Nurse Katee is caring for Adam, a 22-year-old client, in a long-term facility. Which nursing intervention would be appropriate when identifying nursing interventions aimed at promoting and preventing contractures? Select all that apply.
A. Clustering activities to allow uninterrupted periods of rest.
B. Maintaining correct body alignment at all times.
C. Monitoring intake and output, using a urometer if necessary.
D. Using a footboard or pillows to keep feet in the correct position.
E. Performing active and passive range-of-motion exercises.
F. Weighing the client daily at the same time and in the same clothes.
Correct Answers: B, D, & E
Correct body alignment, preventing foot drop, and range-of-motion exercises will help prevent contractures. Clustering activities will help promote adequate rest. Monitoring intake and output and weighing the client will help maintain fluid and electrolyte balance.
Option A: Provide the patient with rest periods in between activities. Consider energy-saving techniques. Rest periods are essential to conserve energy. The patient must learn and accept his/her limitations.
Option B: Help the patient develop sitting balance and standing balance. This helps out in retraining neural pathways, promoting proprioception and motor response. Keep limbs in functional alignment with one or more of the following: pillows, sandbags, wedges, or prefabricated splints.
Option C: Assess input and output record and nutritional pattern. Pressure ulcers build up more rapidly in patients with nutritional insufficiency. Encourage a diet high in fiber and liquid intake of 2000 to 3000 ml per day unless contraindicated.
Option D: Use a footboard or pillows to keep the feet in the correct position. This avoids foot drop and too much plantar flexion or tightness. Maintain feet in a dorsiflexed position.
Option E: Assess the strength to perform ROM to all joints. This assessment provides data on the extent of any physical problems and guides therapy. Testing by a physical therapist may be needed. Execute passive or active assistive ROM exercises to all extremities.
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