A nurse is caring for a newly admited older adult client.

Nurses' Notes

Day 1, 12:00:

Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child.

Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.

Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse.

Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions."

Which of the following interventions should the nurse recommend to include in the client's plan of care?

Select all that apply.

Choice A Reason:

"I will no longer be able to eat nuts." While it's essential to be cautious about certain foods after a colostomy, avoiding nuts altogether may not be necessary. The client should discuss dietary restrictions with their healthcare provider or a registered dietitian.

Choice B Reason:

"I will empty the pouch every 2 to 3 hours." The frequency of pouch emptying can vary depending on the client's individual needs and the ostomy type. There's no fixed schedule for emptying the pouch, so this statement is not necessarily accurate.

Choice C Reason:

"I should expect my stool to be formed." The consistency of stool from a colostomy can vary depending on the location of the stoma and the type of colostomy. It may be formed or semi-formed, but it can also be more liquid or loose, depending on the circumstances. The client should

Choice D Reason:

"I will notify my doctor if the stoma starts to look purple." This statement reflects the client's awareness of the importance of monitoring the stoma's color and seeking medical attention if it appears discolored or compromised. A purple or dark-colored stoma can indicate inadequate blood supply, which is a concern that should be addressed promptly.

discuss stool consistency with their healthcare provider.

Dry, itchy skin is a common concern in older adults, especially during the winter months or in dry environments. Increasing the humidity in the client's environment can help alleviate dryness and itching. Placing a humidifier in the client's room will add moisture to the air and help prevent excessive drying of the skin. It is important to ensure that the humidifier is clean and well-maintained to avoid the growth of bacteria or mould.

Encouraging the client to bathe frequently may further dry out the skin, so it is not recommended. Similarly, applying powder to the skin may exacerbate dryness and should be avoided. Adding moisturizing oil to the bath water may provide temporary relief, but a humidifier will have a more consistent and long-lasting effect on the client's environment.