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Zorluk: ZorAccident, Error, and Injury Prevention

An older adult client who is two days postoperative from abdominal surgery suddenly exhibits severe disorientation and agitation. The client is repeatedly attempting to remove their surgical dressing and peripheral intravenous (IV) catheter. Which of the following actions should the practical nurse (PN) take to prevent client injury? (Select all that apply.)

  1. Wrap a flexible tubular bandage over the IV site and surgical dressing to conceal them from the client's view.Cevap
  2. B
    Apply soft bilateral wrist restraints immediately to protect the integrity of the IV access and surgical wound.
  3. Provide a folded washcloth or a sensory item for the client to hold in their hands.Cevap
  4. D
    Attribute the client's sudden change in mental status to expected age-related cognitive decline and continue routine monitoring.
  5. Notify the registered nurse (RN) immediately to collaborate on assessing the client for underlying causes of the acute agitation.Cevap
  6. F
    Direct the unlicensed assistive personnel (UAP) to evaluate the client's oxygen saturation trends to determine if hypoxia is causing the agitation.

Cevap

The correct actions are to wrap a tubular bandage over the sites to conceal them, provide a sensory item for the client to hold, and notify the RN immediately to assess for underlying physiological causes.
To prevent injury in an agitated client, the PN must prioritize least restrictive safety measures. Concealing medical devices with a tubular bandage and providing a sensory distraction (such as a washcloth) effectively redirect the client's attention and physically protect the sites without restricting their freedom of movement. Furthermore, a sudden onset of confusion and agitation in an older adult is a medical emergency—often indicating acute delirium driven by hypoxia, infection, or medication toxicity. The PN must notify the RN immediately to facilitate a comprehensive assessment and address the root physiological cause of the unsafe behavior.

Adım Adım Çözüm

1
Analyze the client's presentation and immediate risks.
The client is experiencing an acute, sudden-onset episode of confusion and agitation, which increases the immediate risk of self-injury through the removal of essential medical devices.
Identifying the nature of the safety risk guides the selection of appropriate, prioritized interventions.
2
Determine appropriate, least-restrictive injury prevention interventions.
Implementing restraint alternatives, such as concealing the devices with a tubular bandage and providing a tactile distraction like a washcloth, are prioritized over physical restraints.
Regulatory and ethical standards mandate that least restrictive measures must always be attempted and exhausted before physical restraints are utilized to maintain client safety and dignity.
3
Evaluate the clinical urgency and scope of practice requirements.
The PN escalates the acute change in mental status to the RN for a comprehensive assessment rather than delegating evaluation tasks to a UAP or dismissing it as normal aging.
Sudden confusion in an older adult is frequently a symptom of a reversible, acute medical emergency (e.g., hypoxia, sepsis) and requires RN-level or provider-level clinical judgment to diagnose and treat.

Anahtar Kavram

Implementation of least restrictive restraint alternatives and the recognition of acute delirium in older adults.
Tahmini Süre:1m 30s
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Konular

Accident, Error, and Injury Prevention

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