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Difficulty: Very hardAccident, Error, and Injury Prevention

A registered nurse is caring for an older adult client who is being treated for severe sepsis and has a known history of dementia. The client is currently placed on Contact Precautions due to a vancomycin-resistant enterococci (VRE) infection. The client becomes acutely restless and repeatedly attempts to pull at their central venous access device (CVAD), which is currently delivering a continuous life-sustaining norepinephrine infusion. Which of the following is the priority nursing action to prevent accidental line removal and maintain client safety?

  1. A
    Assign an unlicensed assistive personnel (UAP) to provide constant observation and instruct them to evaluate the client's neurological orientation every 15 minutes.
  2. Camouflage the central venous access device site with a protective wrapping and rapidly assess for underlying physiological triggers such as hypoxia or urinary retention.Answer
  3. C
    Transfer the client to an airborne infection isolation room (AIIR) directly across from the nurses' station to facilitate continuous visual monitoring.
  4. D
    Apply bilateral soft wrist restraints to protect the life-sustaining infusion, as emergency protocols permit application prior to obtaining a provider's prescription.

Answer

The priority action is to camouflage the central venous access device site with a protective wrapping and rapidly assess for underlying physiological triggers such as hypoxia or urinary retention.
In an agitated client attempting to pull at medical devices, the priority is to employ the least restrictive safety measures while simultaneously investigating the root cause of the behavior. Camouflaging the line (using a stockinette or long sleeves) visually removes the stimulus without restricting physical movement. Furthermore, acute restlessness in older adults or clients with dementia is frequently the first sign of a physiological deterioration, such as hypoxemia, pain, or a distended bladder. Assessing for and treating these underlying causes is paramount before resorting to any form of physical restraint.

Step-by-Step Solution

1
Analyze the immediate threat to the client.
The client is at risk of dislodging a life-sustaining vasopressor (norepinephrine) infusion due to acute agitation.
Identifying the primary safety risk dictates the urgency and type of intervention required.
2
Determine the legal and ethical guidelines for preventing device removal.
Standards require utilizing the least restrictive measures first, such as camouflaging the line or using distraction, rather than immediately applying physical restraints.
Restraints are interventions of last resort due to the high risk of injury, increased agitation, and psychological harm.
3
Identify the potential causes of sudden behavioral changes.
Acute restlessness in an older adult is frequently a primary indicator of a physiological crisis, such as hypoxemia, a distended bladder, or worsening sepsis.
Treating the underlying cause resolves the agitation safely, whereas ignoring it to merely restrain the patient can lead to rapid physiological deterioration.
4
Evaluate the remaining choices for safety or scope of practice violations.
Delegating neurological assessments to a UAP and misapplying airborne isolation protocols for a VRE infection must be eliminated.
The registered nurse must operate strictly within the legal scope of practice and apply correct transmission-based precautions.

Key Concept

Restraint Alternatives and Root-Cause Assessment of Agitation
Estimated Time:2m 0s
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Topics

Accident, Error, and Injury Prevention

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