Question

Which nursing intervention should receive priority when caring for an immobile client? a. Repositioning every 2 hours b. Assessing for dependent edema each shift c. Auscultating for bowel sounds daily d. Administering a calcium supplement twice a day

Short answer

Repositioning every 2 hours

Step-by-step solution

Understand the Question

Identify the key term in the question: 'immobile client.' This refers to a patient who is unable to move on their own or has severely restricted mobility. The goal is to determine which intervention is most critical for someone in this condition.

Analyze Each Option

Break down what each intervention involves and its importance for an immobile client.

Option A - Repositioning every 2 hours

Repositioning prevents the development of pressure ulcers, improves circulation, and reduces the risk of skin breakdown.

Option B - Assessing for dependent edema each shift

This involves checking for swelling due to fluid accumulation. While important, it doesn't address immediate physical harm.

Option C - Auscultating for bowel sounds daily

Monitoring bowel sounds helps in assessing digestive function but does not prevent immediate health risks from immobility.

Option D - Administering a calcium supplement twice a day

While calcium supplements strengthen bones, this is more of a long-term intervention and not an immediate priority for immobility complications.

Determine Priority

Repositioning every 2 hours is crucial in preventing pressure ulcers and other complications directly related to immobility, making it the highest priority intervention.

Key concepts

Repositioning Techniques

A priority intervention for an immobile client involves regular repositioning. This action is vital for several reasons:
By changing the client's position every 2 hours, you help alleviate pressure on various parts of their body.

• This prevention of sustained pressure is crucial in avoiding the formation of pressure ulcers, also known as bedsores.
• Regular repositioning aids in maintaining proper blood circulation.
• It also helps in reducing the risk of developing skin breakdown or sores.

When implementing repositioning techniques, consider the following:

• Ensure that you use devices like pillows or foam wedges to support and relieve pressure points.
• Pay special attention to bony areas such as the heels, elbows, hips, and the tailbone.
• Always communicate with the client about the process and make sure they are as comfortable as possible.

Through diligent repositioning, you can make a significant difference in the overall care and comfort of immobile clients.

Preventing Pressure Ulcers

Pressure ulcers pose a significant risk to immobile clients due to prolonged pressure on the skin and tissues. These ulcers can lead to severe infections if not addressed promptly. Here's how to prevent them:

• Maintain skin hygiene: Regularly clean and moisturize the client's skin to keep it healthy and resilient.
• Use pressure-relieving devices: Specialized mattresses and cushions can help distribute pressure more evenly across the client's body.
• Provide proper nutrition: A well-balanced diet rich in vitamins and proteins will strengthen the skin and enhance its ability to repair itself.

Furthermore, early detection is crucial. Check the client's skin daily for any signs of redness or breaks in the skin, especially in high-risk areas like the heels and hips. If you spot any potential problems, take immediate action to manage pressure and prevent further damage.
Communication and education are also key. Ensure both the client and any caregivers understand the importance of these preventative measures.

Immobility Management

Managing immobility in clients involves a comprehensive approach to maintain their overall health and wellbeing. This includes preventing complications and promoting as much activity as possible:

• Encourage range-of-motion exercises: These exercises can assist in maintaining joint flexibility and muscle strength.
• Monitor for complications: Stay vigilant for common issues like deep vein thrombosis (DVT), muscle atrophy, and respiratory infections.
• Promote good hygiene and skin care: Regular cleaning and moisturizing, along with frequent inspections, can prevent skin issues.

Psychological care is equally important. Prolonged immobility can affect a client's mental health, leading to feelings of isolation and depression.

• Foster social interactions: Encourage and facilitate visits from family and friends, as well as the use of technology to stay connected.
• Provide mental stimulation: Offer books, puzzles, or other activities to keep the client's mind engaged.

By combining these physical and psychological strategies, caregivers can help manage immobility more effectively, ensuring a higher quality of life for their clients.