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Difficulty: Very hardUse of Restraints and Safety Devices

An 81-year-old client admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD) suddenly exhibits profound confusion, aggressively removes their oxygen mask, and attempts to climb over the raised side rails. Which of the following interventions should the practical nurse (PN) implement? Select all that apply.

  1. Evaluate the client's current pulse oximetry reading and auscultate lung sounds.Answer
  2. Relocate the client to a room with direct visibility from the nurses' station.Answer
  3. Conceal the intravenous tubing and insertion site by placing a long-sleeved hospital gown on the client.Answer
  4. D
    Apply bilateral soft wrist restraints immediately to protect the client from an imminent fall.
  5. E
    Delegate the ongoing evaluation of the client's neurovascular status to the assistive personnel (AP).
  6. F
    Document the sudden onset of disorientation as a normal manifestation of age-related cognitive decline.

Answer

The correct interventions are evaluating oxygenation status, relocating the client for direct visibility, and concealing medical tubing with a gown.
Appropriate care for this client involves a synthesized approach: addressing the most likely physiological cause of the agitation (hypoxia) while simultaneously implementing the least restrictive safety measures (room relocation and line concealment) to prevent self-harm.

Step-by-Step Solution

1
Analyze the client's presentation and underlying diagnoses.
The client has COPD and is suddenly exhibiting confusion and removing oxygen, which strongly points to an acute hypoxic event rather than primary behavioral agitation.
Identifying the root cause of sudden confusion dictates whether the priority is medical intervention (ABCs) or environmental safety.
2
Evaluate the proposed safety interventions against the principle of least restrictive environment.
Relocating the client and camouflaging lines are non-restrictive alternatives. Applying restraints immediately violates the protocol of attempting alternatives first.
Regulatory standards mandate that restraints are an absolute last resort.
3
Review the scope of practice for delegation.
Delegating the 'evaluation' of neurovascular status to an AP is out of scope.
Only licensed nurses (RNs and PNs) possess the training to evaluate clinical findings; APs can only collect basic data.

Key Concept

Management of acute confusion prioritizing least-restrictive safety alternatives and physiological assessment.
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Topics

Use of Restraints and Safety Devices

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