담당 간호사가 초조해하는 치매 대상자를 돌보는 상황을 관찰합니다. 즉각적인 추적 관찰이 필요한 간호 행위는 무엇입니까? 고통을 악화시키거나 더 안전한 사정을 생략할 수 있는 행위를 강조하세요.

Nurses' Notes 1840: The client with moderate dementia begins pacing and says, “I need to pick up my children.” One nurse responds by repeatedly correcting the client's belief and arguing that the children are adults. A second nurse approaches slowly and speaks in a calm voice while reassuring the client about immediate safety. At 1845, staff prepare for the scheduled bath. The first nurse insists that bathing continue while the client cries and pulls away. The assigned nurse pauses and checks for pain, urinary urgency, constipation, hunger, and fatigue. Environmental services is asked to wait, and television volume and hallway noise are reduced near the room. The client is offered a familiar folding activity and a warm drink. Another staff member suggests that wrist restraint be applied before possible physical or environmental triggers are assessed. When the client swings an arm, staff maintain a safe distance and move other clients away. At 1855, the care plan shows that the usual evening routine and familiar caregiver are maintained when possible. The nurse also reports the sudden behavior change during the current shift for evaluation of infection or medication effects. The client accepts the drink and sits with the familiar caregiver. The team documents the trigger assessment and response without forcing the bath.