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Question

Difficulty: HardAccident, Error, and Injury Prevention

A client with a history of vascular dementia is hospitalized for severe dehydration and is receiving continuous intravenous (IV) fluids. During evening rounds, the practical nurse observes the client aggressively pulling at the IV tubing, stating, "I need to untie this rope." Which action should the nurse take first to prevent injury and protect the intravenous access?

  1. Conceal the intravenous insertion site and tubing by loosely applying a stockinette over the client's arm.Answer
  2. B
    Apply prescribed soft bilateral wrist restraints to prevent the client from dislodging the catheter.
  3. C
    Direct an unlicensed assistive personnel to hold the client's hands away from the tubing until the agitation subsides.
  4. D
    Document the behavior as expected sundowning syndrome and assess the intravenous site hourly for intactness.

Answer

Conceal the intravenous insertion site and tubing by loosely applying a stockinette over the client's arm.
The standard of care mandates utilizing the least restrictive intervention first. For clients with dementia, 'out of sight, out of mind' is a highly effective strategy. Concealing the intravenous site with a long sleeve or stockinette removes the visual trigger and protects the line without restricting the client's mobility, preserving their dignity and avoiding the severe physical and psychological hazards associated with physical restraints.

Step-by-Step Solution

1
Identify the immediate safety risk.
The client is actively pulling at a necessary medical device, creating a high risk for hemorrhage, infection, or loss of intravenous access.
Recognizing the immediate threat to client safety dictates the urgency of the intervention.
2
Evaluate the client's cognitive status and behavioral triggers.
The client has dementia and is misinterpreting the medical tubing as a rope, demonstrating a lack of capacity to understand the treatment's necessity.
Understanding the cause of the behavior helps select an intervention that addresses the symptom (visual trigger) without escalating agitation.
3
Apply the hierarchy of least restrictive interventions.
Visual concealment is selected as the priority action over physical restraints or holds.
The standard of care mandates that the least restrictive, non-invasive measures must be attempted and proven ineffective before considering physical restraints.

Key Concept

Restraint Alternatives and Injury Prevention
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Topics

Accident, Error, and Injury Prevention

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