The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?
A.
Assess for discomfort when the procedure is completed.
B.
Instruct the client to keep hands under the sterile field.
C.
Pour cleansing solution onto the sterile cloth field.
D.
Verify that the client has given informed consent.
The Correct answer and Explanation is:
The correct answer is:
B. Instruct the client to keep hands under the sterile field.
Explanation:
During a wound debridement procedure, maintaining sterility is critical to prevent infection. This is especially important when the client is mildly confused, as they may not fully understand the importance of not touching the sterile field or the wound area. The most crucial nursing intervention in this scenario is to ensure the client keeps their hands under the sterile field. This instruction helps maintain the sterile environment by preventing the client from inadvertently contaminating the sterile field or the wound, which could lead to infection and complications.
Option A: Assess for discomfort when the procedure is completed.
Assessing the client’s comfort is important, but it is not the priority for maintaining safety during the procedure. The primary focus should be on preventing contamination and ensuring the sterility of the wound site.
Option C: Pour cleansing solution onto the sterile cloth field.
Pouring a cleansing solution directly onto the sterile cloth field is incorrect and would likely contaminate the sterile field. Cleansing solutions should be poured into a sterile container or directly onto the wound using sterile techniques, not onto the sterile field itself.
Option D: Verify that the client has given informed consent.
Informed consent should be obtained before the procedure begins, not during. While obtaining informed consent is critical, in this scenario, the focus is on ensuring sterility and client safety during the procedure.
Client Safety Considerations:
Clients who are confused or disoriented pose a higher risk for compromising sterile fields due to unintentional movements. The nurse should provide clear and calm instructions, ensuring the client understands to keep their hands away from the sterile area. If necessary, the nurse may need to gently restrain the client’s hands under the sterile drapes to avoid accidental contamination.
In summary, the priority nursing intervention for client safety in this scenario is to instruct the client to keep their hands under the sterile field, ensuring the sterility of the procedure and preventing potential infection.