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Zorluk: ZorUse of Restraints and Safety Devices

A client with a history of early-stage dementia is receiving intravenous (IV) antibiotics on a medical unit for an acute kidney infection. The client suddenly exhibits severe restlessness, continuously attempts to pull at the IV tubing, and tries to climb over the bed rails. The registered nurse (RN) is occupied with an unstable client and asks the practical nurse (PN) to manage this situation. Which of the following is the most appropriate action for the PN to take?

  1. Move the client to a room highly visible from the nursing station, cover the IV insertion site with a protective sleeve, and evaluate the client for untreated pain or hypoxia.Cevap
  2. B
    Apply bilateral soft wrist restraints immediately to secure the IV line and prevent falls, then urgently contact the provider for an emergency restraint order.
  3. C
    Accept the assignment to independently conduct a comprehensive behavioral risk assessment and initiate the facility's physical restraint protocol.
  4. D
    Reorient the client to their surroundings, document the behavior as an expected exacerbation of their chronic dementia, and raise all four side rails.

Cevap

The correct action is to implement least restrictive measures by increasing visibility and camouflaging the IV site, while simultaneously assessing for physiological triggers of the sudden agitation.
The correct answer demonstrates the mandatory implementation of least restrictive safety measures prior to restraint consideration. Moving the client to a visible room increases monitoring without physical restriction, and covering the IV site removes the visual stimulus that prompts the client to pull it. Furthermore, evaluating for pain or hypoxia correctly identifies that sudden, severe restlessness in a client with a known infection is highly indicative of acute delirium secondary to a physiological cause. These actions are both safe and entirely within the practical nurse's scope of practice.

Adım Adım Çözüm

1
Identify the immediate clinical problem and client risk factors.
The client is demonstrating acute agitation, attempting to remove essential medical lines, and presenting a high fall risk, which are classic signs of acute delirium likely triggered by the underlying infection.
Recognizing the difference between baseline dementia and sudden delirium is critical for selecting the correct intervention rather than dismissing the behavior.
2
Determine the legal constraints and scope of practice regarding safety interventions.
The PN identifies that physical restraints are an absolute last resort, and that conducting initial, comprehensive risk assessments to independently initiate a restraint protocol is outside the PN scope of practice.
Adhering to scope of practice protects the client from unauthorized care and ensures compliance with strict federal regulations regarding restraint application.
3
Implement the safest, least restrictive, and most appropriate interventions.
The PN chooses to relocate the client for better observation, cover the IV site to remove the visual trigger, and evaluate for physiological needs like hypoxia, pain, or a full bladder.
These actions fulfill the requirement to try least restrictive alternatives first, address potential root causes of the agitation, and safely manage the client within the PN's scope of practice.

Anahtar Kavram

Least Restrictive Alternatives and PN Scope of Practice
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Konular

Use of Restraints and Safety Devices

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