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Zorluk: ZorBasic Care and Comfort

A nurse is establishing a plan for basic care and comfort for a client who returned to the surgical unit 4 hours ago following a transsphenoidal hypophysectomy. The client has nasal packing in place and is restricted to breathing through the mouth. Which interventions should the nurse include in the client's care plan? Select all that apply.

  1. Administer oral hygiene utilizing a soft foam swab and warm saline rinses.Cevap
  2. B
    Maintain the client in a flat, supine position to reduce the risk of a severe postoperative headache.
  3. C
    Delegate to the unlicensed assistive personnel (UAP) the task of assessing the nasal drip pad for a halo sign.
  4. Apply a continuous layer of water-soluble moisturizer to the client's lips to alleviate dryness.Cevap
  5. E
    Apply bilateral soft wrist restraints to prevent the client from dislodging the nasal packing.
  6. Maintain the head of the bed elevated at a 30-degree angle.Cevap

Cevap

The correct interventions are administering oral hygiene with a soft swab and saline, applying water-soluble moisturizer to the lips, and maintaining the head of the bed elevated at a 30-degree angle.
Following a transsphenoidal hypophysectomy, the client must breathe through the mouth, causing significant dryness. Comfort is maintained by applying water-soluble lip moisturizer and performing oral care with warm saline and soft swabs, as a traditional toothbrush could easily tear the delicate surgical incision located near the upper gum line. Furthermore, maintaining the head of the bed at a 30-degree angle is essential to decrease intracranial pressure, reduce swelling, and prevent cerebrospinal fluid leaks.

Adım Adım Çözüm

1
Analyze the client's surgical procedure and current condition.
The client had a transsphenoidal hypophysectomy, has a delicate suture line in the upper gum or nasal cavity, and is breathing exclusively through the mouth due to nasal packing.
Understanding the surgical approach identifies specific anatomical risks, such as a cerebrospinal fluid leak and suture disruption, alongside immediate comfort needs like a dry mouth.
2
Evaluate the proposed positioning and comfort measures.
Elevating the head of the bed 30 degrees is necessary to decrease intracranial pressure. Flat positioning is harmful. Moisturizing lips and using soft swabs for oral care promote comfort without damaging the surgical site.
Proper positioning and specialized oral hygiene prevent severe complications while addressing basic comfort requirements.
3
Review the delegation and safety interventions.
Assessing for a halo sign is a clinical judgment that the registered nurse must perform. Preemptive restraints are inappropriate and violate the principle of using the least restrictive measures first.
Ensuring safe delegation and the appropriate use of safety devices are core nursing responsibilities.

Anahtar Kavram

Postoperative basic care following transsphenoidal surgery requires meticulous oral hygiene modifications, continuous head elevation, and careful clinical monitoring for complications like cerebrospinal fluid leakage.
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Basic Care and Comfort

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