A nurse is caring for a client who is immobile. Which prophylactic intervention would be used to prevent complications of immobility?

Effective hand hygiene is crucial in preventing the spread of infections in healthcare settings. The Centers for Disease Control and Prevention (CDC) and other health organizations provide guidelines on proper hand hygiene techniques to ensure maximum effectiveness.

Choice A Reason:

“Rub soap on hands for 20 seconds.”

This is the correct action for effective hand hygiene. According to the CDC, scrubbing your hands for at least 20 seconds is essential to remove germs effectively. This duration ensures that all surfaces of the hands, including the backs, between the fingers, and under the nails, are thoroughly cleaned. The CDC recommends singing the “Happy Birthday” song twice as a timer to ensure you scrub for the full 20 seconds.

Choice B Reason:

“Allow hands and arms to dry.”

While drying hands is an important step in hand hygiene, it is not the primary action that makes hand hygiene effective. The focus should be on the thorough scrubbing and cleaning of the hands. After washing, hands should be dried using a clean towel or air dryer to prevent the transfer of germs from wet hands.

Choice C Reason:

“Hold the hands higher than the elbows.”

This technique is often used in surgical hand antisepsis to prevent water from running from the hands down to the elbows, potentially contaminating the hands again. However, for routine hand hygiene, this is not necessary. The primary focus should be on the thorough washing and scrubbing of the hands.

Choice D Reason:

“Adjust the water temperature to feel hot.”

The temperature of the water is less important than the act of scrubbing itself. The CDC states that hands can be washed with either warm or cold water. The key is to use soap and scrub all surfaces of the hands for at least 20 seconds. Hot water can actually be harsh on the skin and is not required for effective hand hygiene.

Choice A Reason:

Urinary tract infections (UTIs) are typically caused by bacteria entering the urinary tract. While strict bed rest can increase the risk of UTIs due to factors like catheter use and reduced mobility, the use of an incentive spirometer does not directly prevent UTIs. Instead, preventing UTIs involves maintaining good hygiene, ensuring adequate fluid intake, and, if necessary, using catheters properly.

Choice B Reason:

Deep vein thrombosis (DVT) is a condition where blood clots form in the deep veins, usually in the legs. This can occur due to prolonged immobility, such as strict bed rest after surgery. Preventing DVT involves measures like using compression stockings, administering anticoagulant medications, and encouraging leg exercises. An incentive spirometer, which is used to improve lung function, does not directly prevent DVT.

Choice C Reason:

Constipation is a common issue for patients on bed rest due to reduced physical activity and changes in diet. Preventing constipation involves ensuring adequate hydration, providing a high-fiber diet, and encouraging as much physical activity as possible. The use of an incentive spirometer, which focuses on respiratory function, does not directly address constipation.

Choice D Reason:

Atelectasis is a condition where the alveoli in the lungs collapse, leading to reduced or absent breath sounds in the affected areas. This is a common postoperative complication, especially in patients on strict bed rest, due to shallow breathing and reduced lung expansion. The use of an incentive spirometer encourages deep breathing and helps to keep the alveoli open, thereby preventing atelectasis. This is why the incentive spirometer is an essential tool for postoperative respiratory care.