A client is recovering from a recent lumbar puncture and has been prescribed strict bed rest. The client is also experiencing generalized weakness, urinary incontinence, and intermittent mild confusion. Which of the following nursing interventions should be included in the care plan to promote comfort, maintain skin integrity, and ensure safety? Select all that apply.
- Provide a dim, quiet environment to minimize sensory stimulation and promote rest.Cevap
- Apply a moisture barrier ointment to the perineal region after cleansing following incontinence.Cevap
- Utilize a friction-reducing draw sheet with a second staff member when turning the client.Cevap
- DMaintain the head of the bed elevated at a 45-degree angle to optimize respiratory function.
- EAssign the unlicensed assistive personnel (UAP) to perform the comprehensive shift assessment of the client's skin.
- FSecure bilateral soft wrist restraints if the client begins pulling at their bed linens during periods of confusion.
Cevap
The correct interventions are providing a dim and quiet environment, applying moisture barrier ointment, and utilizing a friction-reducing draw sheet.
Providing a dim, quiet environment minimizes sensory overload and promotes rest for a confused client. Applying a moisture barrier ointment protects the skin from maceration and breakdown caused by urinary incontinence. Utilizing a friction-reducing draw sheet with assistance prevents shearing forces that can cause deep tissue injury when repositioning.
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Anahtar Kavram
Basic Care and Comfort: Post-procedure Positioning, Skin Integrity, and Safety