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Difficulty: MediumAccident, Error, and Injury Prevention

A nurse on a neurological step-down unit is caring for a client recovering from a traumatic brain injury. The client is restless, disoriented to place, and persistently picking at their peripheral intravenous (IV) line and surgical dressings. Which of the following is the most appropriate initial nursing action to protect the client from self-injury?

  1. A
    Apply soft limb restraints to the client's wrists and immediately contact the healthcare provider for a prescription.
  2. B
    Proceed with administering the client's scheduled routine oral medications before attempting to manage the disruptive behavior.
  3. Conceal the intravenous line and surgical dressings using a protective stretch netting or a cohesive bandage.Answer
  4. D
    Assign Unlicensed Assistive Personnel (UAP) to sit at the bedside and evaluate the client's cognition every 15 minutes.

Answer

The correct action is to conceal the intravenous line and dressings using a protective wrap, cohesive bandage, or stretch netting.
Concealing intravenous lines and surgical dressings with a stretch net, cohesive bandage, or long sleeves is an effective, least-restrictive alternative to physical restraints. For a disoriented client, removing the visual trigger often prevents them from picking at the devices without the need to restrict their physical movement or cause unnecessary distress.

Step-by-Step Solution

1
Analyze the client's behavior and determine the immediate risk level.
The client is restless, disoriented, and at high risk for self-injury by dislodging medical devices and exposing surgical sites.
Traumatic brain injury often causes altered cognition and restlessness, leading to unintentional interference with necessary medical equipment.
2
Identify the standard of care for injury prevention regarding agitated clients.
Nurses must consistently implement and document the least restrictive interventions first before considering any form of physical or chemical restraints.
This standard promotes client autonomy and complies with strict legal, ethical, and facility safety regulations regarding restraint application.
3
Evaluate the available options against the principle of utilizing the least restrictive alternative.
Concealing the lines is a non-restrictive safety measure that effectively removes the visual trigger for the client's picking behavior.
For a confused or disoriented client, removing the device from their direct line of sight often resolves the disruptive behavior without limiting their physical mobility.

Key Concept

In the management of a restless or disoriented client, the nurse must prioritize a safe environment by implementing the least restrictive interventions (such as concealing medical lines) before utilizing physical restraints.
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Topics

Accident, Error, and Injury Prevention

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