A client with a history of early-stage dementia is hospitalized for sepsis and becomes acutely confused, repeatedly attempting to pull out a central venous catheter. An unlicensed assistive personnel (UAP) suggests applying wrist restraints to protect the line. Which action should the registered nurse take to uphold the client's legal rights?
- AApply the wrist restraints immediately under emergency protocols to prevent line dislodgment before attempting other measures.
- BDelegate the UAP to evaluate the client's behavior every fifteen minutes to determine if physical restraints become absolutely necessary.
- Implement less restrictive interventions, such as concealing the catheter with a protective sleeve and utilizing one-to-one observation.Answer
- DInform the family that the sudden agitation is an expected progression of dementia and request they legally consent to physical restraints.
Answer
Implement less restrictive interventions, such as concealing the catheter with a protective sleeve and utilizing one-to-one observation.
Clients have a legal right to the least restrictive environment. Under federal regulations and nursing ethical standards, physical restraints are considered a measure of absolute last resort. The nurse must exhaust and document less restrictive alternatives—such as concealing IV lines, providing a sitter, or reorienting the client—before applying restraints. This approach protects the client from false imprisonment and physical harm while ensuring the central line remains intact.
Step-by-Step Solution
Key Concept
Client Right to the Least Restrictive Environment