A registered nurse is managing the care of a 78-year-old client admitted for intravenous antibiotic therapy due to a systemic infection. The client develops acute delirium, repeatedly attempts to remove the intravenous (IV) catheter, and verbally insists on leaving the facility immediately. The client's legally appointed healthcare proxy is at the bedside and demands that the nurse apply bilateral wrist restraints to ensure the necessary medical treatment is completed without interruption. Which action by the nurse represents the legally correct response to this situation?
- Implement environmental modifications and attempt alternative strategies, such as concealing the IV site, before considering any restrictive devices.Answer
- BApply the requested physical restraints immediately, as the legally appointed healthcare proxy has the authority to mandate compliance with medical interventions.
- CAssign an unlicensed assistive personnel (UAP) to independently assess the client's cognitive status and determine if the IV site remains secure.
- DInform the proxy that the client's disorientation is an expected, normal consequence of advanced age and therefore legal safety interventions are unwarranted.
Answer
Implement environmental modifications and attempt alternative strategies, such as concealing the IV site, before considering any restrictive devices.
The correct answer demonstrates the legal principle of providing care in the least restrictive environment. Regardless of a healthcare proxy's requests, federal laws and nursing standards mandate that non-restrictive alternatives (such as reorientation, concealing medical lines, or providing one-to-one observation) must be implemented and documented as ineffective before any physical or chemical restraints are applied. The nurse must protect the client's legal right to be free from unnecessary restraint.
Step-by-Step Solution
Key Concept
Legal requirements for restraint use and the principle of the least restrictive environment