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Difficulty: Very hardAccident, Error, and Injury Prevention

A practical nurse (PN) is providing care in a subacute rehabilitation facility. An older adult client being treated for a urinary tract infection (UTI) suddenly becomes highly restless, attempts to forcefully remove their indwelling urinary catheter, and begins speaking incoherently. The unlicensed assistive personnel (UAP) in the room suggests immediately applying bilateral wrist restraints to prevent the client from causing urethral trauma. Which sequence of actions by the PN best prioritizes client safety and adherence to injury prevention protocols?

  1. Decline the UAP's suggestion, assign the UAP to remain at the bedside to provide continuous verbal redirection, and immediately assess the client's vital signs and oxygenation status.Answer
  2. B
    Apply the wrist restraints temporarily to prevent immediate tissue injury, and then urgently contact the healthcare provider to obtain a physical restraint prescription.
  3. C
    Explain to the UAP that acute confusion is a common and expected symptom of a UTI in older adults, gently reorient the client to the environment, and dim the room lights.
  4. D
    Instruct the UAP to independently perform a focused neurological assessment and obtain vital signs while the PN leaves the room to review the client's recent laboratory results.

Answer

The PN should decline the use of restraints, use the UAP as a sitter for immediate safety, and perform a physiological assessment to find the root cause of the delirium.
The correct sequence prioritizes the least restrictive environment by utilizing the UAP to maintain continuous observation (a restraint alternative) to prevent the client from pulling the catheter. Concurrently, it requires the PN to immediately assess oxygenation and vital signs, recognizing that sudden severe restlessness is a hallmark sign of acute delirium, which often stems from a reversible physiological crisis rather than just being an expected side effect of aging or a routine UTI.

Step-by-Step Solution

1
Evaluate the immediate safety risk and the proposed intervention (restraints).
Determine that applying restraints bypasses required less-restrictive alternatives and violates safety protocols.
Restraints are a measure of last resort and can actually increase agitation and injury risk if less restrictive measures have not been exhausted.
2
Implement the least restrictive safety intervention.
Assign the UAP to remain at the bedside for continuous visual observation and verbal redirection.
This prevents the client from pulling the catheter out without the need for physical restraints, directly protecting the client from self-injury.
3
Identify the underlying cause of the sudden behavioral change.
Perform a rapid assessment of vital signs and oxygen saturation.
Sudden restlessness and incoherence indicate acute delirium, which is a medical emergency often caused by physiological instability (e.g., hypoxia, advancing infection) that requires immediate nursing assessment.

Key Concept

Prioritizing restraint alternatives and recognizing acute delirium in older adults
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Topics

Accident, Error, and Injury Prevention

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