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Difficulty: MediumUse of Restraints and Safety Devices

An 81-year-old client was recently admitted for management of acute decompensated heart failure. During the evening shift, the client suddenly becomes extremely agitated, pulls off their continuous positive airway pressure (CPAP) mask, and attempts to climb over the bed rails. Which initial action should the practical nurse (PN) take?

  1. Remain with the client to provide direct supervision, implement verbal reorientation, and assess oxygen saturation levels.Answer
  2. B
    Apply bilateral soft wrist restraints to ensure the continuous delivery of airway pressure and subsequently notify the provider.
  3. C
    Document the sudden confusion as an expected manifestation of advanced age and dim the room lights to encourage sleep.
  4. D
    Delegate the task of performing a neurological evaluation to the assistive personnel (AP) to determine if a sitter is required.

Answer

The priority action is to remain with the client to provide direct supervision, implement verbal reorientation, and assess for physiological causes of delirium, such as hypoxemia.
The correct action focuses on implementing the least restrictive safety measures first. Staying with the client provides immediate physical protection from a fall without restricting their freedom of movement. Furthermore, assessing oxygen saturation directly addresses a highly probable physiological cause of the sudden delirium, specifically hypoxemia resulting from the removal of the CPAP mask.

Step-by-Step Solution

1
Analyze the client's clinical presentation and identify the immediate safety risk.
The client is experiencing sudden agitation and delirium, posing an immediate risk for falls and hypoxemia by removing the CPAP mask.
Recognizing the acuity of the behavioral change is essential for prioritizing interventions.
2
Evaluate the proposed interventions against the principle of least restrictive restraints and scope of practice.
Immediate supervision and physiological assessment are non-restrictive and within the PN scope. Restraints are highly restrictive, and delegating assessment is out of scope for an AP.
Standards of care require attempting less restrictive safety measures before resorting to physical restraints.
3
Select the action that provides immediate safety while adhering to practical nursing protocols.
Remaining with the client provides direct safety, prevents injury, and allows for the assessment of underlying causes like hypoxemia.
This approach stabilizes the immediate threat without prematurely applying physical restraints or inappropriately delegating tasks.

Key Concept

Least Restrictive Interventions and Delirium Assessment
Estimated Time:1m 0s
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Topics

Use of Restraints and Safety Devices

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