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Zorluk: OrtaUse of Restraints and Safety Devices

A client admitted to the medical-surgical unit is experiencing acute confusion and repeatedly pulls at a newly inserted indwelling urinary catheter. The client's family member is distressed and demands that the nurse apply physical restraints immediately to prevent injury. Which of the following actions should the practical nurse (PN) implement first?

  1. Conceal the catheter tubing beneath the client's clothing and provide a washcloth for the client to manipulate.Cevap
  2. B
    Contact the healthcare provider to request a PRN (as-needed) prescription for bilateral soft wrist restraints.
  3. C
    Explain to the family member that sudden confusion is an expected age-related change during a hospital stay.
  4. D
    Instruct the unlicensed assistive personnel (UAP) to evaluate the client's level of orientation and determine the need for safety devices.

Cevap

Conceal the catheter tubing beneath the client's clothing and provide a washcloth for the client to manipulate.
The correct answer demonstrates the mandatory use of least restrictive alternatives before applying physical restraints. Concealing medical lines (like a catheter) out of the client's sight and providing a safe, tactile object to manipulate (like a washcloth) are effective first-line, non-restrictive interventions to prevent the dislodgment of medical devices in a confused client.

Adım Adım Çözüm

1
Analyze the clinical scenario and the immediate risk.
The confused client is at risk of dislodging a medical device, and the family is demanding immediate physical restraints.
Understanding the immediate risk helps prioritize nursing interventions based on established safety and legal guidelines.
2
Apply the principles of safe restraint use.
Physical restraints are a measure of absolute last resort. The nurse must first implement and document less restrictive alternatives.
Standard of care and legal regulations mandate that all reasonable alternatives be exhausted before restricting a client's movement.
3
Identify the most appropriate least restrictive alternative.
Concealing the tubing and providing a diversionary object addresses the behavior without using physical restraints.
This intervention maintains the client's physical freedom and dignity while protecting the medical device.

Anahtar Kavram

Physical restraints must only be used as a last resort after all less restrictive alternatives, such as concealing tubes or providing diversionary activities, have been attempted and documented. PRN orders for restraints are never permitted.
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Konular

Use of Restraints and Safety Devices

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