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Difficulty: MediumUse of Restraints and Safety Devices

A client is hospitalized for treatment of a severe urinary tract infection. The client, who has no history of cognitive impairment, suddenly becomes disoriented, restless, and repeatedly tries to pull out their peripheral intravenous line. The family insists that the nurse immediately secure the client's arms to the bed frame. Which action should the practical nurse take first?

  1. A
    Secure the client's wrists to the stationary part of the bed frame and immediately notify the registered nurse to obtain a restraint prescription.
  2. B
    Inform the family that sudden confusion is a normal age-related change and request a prescription for a sedative.
  3. Cover the intravenous site with a long-sleeved gown and provide the client with a safe, familiar object to hold.Answer
  4. D
    Instruct the unlicensed assistive personnel to assess the client's neurological status and determine the need for physical restraints.

Answer

The nurse should first implement least-restrictive alternatives by covering the intravenous site with a long-sleeved gown and providing the client with a safe, familiar object to hold.
Applying a long-sleeved gown to conceal the intravenous line and providing a diversionary object are least-restrictive alternative measures. National safety standards mandate that physical restraints should only be used as a last resort when all other less restrictive alternatives have failed to protect the client from harm.

Step-by-Step Solution

1
Identify the client's immediate safety risk and underlying clinical presentation.
The client is experiencing acute delirium and pulling at medical devices, creating a risk for injury and treatment interruption.
Understanding the cause of the behavior helps guide the selection of appropriate and safe nursing interventions.
2
Evaluate the family's request for immediate physical restraints against standard safety guidelines.
The request for immediate physical restraints is deferred.
Restraints are a last resort and must not be used solely for family convenience or without first attempting non-restrictive alternatives.
3
Select and implement the least restrictive alternative intervention.
The intravenous line is concealed, and a diversionary object is provided to occupy the client's hands.
Concealing tubes (camouflage) and providing distractions (diversion) can effectively prevent device dislodgment without exposing the client to the risks associated with physical restraints.

Key Concept

Least Restrictive Environment and Restraint Alternatives
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Topics

Use of Restraints and Safety Devices

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