluk: ZorBasic Care and Comfort

A palliative care team is managing an older adult client who is completely bedbound due to profound cachexia and intractable bone pain. The client exhibits significant muscle wasting and thin, fragile skin. Which interventions are appropriate to include in the client's non-pharmacologic comfort and skin integrity regimen? Select all that apply.

  1. Limit the elevation of the head of the bed to 30 degrees or less during rest periods.Cevap
  2. Utilize a friction-reducing glide sheet when repositioning the client.Cevap
  3. C
    Place a ring-type air cushion under the client's sacral area to alleviate direct bone pressure.
  4. D
    Direct the unlicensed assistive personnel (UAP) to conduct the staging of newly discovered skin alterations.
  5. E
    Advise the family that the development of non-blanchable sacral erythema is an expected physiological outcome of the normal aging process.
  6. Insert soft foam padding between the client's knees and ankles when placed in a lateral position.Cevap

Cevap

The appropriate interventions are limiting head-of-bed elevation to 30 degrees or less, using a friction-reducing glide sheet, and inserting foam padding between bony prominences.
The correct interventions focus on minimizing mechanical forces that cause tissue damage. Limiting the head of bed elevation to 30 degrees or less minimizes shearing forces on the sacral area. Using a friction-reducing glide sheet prevents epidermal stripping caused by friction when moving the client. Placing foam padding between the knees and ankles prevents tissue ischemia resulting from direct bone-on-bone contact.

Adım Adım Çözüm

1
Analyze the client's risk factors.
The client has profound cachexia, intractable bone pain, muscle wasting, and fragile skin.
Identifying specific vulnerabilities determines which preventative measures are most critical for avoiding skin breakdown and promoting comfort.
2
Evaluate positioning and mobility interventions for safety and efficacy.
Limiting the head of the bed to 30 degrees, using glide sheets, and padding bony prominences are evidence-based practices that reduce shear, friction, and pressure.
These interventions specifically address the mechanical forces that lead to pressure injuries in immobile, cachectic clients.
3
Identify contraindicated practices and scope of practice violations.
Using a ring cushion, dismissing non-blanchable erythema as normal aging, and delegating assessment to UAP must be rejected.
Ring cushions cause venous congestion, non-blanchable erythema is a Stage 1 pressure injury requiring nursing intervention, and assessment cannot be legally delegated.

Anahtar Kavram

Evidence-Based Pressure Injury Prevention and Comfort Care
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Konular

Basic Care and Comfort

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