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Difficulty: MediumSafe Use of Restraints and Safety Devices

An older adult client admitted with severe pneumonia is exhibiting acute confusion and repeatedly pulling at their peripheral intravenous (IV) line. Arrange the following nursing interventions in the correct order of escalation, from the least restrictive measure to the most restrictive.

  1. 1Assess the client for underlying physiological causes of agitation, such as hypoxia or pain.
  2. 2Implement environmental modifications to reduce sensory overload, such as dimming the lights and reducing room noise.
  3. 3Conceal the intravenous insertion site using a tubular stockinette or a long-sleeved hospital gown.
  4. 4Request a one-to-one sitter to provide continuous direct observation of the client.
  5. 5Obtain a primary care provider's prescription and apply bilateral soft wrist restraints.

Answer

The correct sequence of escalating interventions is: Assess for physiological causes first, implement environmental modifications, conceal the IV site, arrange for a one-to-one sitter, and finally, apply physical restraints.
Client safety protocols require nurses to systematically escalate care using the least restrictive alternatives first. This process always begins with assessing and treating reversible physiological causes of agitation. If confusion persists, nurses employ environmental de-escalation, followed by device camouflage (like a stockinette), and human observation (a sitter). Physical restraints are only legally and ethically permissible as a final resort when all other measures fail.

Step-by-Step Solution

1
Assess the client for physiological causes of agitation (e.g., hypoxia).
Identifies or rules out reversible medical conditions.
Per the nursing process, assessment must occur before any intervention. Treating an underlying cause like hypoxia is the most effective way to resolve confusion.
2
Implement environmental modifications (e.g., dim lights).
Decreases sensory overload and promotes a calming environment.
This is the least restrictive behavioral intervention and serves as a foundational comfort measure.
3
Conceal the IV site with a stockinette.
Removes the visual reminder of the medical device.
Out of sight often means out of mind for a confused client. This is a non-restrictive physical alternative to secure the device.
4
Arrange for a one-to-one sitter.
Ensures the client's safety through continuous direct observation.
Direct observation is resource-intensive but highly effective, serving as the final step before restricting a client's physical freedom.
5
Apply soft wrist restraints after obtaining a provider's prescription.
Physically prevents the client's hands from reaching the IV line.
Physical restraints are strictly the intervention of last resort when all other documented alternatives have failed to ensure client safety.

Key Concept

The standard of care for restraint application requires a stepwise escalation from the least restrictive measures to the most restrictive, beginning always with assessment and treating underlying causes.
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Safe Use of Restraints and Safety Devices

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