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Zorluk: ZorBasic Care and Comfort

A geriatric client with right-sided heart failure and marked dependent edema is receiving inpatient care. The client also has right-sided hemiplegia secondary to a past cerebrovascular event. Over the last few hours, the client has become highly restless and is experiencing new-onset urinary incontinence. Which intervention regarding the client's comfort and care is the most appropriate?

  1. A
    Elevate the lower extremities sharply above the level of the heart using a wedge device to rapidly reduce the accumulation of peripheral edema.
  2. B
    Delegate the unlicensed assistive personnel (UAP) to assess the perineal skin integrity and apply a hydrocolloid dressing to any areas of persistent redness.
  3. Support the flaccid right extremities in proper anatomical alignment using pillows and apply a moisture barrier ointment to the perineum after cleansing.Cevap
  4. D
    Initiate a routine toileting schedule and advise the family that the sudden incontinence is a normal, age-related response to the stress of hospitalization.

Cevap

Support the flaccid right extremities in proper anatomical alignment using pillows and apply a moisture barrier ointment to the perineum after cleansing.
The correct intervention addresses two critical basic care needs safely: it prevents musculoskeletal damage (joint subluxation and contractures) in the paralyzed limbs through supportive alignment, and it prevents skin breakdown from moisture and acidity related to the new-onset incontinence.

Adım Adım Çözüm

1
Analyze the client's complex presentation, noting the history of right-sided heart failure, right hemiplegia, and acute changes (restlessness, incontinence).
Recognize that the client needs immediate skin protection and musculoskeletal support while avoiding interventions that could worsen the cardiac status.
Multisystem conditions require prioritizing interventions that provide comfort without inducing physiological harm.
2
Evaluate the safety of positioning interventions for edema in the context of heart failure.
Determine that sharply elevating the legs is contraindicated as it overloads the failing right ventricle.
Increased preload exacerbates right-sided heart failure.
3
Review the scope of delegation and principles of geriatric assessment.
Rule out UAP delegation for skin assessment and reject the assumption that acute changes are normal aging.
Assessments must be performed by the RN, and sudden behavioral/elimination changes indicate acute pathology.
4
Select the intervention that safely addresses physical comfort (alignment) and skin integrity (barrier ointment).
The correct action focuses on protective basic care within the RN's scope.
This intervention prevents complications of hemiplegia and incontinence without risking cardiac decompensation.

Anahtar Kavram

Safe positioning and hygiene maintenance in clients with complex, multi-system comorbidities.
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Konular

Basic Care and Comfort

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