A registered nurse (RN) is caring for a 75-year-old client experiencing acute delirium secondary to a severe infection. The client is restless, repeatedly attempts to pull out a continuous intravenous (IV) catheter, and tries to climb over the bed rails. The client's visiting adult child becomes frustrated and demands that the nurse physically restrain the client to prevent injury. Which legally sound nursing action should the RN implement first?
- AApply soft bilateral wrist restraints immediately to protect the IV access, then contact the healthcare provider for a formal legal order.
- BDelegate an unlicensed assistive personnel (UAP) to remain at the bedside and assess the client's level of agitation every 15 minutes.
- CExplain to the family that sudden, severe confusion is a normal physiological part of the aging process and physical interventions are not legally permitted.
- Relocate the client to a room closer to the nurses' station, conceal the IV tubing, and attempt reorientation before considering restrictive measures.Answer
Answer
The nurse should relocate the client, conceal the IV tubing, and attempt reorientation, as these are non-restrictive alternatives that must legally be utilized before applying restraints.
Under the Patient's Bill of Rights and federal healthcare regulations, clients have a legal right to be free from unnecessary physical and chemical restraints. The nurse is legally mandated to implement and document less restrictive alternatives (such as moving the client closer to the nursing station, hiding IV lines, or attempting reorientation) before considering restraints. Restraints are a measure of absolute last resort to prevent imminent harm when all other measures fail.
Step-by-Step Solution
Key Concept
Clients have a fundamental legal right to be free from physical and chemical restraints. Restraints may only be legally applied after all less restrictive alternatives have been implemented, documented, and proven ineffective.