An older adult client who underwent a right total hip arthroplasty (posterior approach) 2 days ago has developed acute delirium. The client is restless, frequently attempts to get out of bed unassisted, and requires assistance with activities of daily living. When updating the client's plan of care, what interventions should the nurse implement to safely address the client's basic care and comfort needs? Select all that apply.
- Maintain an abduction wedge between the client's legs while resting in a supine position.Cevap
- BProvide a standard low-seated bedside commode to facilitate bowel elimination.
- CDelegate the unlicensed assistive personnel (UAP) to evaluate the client's skin integrity over the sacrum.
- DApply bilateral soft wrist restraints immediately to prevent the client from sustaining a fall.
- EReassure the family that the client's sudden confusion is a normal cognitive change in older adults following surgery.
- Implement a scheduled toileting routine and provide a well-lit environment during waking hours.Cevap
Cevap
The correct actions are to maintain an abduction wedge between the client's legs while resting in a supine position, and to implement a scheduled toileting routine while providing a well-lit environment during waking hours.
The correct interventions focus on safely meeting the client's fundamental physiological needs without compromising surgical integrity. Maintaining an abduction wedge is essential to prevent hip adduction and dislocation after a posterior approach arthroplasty. A scheduled toileting routine combined with a well-lit environment addresses the client's elimination needs proactively and serves as a highly effective, non-pharmacologic intervention to manage delirium and reduce restlessness.
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Basic Care and Comfort Integration for Complex Postoperative Clients