An older adult client with moderate dementia is hospitalized for the treatment of pneumonia. During the night shift, the client becomes restless, is frequently incontinent of urine, and repeatedly attempts to remove their intravenous (IV) catheter. Which basic care and comfort interventions should the nurse include in the plan of care? Select all that apply.
- Establish a scheduled toileting routine for the client every 2 hours.Cevap
- BDelegate the assessment of the client's perineal skin integrity to the unlicensed assistive personnel (UAP).
- CApply bilateral soft wrist restraints to ensure the continuous infusion of intravenous fluids.
- Conceal the intravenous insertion site by loosely covering it with a stockinette or long-sleeved gown.Cevap
- EManage the sudden onset of severe urinary incontinence by recognizing it as an expected physiological aging change.
- Offer a warm, caffeine-free beverage and reduce ambient environmental stimuli prior to sleep.Cevap
Cevap
The correct interventions are establishing a scheduled toileting routine, concealing the IV site, and offering a warm caffeine-free beverage while reducing environmental stimuli.
The correct interventions focus on proactive, non-restrictive care. Establishing a scheduled toileting routine directly addresses incontinence while protecting skin integrity. Concealing the IV site is a recognized, evidence-based alternative to restraints that reduces the visual stimulus prompting the client to pull the line. Offering a warm, caffeine-free beverage and reducing environmental stimuli are standard sleep hygiene practices that decrease sensory overload and promote comfort.
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Basic Care and Comfort interventions for older adults with cognitive impairment