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Difficulty: Very hardMental Health Concepts

An 82-year-old client is admitted to the medical-surgical unit for treatment of urosepsis. The client has a documented baseline of early-stage Alzheimer's disease but is typically oriented to person and place. During the night shift, the client suddenly becomes highly agitated, insists that spiders are crawling on the bedsheets, and repeatedly pulls at their intravenous (IV) tubing. The client's temperature is 101.4°F (38.6°C). Which action should the practical nurse (PN) take first?

  1. Conceal the intravenous insertion site with a tubular elastic bandage and remain in the room with the client.Answer
  2. B
    Request a prescription for soft limb restraints from the healthcare provider to prevent disruption of the life-saving intravenous therapy.
  3. C
    Document the worsening of the client's Alzheimer's disease and request a psychiatric consultation for management of the new visual hallucinations.
  4. D
    Present reality by showing the client that there are no spiders and logically explain the importance of the intravenous antibiotics.

Answer

Conceal the intravenous insertion site with a tubular elastic bandage and remain in the room with the client.
The client is experiencing acute delirium, likely precipitated by the systemic infection (urosepsis) and elevated temperature. The sudden onset of visual hallucinations and agitation creates an immediate safety risk regarding the disruption of essential medical equipment. The priority is to protect the IV line using the least restrictive method available. Concealing the IV site removes the visual stimulus that prompts the confused client to pull on the tubing, and staying with the client provides continuous safety monitoring without the need for physical restraints.

Step-by-Step Solution

1
Analyze the client's sudden change in behavior and sensory perception.
The acute onset of hallucinations and severe agitation, combined with a fever and an underlying infection (urosepsis), points to acute delirium rather than a progression of Alzheimer's disease.
Differentiating between acute delirium and baseline dementia is critical for determining appropriate nursing interventions and preventing missed medical complications.
2
Identify the immediate priority for the client's care.
The primary risk is the client pulling out the IV catheter, which is essential for administering antibiotics to treat the urosepsis.
Maintaining physiological integrity and patient safety are the highest priorities in this scenario.
3
Select the nursing intervention that addresses the priority using the least restrictive means.
Covering the IV site removes the visual trigger that prompts the client to pull at the line, and staying with the client ensures safety without utilizing physical or chemical restraints.
Standards of care dictate that non-pharmacological, least-restrictive alternatives must be implemented and exhausted before applying physical restraints.

Key Concept

Management of Acute Delirium and Least Restrictive Interventions
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Mental Health Concepts

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