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Difficulty: MediumUse of Restraints and Safety Devices

A practical nurse (PN) is caring for an older adult client on a medical unit. The client abruptly becomes highly agitated and begins pulling continuously at an indwelling urinary catheter. A family member at the bedside insists that the nursing staff secure the client's hands to the bed. Which action should the PN take first?

  1. A
    Contact the healthcare provider immediately to obtain a prescription for physical restraints.
  2. B
    Assign the unlicensed assistive personnel (UAP) to evaluate the client's behavioral changes and catheter site.
  3. Check the catheter tubing for kinks and assess the client for a distended bladder.Answer
  4. D
    Reassure the family that acute confusion is a normal response to the hospital environment in older adults.

Answer

Check the catheter tubing for kinks and assess the client for a distended bladder.
Agitation and pulling at medical devices are often signs of acute physical discomfort or unmet needs. Identifying and resolving the root cause, such as a blocked catheter causing painful urinary retention, is the primary alternative to utilizing physical restraints. The nurse must always address physiological needs before considering restrictive measures.

Step-by-Step Solution

1
Analyze the client's behavior and the family's request for restraints.
The client is experiencing sudden agitation and the family is requesting a physical safety device.
Establishing the clinical situation determines the necessary safety protocol and immediate nursing priorities.
2
Recall the standard guidelines for restraint application.
Physical restraints are a measure of last resort and cannot be applied without exhausting less restrictive alternatives.
Safety standards mandate prioritizing alternative interventions to prevent the hazards associated with physical restraints.
3
Identify the least restrictive intervention that addresses the root cause of the behavior.
The client's agitation may be caused by a painful full bladder due to a blocked catheter. Checking the device addresses the potential root cause.
Resolving underlying physiological discomfort often eliminates the behavior and the need for restraints entirely.

Key Concept

Prioritizing alternative interventions and identifying the root causes of agitation before considering physical restraints.
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Topics

Use of Restraints and Safety Devices

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