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Zorluk: OrtaBasic Care and Comfort

A clinical team is providing hygiene and mobility support for a bedfast client who exhibits new-onset urinary incontinence and a localized, non-blanchable redness over the sacral area. Which interventions are appropriate for this client? Select all that apply.

  1. Apply a zinc oxide-based moisture barrier cream to the perineum after cleansing.Cevap
  2. B
    Elevate the head of the bed to 90 degrees during periods of rest to minimize sacral pressure.
  3. Utilize a friction-reducing device, such as a lift sheet, when repositioning the client in bed.Cevap
  4. D
    Instruct the unlicensed assistive personnel to assess the size and color of the sacral redness during morning care.
  5. E
    Reassure the family that the new-onset urinary incontinence is an expected physiological change associated with aging.
  6. Establish an individualized turning schedule that rotates the client's position at least every two hours.Cevap

Cevap

The appropriate interventions include applying a moisture barrier cream to the perineum, utilizing a friction-reducing device during repositioning, and establishing a turning schedule of at least every two hours.
Maintaining basic care and comfort for a bedfast client with impaired skin integrity requires strategies that minimize pressure, shear, and moisture. Applying a zinc-oxide moisture barrier protects the skin from the corrosive effects of urine. Using a lift sheet minimizes friction and shearing forces that damage fragile epidermal layers during movement. Repositioning the client at least every two hours ensures that blood flow is restored to vulnerable tissues over bony prominences like the sacrum.

Adım Adım Çözüm

1
Analyze the client's risk factors and clinical presentation.
The client is bedfast (immobility risk), has new-onset incontinence (moisture/pathology risk), and has non-blanchable sacral redness (Stage 1 pressure injury).
Identifying the specific threats to the client's skin integrity and basic comfort guides appropriate evidence-based interventions.
2
Evaluate each intervention for safety, efficacy, and scope of practice.
Moisture barriers, friction-reducing devices, and frequent turning directly mitigate moisture and pressure risks. High Fowler's positioning, delegating assessments, and ignoring new-onset incontinence are unsafe or improper practices.
Nursing interventions must adhere to standard protocols for pressure injury prevention and proper delegation guidelines.

Anahtar Kavram

Basic Care and Comfort: Skin Integrity and Mobility Interventions
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