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Difficulty: MediumAccident, Error, and Injury Prevention

While conducting afternoon rounds on a medical unit, a nurse observes a 68-year-old client who was previously fully oriented now suddenly attempting to climb over the bed rails and forcefully tugging at an indwelling urinary catheter. An assistive personnel in the room offers to quickly apply soft wrist restraints to prevent immediate self-injury. What is the most appropriate priority action for the nurse to take?

  1. A
    Permit the application of wrist restraints and immediately contact the healthcare provider for a prescription.
  2. Conduct a rapid physical assessment including vital signs to identify a physiological cause for the sudden agitation.Answer
  3. C
    Attribute the behavior to expected age-related cognitive changes and reorient the client to the room.
  4. D
    Delegate the removal of the urinary catheter to the assistive personnel to eliminate the source of irritation.

Answer

Conduct a rapid physical assessment including vital signs to identify a physiological cause for the sudden agitation.
The correct action prioritizes the nursing process by emphasizing assessment before intervention. Sudden onset of confusion and agitation in an older adult is a hallmark sign of delirium, often caused by a physiological issue such as hypoxia, a urinary tract infection, or medication effects. The nurse must first gather data to identify and treat the underlying cause using the least restrictive approach. Implementing restraints without an assessment increases the risk of client injury and fails to resolve the root cause.

Step-by-Step Solution

1
Recognize the sudden onset of confusion and agitation as a potential sign of acute delirium rather than normal aging.
Identifies the immediate need to investigate underlying physiological causes.
Sudden behavioral changes in older adults are often triggered by acute medical issues such as hypoxia, infection, or electrolyte imbalances.
2
Evaluate the assistive personnel's suggestion to use restraints.
Determines that applying restraints is inappropriate at this stage.
Restraints are a measure of last resort and must only be used after all other less restrictive alternatives have been exhausted, as they can exacerbate agitation and lead to further injury.
3
Prioritize the initial nursing intervention based on the nursing process.
Selects physical assessment as the priority action over immediate intervention or delegation.
Data collection must precede intervention. Identifying a reversible cause allows for targeted treatment without the use of restrictive devices or unsafe practices.

Key Concept

Prioritizing the nursing process (assessment first), utilizing least restrictive interventions, and recognizing signs of delirium to prevent client injury.
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Topics

Accident, Error, and Injury Prevention

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