An older adult client receiving continuous bladder irrigation (CBI) following a prostate resection develops sudden, severe confusion. The client is highly restless, repeatedly attempting to pull out the three-way urinary catheter, and trying to climb over the bed rails. Which interventions should the practical nurse (PN) implement to maintain client safety? Select all that apply.
- Provide a repetitive diversionary activity, such as folding towels, to occupy the client's hands.Answer
- Conceal the three-way catheter tubing beneath the client's hospital gown and bed linens.Answer
- Assign an available unlicensed assistive personnel (UAP) to provide one-to-one continuous observation.Answer
- DApply soft limb restraints to the client's wrists to prevent dislodgement of the catheter.
- EAttribute the sudden onset of confusion to expected age-related dementia and document the behavior.
- FPerform an initial comprehensive psychological assessment to establish the exact etiology of the delirium.
Answer
The correct interventions are to provide a diversionary activity, conceal the catheter tubing, and assign a UAP for one-to-one observation.
The correct choices represent the least restrictive alternatives for maintaining the safety of a confused client. Concealing the tubing removes the visual trigger, diversionary activities occupy the client's hands safely, and a dedicated sitter provides immediate redirection, all of which protect the client and the medical device without resorting to physical restraints.
Step-by-Step Solution
Key Concept
Prioritizing least restrictive restraint alternatives and adhering to the PN scope of practice during acute client delirium.