The female client has urinary incontinence and malnutrition. Which is the most important information for the nurse to include in client teaching to maintain skin integrity?
1. Apply barrier protection to perineum.
2. Keep the perineal skin clean and dry.
3. Visit community center to obtain food.
4. Adhere to well-balanced diet for meals.
2
2. The most important information for the nurse to share with the client who has malnutrition and is incontinent is to keep the skin clean and dry. This is the priority because a poorly nourished client is at high risk for skin breakdown if the skin is ex-posed to urine regularly because the body lacks adequate plasma proteins and, there-by, the ability to repair damaged tissue.
1. One aspect of maintaining clean and dry skin can be to apply a barrier ointment; however, the nurse reminds the client to use the barrier only on intact skin.
3 and 4. The skin is more fragile and prone to breakdown in a client who is malnou-rished; the nurse can provide community resources for the client to obtain food and instructs the client about planning and eating a well-balanced diet as another part of a plan to maintain skin integrity.
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1. Checking to make sure two fingers can be placed between the restraints and the arm. 2. Releasing the teen from the restraints because they are illegal. 3. Provide one-on-one staff observations for the girl. 4. Place the teen in a prone position to provide safety for the staff. 5. Should not be placed in soft restraints as this is a violation of the Nursing Standards Act.
A nurse has been promoted to nurse manager. This new nurse manager can foster the decentralized decision-making model by ____________________
Fill in the blank(s) with correct word