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Difficulty: HardBasic Care and Comfort

A nurse is developing a plan of care for a 76-year-old client with advanced Alzheimer's disease who is hospitalized for dehydration and receiving continuous intravenous (IV) fluids. The client is restless, repeatedly attempts to pull out the IV catheter, and has a healing stage 2 pressure injury on the sacrum. Which intervention is the most appropriate for the nurse to implement to promote client comfort and safety?

  1. Provide a sensory fidget apron or textured activity blanket for the client's hands.Answer
  2. B
    Instruct the unlicensed assistive personnel (UAP) to apply soft bilateral wrist restraints.
  3. C
    Maintain the client's bed in a continuous high-Fowler's position to ensure visibility from the nursing station.
  4. D
    Document the restless behavior as an expected manifestation of advanced dementia and dim the room lights.

Answer

Provide a sensory fidget apron or textured activity blanket for the client's hands.
The correct answer provides a least-restrictive, non-pharmacological comfort measure. A sensory 'fidget' blanket safely occupies the client's hands, effectively distracting them from the IV line. This promotes comfort, prevents the disruption of medical therapy, and avoids the physiological complications associated with physical restraints or harmful positioning.

Step-by-Step Solution

1
Assess the client's multiple risk factors and immediate basic care needs.
The client exhibits cognitive impairment with agitation, risks disrupting their IV therapy, and has compromised sacral skin integrity.
Comprehensive assessment prevents implementing an intervention that solves one problem while exacerbating another.
2
Evaluate options for managing the client's pulling at the IV line.
Physical restraints must be avoided unless absolutely necessary. Non-pharmacological comfort measures and alternatives must be prioritized.
Standards of care dictate using the least restrictive interventions to maintain dignity, comfort, and physical safety.
3
Consider the impact of safety interventions on the existing pressure injury.
Positioning strategies designed for monitoring must not increase friction or shear on the sacrum.
Basic care requires protecting and promoting the healing of compromised skin.
4
Select the optimal holistic intervention.
Providing a sensory blanket safely redirects the client's hands, protecting the IV line while completely avoiding the physiological and ethical complications of restraints or improper positioning.
This directly addresses the agitation through therapeutic distraction while maintaining physiological integrity.

Key Concept

Non-pharmacological comfort measures and restraint alternatives
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Topics

Basic Care and Comfort

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