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Difficulty: MediumUse of Restraints and Safety Devices

An 80-year-old client admitted with pneumonia becomes acutely restless, disoriented, and repeatedly attempts to pull out their peripheral intravenous (IV) catheter. Which action should the practical nurse (PN) take first?

  1. Conceal the intravenous insertion site by covering it with a long-sleeved gown or stockinette bandage.Answer
  2. B
    Apply bilateral soft wrist restraints to prevent the client from dislodging the catheter.
  3. C
    Document the acute disorientation as an expected finding for an older adult client in an unfamiliar hospital environment.
  4. D
    Administer a prescribed as-needed (PRN) intravenous (IV) push sedative to quickly calm the client.

Answer

The practical nurse should first attempt to conceal the intravenous site by covering it, utilizing a least restrictive alternative before considering physical or chemical restraints.
The correct action is to conceal the intravenous site with a long-sleeved gown or stockinette bandage. This is a recognized, evidence-based, least restrictive alternative to physical restraints. According to safety protocols, nurses must always attempt and document less restrictive measures (such as reorientation, camouflage of tubes, or placing the client closer to the nurses' station) before resorting to restraints.

Step-by-Step Solution

1
Assess the situation and identify the client's behavior as a risk for dislodging essential medical equipment.
The client is at risk for harming themselves by pulling out the IV line due to acute disorientation.
Accurate situational assessment is the first step in clinical decision-making and prioritizing patient safety.
2
Recognize the legal and ethical standard of care regarding restraints.
The nurse identifies that the least restrictive interventions must be implemented before resorting to any form of restraint.
Federal guidelines and nursing standards mandate the use of alternatives to physical restraints whenever possible to protect client rights and prevent restraint-related injuries.
3
Implement a non-restrictive alternative intervention.
The nurse covers the IV site with a stockinette or long sleeve to remove the visual trigger.
If the client cannot see the IV catheter, they are significantly less likely to pick at or pull it, effectively solving the safety issue without restricting their movement.

Key Concept

Least Restrictive Alternatives to Restraints
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Topics

Use of Restraints and Safety Devices

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