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Difficulty: HardUse of Restraints and Safety Devices

A resident in a skilled nursing rehabilitation unit suddenly develops severe disorientation during the evening shift and begins pulling forcefully on their indwelling urinary catheter. The assistive personnel (AP) present in the room insists that bilateral soft wrist restraints must be applied immediately to prevent traumatic urethral injury. Which action should the practical nurse (PN) prioritize?

  1. Initiate one-to-one continuous supervision and assess the resident for physiological triggers of the acute confusion.Answer
  2. B
    Apply the soft wrist restraints immediately as a temporary emergency measure before exploring environmental modifications.
  3. C
    Direct the AP to manually hold the resident's hands down while the PN leaves the room to obtain a restraint prescription.
  4. D
    Conclude that the abrupt confusion is an expected manifestation of progressive dementia and request a sedative prescription.

Answer

The priority action is to implement one-to-one continuous supervision and assess for underlying physiological causes of the sudden confusion.
The correct action addresses the immediate safety threat using the least restrictive method available (continuous supervision) while simultaneously prompting an investigation into the physiological cause of the sudden disorientation. Sudden confusion is a red flag for acute delirium, not normal aging.

Step-by-Step Solution

1
Analyze the clinical presentation and the immediate safety risk.
The client is experiencing a sudden onset of severe disorientation and is at risk of self-injury by pulling on a medical device.
Identifying the nature of the cognitive change (sudden versus gradual) and the specific risk dictates the urgency and type of intervention required.
2
Evaluate the assistive personnel's recommendation against restraint protocols.
The suggestion to immediately apply physical restraints violates the legal and ethical requirement to utilize least restrictive alternatives first.
Physical restraints are a last resort and cannot be applied simply because a device is at risk of being pulled; alternatives must be exhausted and documented.
3
Determine the priority nursing intervention.
The PN must establish immediate safety through non-restrictive direct observation (1:1 supervision) while conducting a nursing assessment.
Direct observation protects the client without restricting freedom of movement, and assessing the client addresses the root physiological cause of acute delirium.

Key Concept

Prioritizing least restrictive alternatives and recognizing acute delirium.
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Topics

Use of Restraints and Safety Devices

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