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Question

Difficulty: MediumAccident, Error, and Injury Prevention

An older adult client with moderate dementia is continuously grasping and pulling at their peripheral intravenous (IV) catheter. Which initial intervention should the practical nurse implement to prevent the client from dislodging the device?

  1. Cover the IV insertion site and tubing with a tubular stockinette.Answer
  2. B
    Obtain a provider prescription to apply bilateral soft hand mitts.
  3. C
    Explain the medical necessity of the IV fluids to encourage client cooperation.
  4. D
    Instruct the unlicensed assistive personnel to assess the site hourly for redness.

Answer

Covering the intravenous site and tubing with a tubular stockinette or long sleeves.
The principle of utilizing the least restrictive intervention dictates that nurses should first attempt to remove visual triggers before resorting to physical restraints. For a client with dementia who is pulling at medical devices, concealing the intravenous line with a stockinette, bandage, or long-sleeved gown effectively reduces the impulse to pick at the device by putting it out of sight, all without restricting the client's freedom of movement.

Step-by-Step Solution

1
Identify the primary safety hazard.
The client is at high risk of dislodging an invasive medical device, which could cause injury or bleeding.
Accident and injury prevention requires immediate recognition of behaviors that compromise medical equipment.
2
Evaluate the client's cognitive status.
The client has moderate dementia, meaning verbal instructions or logical reasoning will not alter their behavior.
Interventions must be tailored to the client's cognitive abilities to be effective.
3
Select an intervention based on the principle of the least restrictive environment.
Camouflaging the site with a stockinette is chosen over restraints.
Standards of care dictate that nurses must always implement the least restrictive effective intervention before considering physical or chemical restraints.

Key Concept

Restraint Alternatives and Hazard Prevention
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Topics

Accident, Error, and Injury Prevention

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