A client with mild cognitive impairment returned to the medical-surgical unit following a diagnostic lumbar puncture. The client is visibly restless, continuously attempts to sit up on the edge of the bed, and grasps at the bed linens. Which intervention is most appropriate to manage this client's care and comfort?
- Maintain the client in a flat, supine position and provide a familiar sensory diversion object.Cevap
- BElevate the head of the bed to a semi-Fowler's position to ease the client's agitation and promote rest.
- CApply bilateral soft wrist restraints to ensure the client does not reach behind and disrupt the puncture site.
- DDirect the unlicensed assistive personnel to assess the client's lower back dressing for signs of clear drainage.
Cevap
Maintain the client in a flat, supine position and provide a familiar sensory diversion object.
Following a lumbar puncture, clients must remain flat and supine for several hours to prevent cerebrospinal fluid (CSF) leakage from the puncture site, which can cause a debilitating spinal headache. Because the client is restless and attempting to sit up, the nurse must intervene to maintain this required position. Providing a sensory diversion object is an effective, non-pharmacological comfort measure that keeps the client's hands occupied and safely redirects their attention without the need for physical restraints.
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Anahtar Kavram
Post-Lumbar Puncture Positioning and Non-Pharmacological Comfort