A registered nurse is developing a plan of care for an older adult client who is on strict bed rest due to a severe exacerbation of rheumatoid arthritis. The client has recently developed urinary incontinence and exhibits extremely dry, itchy skin on the upper extremities. Which of the following nursing interventions should be included in the basic care and comfort plan? Select all that apply.
- Float the client's heels off the mattress surface by placing a supportive pillow under the lower legs.Cevap
- Apply a moisture barrier ointment to the perineal region after cleansing following each incontinent episode.Cevap
- CMaintain the head of the bed continuously elevated at 90 degrees to promote optimal lung expansion.
- DInstruct the unlicensed assistive personnel (UAP) to evaluate the client's sacral area for early signs of skin breakdown.
- EDocument the client's new onset of urinary incontinence as an expected physiological consequence of advanced age.
- Apply a prescribed emollient lotion to the client's upper extremities immediately after bathing while the skin remains damp.Cevap
Cevap
The correct interventions are floating the client's heels off the mattress, applying a moisture barrier to the perineum after incontinence, and applying emollient lotion to the extremities while the skin is damp.
Appropriate basic care and comfort measures for a bedridden client with incontinence and dry skin must focus heavily on preventing pressure injuries and maintaining skin integrity. Floating the heels completely off the bed removes pressure from the vulnerable calcaneus bone. Applying a moisture barrier protects perineal skin from the corrosive effects of urine. Using emollients immediately after bathing seals in essential moisture to treat excessively dry, itchy skin.
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Basic Care and Comfort: Skin Integrity, Positioning, and Scope of Practice
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