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Difficulty: Very hardAccident, Error, and Injury Prevention

An interdisciplinary care team is managing an older adult client admitted for severe aspiration pneumonia. The client, who has a documented history of major neurocognitive disorder, is colonized with methicillin-resistant Staphylococcus aureus (MRSA) in the nares. Over the past hour, the client has developed acute hyperactive delirium, continuously attempts to climb out of bed, and is aggressively picking at their peripheral intravenous (PIV) site. Which comprehensive action plan should the nurse implement first to prevent client injury?

  1. Cover the peripheral intravenous site with a tubular elastic bandage for concealment, provide a sensory activity apron for distraction, and arrange for continuous bedside observation by a staff member utilizing a gown and gloves.Answer
  2. B
    Secure the client's arms with bilateral soft wrist restraints attached to the movable portion of the bed frame, then contact the healthcare provider immediately for a restraint prescription to prevent intravenous line dislodgment.
  3. C
    Assign unlicensed assistive personnel (UAP) to provide one-to-one bedside observation, with specific instructions to independently evaluate and document the peripheral neurovascular status of the client's intravenous arm every hour.
  4. D
    Transfer the client to a negative-pressure airborne infection isolation room near the nurses' station to enhance direct visual monitoring, and require all entering personnel to wear N95 respirators.

Answer

The most appropriate comprehensive plan is to cover the peripheral intravenous site with a tubular elastic bandage, provide a sensory activity apron, and arrange for continuous bedside observation by a staff member utilizing a gown and gloves.
The correct action plan effectively synthesizes three critical nursing responsibilities. First, it utilizes non-restrictive alternatives to physical restraints by concealing the intravenous site and providing a sensory distraction. Second, it safely employs continuous observation without delegating nursing assessments. Third, it correctly implements contact precautions by requiring the observing staff member to don a gown and gloves for a client with MRSA colonization.

Step-by-Step Solution

1
Analyze the client's immediate safety and environmental risks.
The client is at high risk for falls and therapy disruption due to delirium, complicated by MRSA colonization which poses a transmission risk.
Identifying the precise combination of hazards dictates the necessary environmental, physical, and infection control interventions.
2
Evaluate potential restraint alternatives to address the pulling of the intravenous line.
Concealing the IV line with a tubular bandage and offering a sensory apron provides distraction without physically restricting the client's movement.
Standards of care mandate attempting and documenting less restrictive measures before applying physical restraints, especially in clients with neurocognitive disorders.
3
Determine appropriate delegation strategies for continuous observation.
A bedside observer is assigned to prevent falls, but all clinical assessments remain the sole responsibility of the registered nurse.
Unlicensed personnel can be delegated continuous observation duties but cannot legally perform nursing assessments.
4
Apply appropriate transmission-based precautions for the assigned bedside observer.
The observer is instructed to wear a gown and gloves while in the client's room.
MRSA colonization strictly requires contact precautions, ensuring environmental safety and preventing pathogen cross-contamination.

Key Concept

Prioritizing Restraint Alternatives, Safe Delegation, and Infection Control Precautions
Estimated Time:2m 0s
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Topics

Accident, Error, and Injury Prevention

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