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Difficulty: HardUse of Restraints and Safety Devices

An older adult client receiving continuous enteral feedings via a nasogastric (NG) tube suddenly becomes restless and repeatedly attempts to remove the tubing. Which actions should the practical nurse (PN) implement to maintain client safety? Select all that apply.

  1. Route the feeding tubing discreetly under the client's clothing to minimize visual and tactile stimulation.Answer
  2. B
    Apply bilateral mitten restraints immediately to prevent tube dislodgement while awaiting the provider's evaluation.
  3. Provide the client with a safe, tangible item such as a folded washcloth to manipulate with their hands.Answer
  4. D
    Attribute the sudden onset of restlessness to expected age-related cognitive decline and dim the room lights.

Answer

The correct actions are to route the feeding tubing discreetly under the clothing and to provide a tangible item for the client to manipulate.
Implementing non-restrictive alternatives is the mandatory first step in managing a client at risk of disrupting medical devices. Camouflaging the medical tubing under clothing reduces visual and tactile triggers. Concurrently, providing a designated object for the client to hold serves as a safe diversionary activity that occupies their hands without limiting their freedom of movement.

Step-by-Step Solution

1
Analyze the client's behavior and the immediate risk to the medical device.
The client is acutely agitated and at risk of removing the life-sustaining NG tube, requiring prompt safety interventions.
Protecting necessary medical equipment is a clinical priority, but interventions must be balanced with the patient's right to the least restrictive environment.
2
Identify appropriate least-restrictive restraint alternatives.
Camouflaging the tube under clothing and providing diversionary tactile activities (like a washcloth) are selected as the initial interventions.
Clinical guidelines and nursing standards mandate that non-restrictive alternatives must be attempted and documented before chemical or physical restraints are considered.
3
Evaluate the remaining options for safety violations and scope of practice errors.
Applying immediate physical restraints and attributing sudden confusion to normal aging are identified as unsafe, incorrect practices.
Immediate physical restraint bypasses required legal alternatives. Furthermore, sudden confusion in an older adult indicates a potential acute physiological issue (delirium) that requires medical assessment, not dismissal as normal aging.

Key Concept

Implementation of Restraint Alternatives and Delirium Recognition
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Topics

Use of Restraints and Safety Devices

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