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Difficulty: EasySafe Use of Restraints and Safety Devices

An older adult client with acute delirium is continuously pulling at a newly inserted peripheral intravenous (IV) catheter. The primary healthcare provider has been notified. Arrange the following safety interventions in order from the least restrictive measure to the most restrictive measure.

  1. 1Attempt verbal de-escalation and explain the necessity of the IV therapy.
  2. 2Conceal the IV site using a loose, long-sleeved hospital gown.
  3. 3Apply unanchored padded hand mitts to the client's hands.
  4. 4Secure soft wrist restraints to the movable portion of the bed frame.

Answer

The correct sequence from least restrictive to most restrictive is: attempting verbal de-escalation, concealing the IV site, applying unanchored padded hand mitts, and finally securing soft wrist restraints to the bed frame.
The standard of care for client safety requires implementing interventions starting with the least restrictive measures. Verbal interventions come first, followed by environmental modifications like concealing the site. If those fail, mild physical barriers like unanchored mitts are used. Tethered physical restraints are utilized only when all other alternatives have failed.

Step-by-Step Solution

1
Identify the least restrictive independent nursing intervention.
Attempting verbal de-escalation is the initial step as it imposes no physical restriction on the client.
Nursing standards dictate starting with non-physical, interpersonal communication techniques before altering the environment or applying physical barriers.
2
Identify the next least restrictive environmental modification.
Concealing the IV site with a long-sleeved gown removes the visual trigger.
Out of sight, out of mind principles work well for confused clients and do not restrict their movement.
3
Evaluate physical barriers that do not tether the client.
Applying unanchored padded hand mitts prevents the client from grasping the IV line while preserving arm mobility.
Mitts are a physical barrier but are less restrictive than tying a limb to a fixed structure.
4
Identify the most restrictive intervention.
Applying soft wrist restraints tied to the bed frame is the final resort.
This severely limits physical mobility and requires strict adherence to legal guidelines, provider prescriptions, and facility restraint protocols.

Key Concept

Least Restrictive Environment and Restraint Escalation
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Topics

Safe Use of Restraints and Safety Devices

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