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Zorluk: Çok zorAccident, Error, and Injury Prevention

An older adult client with severe chronic obstructive pulmonary disease (COPD) is admitted for acute hypercapnic respiratory failure and requires continuous bilevel positive airway pressure (BiPAP). The client becomes intensely agitated, repeatedly attempting to remove the BiPAP mask and grasp at an indwelling arterial line. The healthcare provider prescribes bilateral soft wrist restraints and PRN intravenous lorazepam for severe agitation. Which intervention should the nurse implement to best maintain client safety?

  1. A
    Administer the prescribed PRN lorazepam to reduce anxiety and increase tolerance of the noninvasive ventilation.
  2. B
    Apply the prescribed soft wrist restraints and delegate unlicensed assistive personnel (UAP) to assess the client's respiratory rate every 15 minutes.
  3. Place padded mitts on the client's hands and initiate continuous one-to-one observation with a trained sitter.Cevap
  4. D
    Secure the prescribed soft wrist restraints to the movable part of the bed frame and release them every 2 hours for skin care.

Cevap

Place padded mitts on the client's hands and initiate continuous one-to-one observation with a trained sitter.
The correct answer emphasizes using the least restrictive alternative (padded mitts) combined with continuous observation (1:1 sitter). This approach prevents the client from grasping critical life-support devices without utilizing dangerous sedatives or restrictive limb ties that could exacerbate the respiratory failure by increasing metabolic demand and agitation.

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1
Analyze the client's primary physiological risk.
The client is in acute hypercapnic respiratory failure; any intervention that depresses respiratory drive (like lorazepam) or increases metabolic demand (like fighting limb restraints) is a critical life threat.
Airway and breathing must be prioritized over managing the agitation.
2
Evaluate the safety interventions available.
The options are chemical restraints, physical limb restraints, improper delegation of monitoring, or less restrictive physical alternatives (mitts) with direct observation.
Nurses are required to use the least restrictive restraint alternative that ensures safety.
3
Select the safest, least restrictive intervention that protects the medical devices.
Applying padded mitts and utilizing a 1:1 sitter protects the BiPAP mask and arterial line without depressing the respiratory drive or unlawfully delegating assessments.
This strategy addresses the immediate physical threat (device removal) while honoring safety protocols regarding restraint escalation and scope of practice.

Anahtar Kavram

Accident, Error, and Injury Prevention: Restraint Alternatives and Prioritization
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Konular

Accident, Error, and Injury Prevention

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