An older adult client in a subacute care unit suddenly becomes extremely restless, exhibits acute confusion, and attempts to climb out of bed. The client's baseline cognition is intact. In which order should the practical nurse (PN) prioritize the following actions? Arrange the steps from highest priority (first action) to lowest priority (last action).
- 1Stay at the client's bedside to prevent a fall and provide calm, verbal reassurance.
- 2Measure vital signs, including oxygen saturation, to check for physiological instability.
- 3Evaluate the client for other potential delirium triggers, such as urinary retention or pain.
- 4Report the acute cognitive changes and gathered assessment data to the registered nurse (RN).
- 5Document the incident, the specific behaviors observed, and the nursing interventions provided.
Answer
The correct sequence prioritizes immediate client safety, followed by assessment of life-threatening conditions (ABCs), assessment of common delirium triggers, communication with the RN, and finally, documentation.
The correct sequence follows Maslow's Hierarchy of Needs and the Nursing Process. Immediate physical safety (preventing a fall) is the absolute highest priority. Next, assessing for ABC compromises (vital signs, oxygen saturation) takes precedence over assessing other localized discomforts (urinary retention). Once the comprehensive data is gathered, the PN reports to the RN for collaborative management, and finally documents the entire event as the last step.
Step-by-Step Solution
Key Concept
Prioritization of Care for Acute Delirium in Older Adults