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Question

Difficulty: MediumUse of Restraints and Safety Devices

A geriatric client admitted with a cerebrovascular accident is receiving continuous intravenous (IV) fluids. The client exhibits acute confusion and persistently picks at the IV insertion site and tubing. After attempting verbal reorientation without success, which action should the practical nurse (PN) take first?

  1. Conceal the intravenous insertion site and tubing by placing a long-sleeved gown over the client's arm.Answer
  2. B
    Apply soft limb restraints to the client's wrists to prevent dislodgement of the catheter.
  3. C
    Explain the risks and benefits of physical restraints to the client's family to obtain informed consent.
  4. D
    Ask the client why they are pulling on the tubing and provide reassurance that the therapy is almost finished.

Answer

Conceal the intravenous insertion site and tubing by placing a long-sleeved gown over the client's arm.
The use of physical restraints must always be a last resort. The practical nurse (PN) must first attempt less restrictive alternatives. Concealing the intravenous tubing with a long-sleeved gown or a tubular bandage removes the visual stimulus, which is often an effective and non-restrictive method to prevent a confused client from pulling at medical devices.

Step-by-Step Solution

1
Analyze the client's behavior and the immediate risk.
The confused client is at risk of dislodging a necessary intravenous line, presenting a safety and treatment hazard.
Identifying the specific safety threat is required to determine the appropriate intervention.
2
Evaluate the proposed interventions against the principle of least restrictive environment.
Physical restraints restrict freedom of movement, whereas concealing the tubing is a non-restrictive, environmental alternative.
Standards of care dictate that the least restrictive measures must be implemented and evaluated before physical restraints are considered.
3
Select the most appropriate initial nursing action.
The nurse chooses to camouflage the intravenous line with a long-sleeved gown.
This removes the visual trigger for the confused client, addressing the behavior safely without the use of restraints.

Key Concept

Least Restrictive Alternatives to Restraints
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Topics

Use of Restraints and Safety Devices

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