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Zorluk: OrtaBasic Care and Comfort

The registered nurse is developing a comprehensive care profile for an 82-year-old client who exhibits profound immobility, frequent episodes of urinary incontinence, and an elevated risk for pressure injuries. Which of the following interventions should the nurse incorporate into the management plan? Select all that apply.

  1. Position the client using a 30-degree lateral tilt while side-lyingCevap
  2. Utilize a friction-reducing device when moving the client upward in the bedCevap
  3. C
    Maintain the head of the bed consistently at a 60-degree angle
  4. D
    Assign the initial Braden Scale skin assessment to the assistive personnel
  5. Apply an evidence-based moisture barrier ointment to the perineum after cleansingCevap
  6. F
    Document the recent onset of severe incontinence as an expected age-related change

Cevap

The correct interventions are positioning the client in a 30-degree lateral tilt, utilizing a friction-reducing device for movement, and applying a moisture barrier ointment to the perineum.
Maintaining skin integrity in a highly vulnerable client requires a multi-faceted approach. Implementing a 30-degree lateral tilt effectively offloads weight from prominent bony structures without placing undue stress on the trochanter. Utilizing friction-reducing devices during repositioning prevents the mechanical shearing that tears epidermal layers. Finally, applying a moisture barrier shields the skin from the corrosive environment created by continuous urinary incontinence, preventing maceration.

Adım Adım Çözüm

1
Analyze the client's risk profile based on the clinical presentation.
The client has three major risk factors for skin breakdown: advanced age, profound immobility, and moisture from incontinence.
Identifying the specific etiologies of potential skin breakdown dictates which preventative nursing interventions are required.
2
Evaluate the proposed positioning and mobility interventions against evidence-based standards.
A 30-degree lateral tilt and the use of friction-reducing devices are proven methods to minimize direct pressure and shearing forces.
Standard clinical guidelines for pressure injury prevention mandate the reduction of both pressure magnitude and shear stress on vulnerable tissues.
3
Differentiate appropriate nursing responsibilities and pathological signs from normal aging.
Initial risk assessments must remain with the RN, and sudden severe incontinence requires medical investigation rather than acceptance as normal aging.
Patient safety relies on proper delegation scope and the accurate recognition of acute pathophysiological changes.

Anahtar Kavram

Pressure Injury Prevention and Skin Integrity Maintenance
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Konular

Basic Care and Comfort

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