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Difficulty: MediumSafe Use of Restraints and Safety Devices

A staff nurse is caring for a client with acute delirium who is continuously attempting to pull out their continuous bladder irrigation (CBI) catheter. The nurse determines that physical safety devices may be necessary to prevent injury. Which action must the nurse take first before applying physical restraints?

  1. Implement and document the failure of less restrictive interventions, such as concealing the catheter tubing or providing a distraction device.Answer
  2. B
    Request a PRN (as-needed) prescription for soft wrist restraints from the healthcare provider to use when the client becomes excessively agitated.
  3. C
    Delegate the initial application of the restraints and the baseline skin assessment to an experienced unlicensed assistive personnel (UAP).
  4. D
    Administer the client's prescribed intravenous sedative to act as a chemical restraint prior to applying physical devices.

Answer

The nurse must first implement and document the failure of less restrictive interventions, such as concealing the catheter tubing or providing a distraction device.
According to standard nursing guidelines and healthcare regulations, physical restraints are an intervention of last resort. The nurse must first attempt, evaluate, and thoroughly document the failure of less restrictive alternatives (such as reorientation, hiding lines, utilizing sitters, or providing diversionary activities) before initiating restraints.

Step-by-Step Solution

1
Analyze the client's clinical presentation and the immediate risk to their safety.
The client is at risk for injury by attempting to remove the continuous bladder irrigation catheter, prompting the nurse to consider protective measures.
Maintaining client safety and preventing the disruption of essential medical treatments is a high priority.
2
Evaluate the proposed intervention (physical restraints) against standard legal and ethical guidelines.
Restraints are identified as an intervention of last resort with strict regulatory requirements.
CMS and NCLEX standards require that less restrictive alternatives must be attempted and proven ineffective before any restraint is applied.
3
Select the most appropriate initial nursing action based on the requirement for least restrictive measures.
The nurse must trial and document alternatives like concealing the tube, reorientation, or using distraction items.
This complies with safety protocols and protects the client from the potential physical and psychological harm of unnecessary restraint.

Key Concept

Least Restrictive Environment and Restraint Alternatives
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Topics

Safe Use of Restraints and Safety Devices

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