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Zorluk: Çok zorAccident, Error, and Injury Prevention

A practical nurse (PN) is caring for an 82-year-old client admitted with bacterial pneumonia and a history of moderate Alzheimer's disease. The client is receiving continuous intravenous (IV) antibiotics and oxygen therapy. During the evening shift, the client becomes acutely disoriented, highly agitated, and repeatedly attempts to climb over the bed rails. Which of the following actions should the PN implement to ensure client safety and prevent injury? Select all that apply.

  1. Camouflage the IV tubing and insertion site by gently covering the client's arm with a stockinette or long-sleeved gown.Cevap
  2. Perform a focused data collection to identify potential physiological triggers for the agitation, such as hypoxia, pain, or urinary retention.Cevap
  3. C
    Document the acute onset of disorientation and agitation as an expected disease progression of the client's Alzheimer's dementia.
  4. Lower the bed to the lowest possible setting, activate the bed exit alarm, and place high-impact fall mats next to the bed.Cevap
  5. E
    Assign an unlicensed assistive personnel (UAP) to provide one-to-one observation and evaluate the client's orientation status every 30 minutes.
  6. F
    Apply bilateral soft wrist restraints using a quick-release tie attached to the movable portion of the bed frame to protect the IV site.

Cevap

The correct actions are to camouflage the IV site, perform a focused data collection for physiological triggers, and utilize environmental safety measures like lowering the bed and activating alarms.
The priority for an agitated, confused client is maintaining safety using the least restrictive methods. Camouflaging tubes, utilizing bed alarms, lowering the bed, and investigating underlying physiological causes (such as hypoxia from pneumonia) effectively prevent injury without unlawfully restraining the client or delegating outside of the nursing scope of practice.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and recent cognitive changes.
The client has a history of chronic dementia but is experiencing a sudden, acute onset of severe agitation and disorientation.
Recognizing that acute confusion is indicative of delirium rather than chronic dementia is crucial for identifying life-threatening physiological causes.
2
Apply the principle of least restrictive interventions for client safety.
Identify environmental modifications and diversionary tactics that can be implemented before resorting to physical restraints.
Physical restraints are a last resort due to the high risk of compounding injury, skin breakdown, and psychological distress.
3
Evaluate the proposed safety interventions against the Practical Nurse (PN) scope of practice.
Determine that assessing physiological triggers is within the PN scope, but delegating the evaluation of orientation to a UAP is unlawful.
The PN remains accountable for the assessment and evaluation of the client; unlicensed personnel can observe for safety but cannot clinically evaluate.

Anahtar Kavram

Prioritizing least restrictive safety interventions and differentiating acute delirium from chronic dementia while maintaining strict delegation standards.
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Konular

Accident, Error, and Injury Prevention

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