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Difficulty: HardUse of Restraints and Safety Devices

During the night shift, a 75-year-old client who is two days postoperative following a hip arthroplasty suddenly becomes highly agitated and attempts to climb over the side rails. The unlicensed assistive personnel (UAP) recommends applying a vest restraint to prevent a fall. Which action should the practical nurse (PN) take first?

  1. A
    Contact the healthcare provider immediately to obtain a prescription for a physical restraint.
  2. B
    Document the client's behavior as an expected age-related change known as sundowning syndrome.
  3. C
    Perform a comprehensive neurological and psychiatric assessment to determine the etiology of the behavioral change.
  4. Assign a staff member to remain in the room with the client while gathering data on potential reversible causes of the agitation.Answer

Answer

The practical nurse should first implement a less restrictive alternative, such as assigning a staff member for one-to-one observation, while collecting data to identify potential reversible causes of the sudden agitation.
The correct approach requires the implementation of least restrictive alternatives, such as one-to-one observation (a sitter), before considering physical restraints. Additionally, gathering focused data on potential underlying physiological causes (e.g., hypoxia, pain, infection) is within the PN scope of practice and is essential for addressing the root cause of acute delirium.

Step-by-Step Solution

1
Evaluate the clinical scenario and the UAP's recommendation.
The client is experiencing sudden, severe agitation and is at high risk for a fall, prompting a suggestion for physical restraints.
Immediate safety must be prioritized, but interventions must comply with strict legal and ethical restraint guidelines.
2
Apply the principles of least restrictive interventions.
Physical restraints cannot be applied simply because a client is agitated. Less restrictive alternatives must be attempted and documented first.
Restraints pose significant risks to client safety and dignity, and are legally mandated to be a measure of last resort.
3
Determine the appropriate nursing intervention within the PN scope of practice.
The PN can delegate a sitter for continuous observation and gather data (e.g., checking oxygen saturation, vital signs, or pain levels) to identify the cause of delirium.
Providing a sitter ensures immediate safety without a restraint. Gathering focused data is within the PN scope, whereas performing a comprehensive initial diagnostic assessment is not.

Key Concept

Least Restrictive Restraint Alternatives and PN Scope of Practice
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Topics

Use of Restraints and Safety Devices

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