An older adult client with mild dementia is hospitalized for pneumonia and is observed repeatedly pulling at their peripheral intravenous (IV) catheter. The practical nurse (PN) must implement safety measures to prevent the removal of the device without using physical restraints. Place the following non-pharmacological interventions in the correct order of implementation, starting with the initial nursing action to the most restrictive alternative.
- 1Perform data collection to identify unmet physiological needs, such as pain or a full bladder.
- 2Engage the client in a safe diversionary activity, such as holding a soft washcloth.
- 3Conceal the intravenous site and tubing using a tubular elastic bandage.
- 4Arrange for continuous one-to-one supervision by an unlicensed assistive personnel (UAP).
Answer
The correct sequence begins with data collection to identify underlying causes, followed by diversionary activities, then camouflaging the medical device, and finally utilizing one-to-one supervision as the most restrictive non-restraint alternative.
In accordance with the least restrictive environment principle, the PN must first collect data to rule out physiological causes of agitation. If the behavior persists, the PN should attempt the least invasive behavioral interventions, such as distraction or redirection. If diversion fails, visually camouflaging the medical device removes the stimulus. Finally, if the client continues to pose a safety risk, continuous one-to-one supervision is utilized as a last resort before considering physical or chemical restraints.
Step-by-Step Solution
Key Concept
Prioritization of Non-Pharmacological Restraint Alternatives