An older adult client with acute confusion is restless and repeatedly attempts to get out of bed without assistance, creating a high risk for falls. In what order should the practical nurse (PN) implement the following safety interventions, from least restrictive to most restrictive?
- 1Identify and address underlying physiological triggers, such as a full bladder or untreated pain.
- 2Relocate the client to a room directly across from the nursing station for frequent visual monitoring.
- 3Activate a bed-exit alarm system to alert nursing staff immediately upon movement.
- 4Apply prescribed soft limb restraints as a final measure to prevent injury.
Cevap
The correct sequence from least to most restrictive is to first address physiological triggers, then relocate the client for better visualization, next activate a bed-exit alarm, and finally apply physical restraints as a last resort.
When managing a client at high risk for falls due to confusion, the nurse must follow the principle of using the least restrictive intervention first. The sequence begins with assessing and treating underlying physiological causes. If agitation persists, environmental modifications like moving the client closer to the nursing station are implemented. Next, technological safety devices such as bed alarms are utilized. Finally, if all non-restrictive alternatives have failed and the client's safety is in immediate jeopardy, physical restraints may be applied with a healthcare provider's prescription.
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Anahtar Kavram
Hierarchy of Least Restrictive Interventions for Fall Prevention