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Difficulty: MediumSafe Use of Restraints and Safety Devices

A registered nurse on a neurology step-down unit is developing a care plan for an individual with acute encephalitis who is increasingly agitated and repeatedly attempting to dislodge a central venous catheter. Arrange the following interventions in the correct sequence, from the least restrictive action to the most restrictive measure.

  1. 1Evaluate for reversible physiological causes of the agitation.
  2. 2Implement environmental calming strategies, such as decreasing noise and dimming lights.
  3. 3Cover the central venous catheter using a protective elastic sleeve.
  4. 4Enlist a trained hospital sitter for continuous one-to-one observation.
  5. 5Apply soft protective mittens that are not tied to the bed frame.
  6. 6Secure bilateral soft wrist restraints to the movable portion of the bed frame.

Answer

The correct sequence from least to most restrictive is: 1) Evaluate for physiological causes, 2) Implement environmental calming strategies, 3) Cover the central venous catheter, 4) Enlist a hospital sitter, 5) Apply non-tethered soft mittens, and 6) Secure bilateral soft wrist restraints.
The standard of nursing care mandates exhausting all least restrictive alternatives before utilizing physical restraints. The proper sequence begins with the foundational nursing process (assessment of physiological causes) and logically progresses through environmental manipulation, camouflaging medical devices, utilizing direct human observation (sitter), and applying non-tethered physical devices (mittens), before culminating in the most restrictive measure possible (tethered limb restraints).

Step-by-Step Solution

1
Apply the nursing process to assess the root cause of agitation.
Physiological needs such as pain, hypoxia, or urinary retention are identified and addressed first.
Assessing for and treating the underlying cause is the least restrictive and most fundamental nursing intervention.
2
Implement non-physical, non-restrictive environmental modifications.
Sensory overload is minimized by dimming lights and reducing ambient noise.
Environmental manipulation is a primary non-pharmacological alternative to restraints that preserves full client autonomy.
3
Conceal the medical device without restricting the client.
The central venous catheter is covered with a protective elastic sleeve.
Removing the visual stimulus of the tubing prevents the individual from pulling it while maintaining complete freedom of movement.
4
Utilize human resources for continuous observation and redirection.
A trained hospital sitter is stationed in the room.
A sitter provides constant supervision and verbal de-escalation, which is more restrictive than environmental changes but less restrictive than physical devices.
5
Implement the least restrictive physical device.
Soft protective mittens are applied but not tied down to the bed.
Mittens prevent the grasping of lines while still allowing the individual full range of motion of their arms.
6
Apply physical limb restraints as a last resort.
Bilateral soft wrist restraints are secured to the movable portion of the bed frame following a provider order.
Limb restraints entirely restrict extremity movement and are the most restrictive intervention, legally requiring all other alternatives to have failed.

Key Concept

Hierarchy of Least Restrictive Interventions
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Topics

Safe Use of Restraints and Safety Devices

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