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Zorluk: OrtaBasic Care and Comfort

A healthcare team is managing an immobile older adult client who has severe osteoarthritis and frequent urinary incontinence. Which nursing interventions should be incorporated into the plan of care to promote comfort and maintain physiological integrity? Select all that apply.

  1. Cleanse the skin promptly after any soiling using a pH-balanced, no-rinse body wash.Cevap
  2. B
    Direct the unlicensed assistive personnel (UAP) to evaluate the client's sacral area for early signs of skin breakdown.
  3. Employ a foam wedge to support the client in a 30-degree laterally inclined position.Cevap
  4. D
    Explain to the family members that sudden, severe cognitive confusion is a normal manifestation of the aging process.
  5. Apply a zinc oxide-based moisture barrier cream to the perineum following incontinent episodes.Cevap
  6. F
    Place a tightly rolled towel directly underneath the client's knees to reduce lower back tension.

Cevap

The correct interventions are cleansing the skin promptly with a pH-balanced product, using a foam wedge to maintain a 30-degree lateral tilt, and applying a moisture barrier cream to the perineal area.
Proper care for a bedbound and incontinent client focuses on meticulous skin hygiene and safe positioning. Cleansing with pH-balanced, no-rinse products prevents the stripping of natural skin oils, while applying moisture barrier creams shields the epidermis from the caustic effects of urine. Positioning the client in a 30-degree lateral tilt effectively redistributes body weight, avoiding excessive pressure on vulnerable bony prominences like the sacrum and greater trochanter.

Adım Adım Çözüm

1
Analyze the client's primary risk factors based on the clinical presentation.
The client is completely immobile and experiences frequent incontinence, placing them at severe risk for pressure injuries and incontinence-associated dermatitis.
Identifying the highest risks directs the selection of appropriate preventive nursing interventions.
2
Evaluate the proposed skin care and hygiene interventions.
Using pH-balanced cleansers and barrier creams protects the skin's integrity, while delegating clinical assessment to a UAP is unsafe and violates scope of practice.
Proper topical care prevents skin breakdown, but the RN must perform the actual evaluation of the skin.
3
Evaluate the proposed positioning and systemic care interventions.
A 30-degree lateral tilt safely relieves pressure. Placing a roll under the knees causes venous stasis and is contraindicated. Furthermore, assuming sudden confusion is normal ignores potential acute complications like a urinary tract infection.
Nursing interventions must be evidence-based to prevent harm such as deep vein thrombosis or delayed treatment of infections.

Anahtar Kavram

Basic Care and Comfort: Immobility and Skin Integrity
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Konular

Basic Care and Comfort

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