A nurse is planning care for an 82-year-old client admitted with an acute exacerbation of heart failure. The client has marked lower extremity edema, requires continuous supplemental oxygen, and is on strict bed rest. During the night shift, the client becomes increasingly restless and makes repeated attempts to climb out of bed. Which of the following basic care and safety interventions should the nurse include in the client's plan of care? Select all that apply.
- ADocument the acute onset of restlessness as a normal manifestation of the aging process
- Apply a bed alarm system and ensure the bed is locked in the lowest positionCevap
- CInstruct the unlicensed assistive personnel (UAP) to evaluate the client's heels and sacrum for early signs of skin breakdown
- DPlace rolled pillows directly behind the client's knees to elevate the edematous lower extremities
- Elevate the head of the bed to at least 45 degrees to optimize respiratory effort and promote physical comfortCevap
- FApply bilateral soft wrist restraints immediately to prevent the client from falling or sustaining an injury
Cevap
The correct interventions are to apply a bed alarm system while keeping the bed in the lowest position, and to elevate the head of the bed to at least 45 degrees.
Applying a bed alarm and keeping the bed in the lowest position are the safest, least restrictive measures to prevent falls in a restless client. Elevating the head of the bed to at least 45 degrees (Fowler's position) uses gravity to reduce venous return to the heart and lowers the diaphragm, which optimizes lung expansion, improves oxygenation, and promotes physical comfort for a client with heart failure.
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Basic Care, Comfort, and Safety Interventions in the Older Adult