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Zorluk: OrtaBasic Care and Comfort

A nurse is caring for a client who is immobilized in skeletal traction following a fractured right femur. The client reports sacral discomfort from prolonged bed rest. Which nursing intervention is most appropriate to promote comfort and maintain skin integrity?

  1. A
    Elevate the head of the bed to a high Fowler's position for extended periods to enhance comfort.
  2. B
    Direct the unlicensed assistive personnel to evaluate the skin integrity around the skeletal pin insertion sites.
  3. Provide an overhead trapeze and instruct the client to use it to assist with lifting off the bed.Cevap
  4. D
    Temporarily lift the traction weights for several minutes each shift to relieve continuous tension on the leg.

Cevap

Provide an overhead trapeze and instruct the client to use it to assist with lifting off the bed.
Providing an overhead trapeze allows the client to safely assist with lifting their upper body off the mattress. This promotes client independence, prevents complications of immobility, and allows the nurse to provide back care and alleviate sacral pressure without disrupting the therapeutic alignment of the skeletal traction.

Adım Adım Çözüm

1
Analyze the client's current condition and therapeutic devices.
The client is experiencing sacral discomfort but is confined to bed with skeletal traction for a fractured femur.
Understanding the physical constraints of skeletal traction is necessary to determine which comfort measures are safe to implement.
2
Evaluate the proposed interventions against the principles of skeletal traction and safe nursing care.
Lifting weights and placing the client in high Fowler's position are contraindicated as they disrupt traction alignment and increase sacral shearing. Assessing pin sites cannot be delegated.
Therapeutic alignment and client safety must be maintained while attempting to address comfort.
3
Select the intervention that safely promotes comfort and skin integrity.
An overhead trapeze is identified as the safest and most effective intervention.
The trapeze offloads sacral pressure, promotes circulation, and assists with bed mobility while keeping the affected leg in continuous, correct alignment.

Anahtar Kavram

Basic Care and Comfort in Skeletal Traction
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Konular

Basic Care and Comfort

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