A client with mild cognitive impairment is repeatedly pulling at their intravenous (IV) tubing. Which less restrictive interventions should the nurse implement to protect the IV line before considering physical restraints? Select all that apply.
- Provide the client with a sensory activity apron or washcloths to fold.Answer
- Relocate the client to a room closer to the nursing desk for enhanced observation.Answer
- CApply soft wrist restraints immediately to ensure the IV line is not dislodged.
- Conceal the intravenous tubing and insertion site from view using a loose tubular bandage.Answer
- EAssign the unlicensed assistive personnel (UAP) to assess the IV site for signs of phlebitis every hour.
Answer
The nurse should provide a sensory activity to keep the hands occupied, relocate the client for closer observation, and conceal the IV site to remove the visual trigger.
Before applying any physical restraints, the nurse must attempt and document less restrictive safety measures. Keeping the client's hands occupied with a sensory activity (such as folding washcloths) redirects their attention away from medical devices. Moving the client closer to the nursing station allows staff to monitor the client frequently without physically restricting them. Finally, concealing the IV tubing with a loose tubular bandage removes the visual trigger that often prompts confused clients to pick at their lines, effectively protecting the IV access without limiting movement.
Step-by-Step Solution
Key Concept
Restraint Alternatives and Least Restrictive Interventions