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Difficulty: Very hardBasic Care and Comfort

An 82-year-old client with advanced Alzheimer's disease and a history of dysphagia is admitted for the treatment of aspiration pneumonia. During the night shift, the client experiences a sudden onset of severe agitation, repeatedly attempts to dislodge a peripheral intravenous (IV) catheter, and demonstrates an inability to remain in bed. To promote the client's basic care and comfort while ensuring safety, which action should the nurse take?

  1. Conceal the intravenous site using a tubular elastic bandage, provide a sensory activity apron for tactile diversion, and assist the client to sit in a bedside rocking chair.Answer
  2. B
    Request a prescription for soft bilateral wrist restraints to secure the client's hands, ensuring the critical infusion of intravenous antibiotics is not interrupted.
  3. C
    Delegate the administration of the client's first oral intake of pureed foods to an experienced unlicensed assistive personnel (UAP) with strict instructions to report coughing.
  4. D
    Position the client supine with the head of the bed elevated 15 degrees to promote rest and physically deter the client from continually attempting to exit the bed.

Answer

The correct action is to conceal the intravenous site using a tubular elastic bandage, provide a sensory activity apron, and assist the client to sit in a bedside rocking chair.
The correct nursing action synthesizes basic care and comfort principles by utilizing non-pharmacological de-escalation techniques. Camouflaging the IV site with an elastic sleeve removes the visual stimulus that prompts the client to pull at it, acting as a highly effective, non-restrictive alternative to restraints. Furthermore, providing a sensory apron offers safe tactile diversion, and the rhythmic motion of a rocking chair promotes self-soothing, effectively addressing the psychomotor agitation often seen in clients with dementia and delirium.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has advanced dementia, aspiration pneumonia, and sudden severe agitation with a risk of IV dislodgment.
Understanding the intersection of cognitive impairment, respiratory distress, and safety risks dictates the priority of care.
2
Evaluate the requirement for safety versus the standard of basic care and comfort.
Interventions must prevent the removal of the IV line while adhering to the principle of using the least restrictive measures possible.
Restraints can exacerbate agitation in dementia clients and are strictly regulated as a last-resort intervention.
3
Identify appropriate non-pharmacological comfort measures.
Select interventions that provide distraction and physical soothing (sensory aprons, rocking chairs) and remove visual triggers (camouflaging the IV).
These methods directly address the psychomotor agitation associated with dementia and delirium without compromising physiological safety.
4
Critically evaluate all other options for clinical contraindications.
Eliminate options that involve premature restraints, improper delegation of a high-risk assessment, or positioning that increases aspiration risk.
Ensuring holistic safety requires recognizing hidden hazards in seemingly routine interventions.

Key Concept

Non-Pharmacological Comfort and Restraint Alternatives in Dementia Care
Estimated Time:1m 30s
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Topics

Basic Care and Comfort

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