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Zorluk: OrtaSafe Use of Restraints and Safety Devices

An older adult client is hospitalized for treatment of a severe urinary tract infection. The client becomes acutely confused and continuously attempts to pull out their peripheral intravenous (IV) catheter. A colleague suggests obtaining a prescription for physical restraints. Which action should the nurse take first?

  1. Implement and document less restrictive interventions, such as concealing the IV site with a stockinette and offering a distraction.Cevap
  2. B
    Request a PRN (as-needed) prescription for soft wrist restraints from the healthcare provider to use only during periods of severe agitation.
  3. C
    Instruct the unlicensed assistive personnel to assess the client's level of orientation and determine if a bedside sitter is necessary.
  4. D
    Document the behavior in the client's chart, recognizing that sudden confusion is a normal physiological part of the aging process.

Cevap

The nurse should implement and document less restrictive interventions, such as concealing the IV site with a stockinette and offering a distraction.
The standard of care requires nurses to attempt and document less restrictive alternatives before resorting to physical restraints. Concealing the intravenous site with clothing or a stockinette, along with providing a safe distraction, are effective, non-restrictive measures that can prevent a confused client from disrupting their medical therapy.

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1
Identify the client's immediate safety risk.
The older adult client is confused and at risk of disrupting essential medical therapy (IV access).
Recognizing the risk helps prioritize the need for a safe and effective intervention.
2
Evaluate the proposed intervention (physical restraints) against nursing standards.
Physical restraints should be a last resort. Less restrictive alternatives must be exhausted first, and PRN orders are prohibited.
The use of restraints carries significant physical and psychological risks. Strict legal and ethical guidelines mandate prioritizing the least restrictive measures.
3
Select the most appropriate initial nursing action.
The nurse should implement non-restrictive measures, such as covering the IV site and providing sensory distraction.
This action addresses the safety concern while complying with the standard of care for restraint avoidance.

Anahtar Kavram

Restraint Alternatives and Safety Devices
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Konular

Safe Use of Restraints and Safety Devices

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