A nurse is caring for an older adult client with dementia who is confused and repeatedly attempting to pull out a peripheral intravenous (IV) catheter. Which interventions should the nurse implement as alternatives to physical restraints? Select all that apply.
- Apply a loose stockinette or elastic bandage over the IV site to conceal it.Answer
- Relocate the client to a room closer to the nursing station.Answer
- Provide the client with a safe, repetitive activity such as folding washcloths.Answer
- DElevate all four bed side rails to prevent the client from exiting the bed unassisted.
- EAdminister a prescribed as-needed (PRN) dose of a sedative medication to calm the client.
- FInstruct the unlicensed assistive personnel (UAP) to assess the client's behavior and orientation every 15 minutes.
Answer
The nurse should conceal the IV site with a stockinette, relocate the client near the nursing station, and provide a diversionary activity like folding washcloths.
Effective alternative interventions to restraints focus on reducing the client's urge to interfere with medical devices and ensuring close monitoring without restricting their freedom of movement. Concealing the IV site with a loose bandage removes the visual trigger. Relocating the client near the nursing station allows for frequent visual checks by the staff. Providing a safe, repetitive activity distracts the client and channels their restless energy safely.
Step-by-Step Solution
Key Concept
Restraint alternatives and maintaining a safe care environment