A nurse is developing a safety care plan for an older adult client with advanced dementia who is at a high risk for falls. To strictly adhere to the ethical and legal principle of utilizing the least restrictive environment, arrange the following fall prevention interventions in order of implementation, from the LEAST restrictive (baseline measure) to the MOST restrictive (last resort).
- 1Implement universal safety measures by keeping the bed in the lowest position and locking the wheels.
- 2Apply specific visual identifiers, such as a color-coded fall-risk wristband and non-slip footwear.
- 3Activate a weight-sensitive bed and chair alarm system to alert staff of unassisted movement.
- 4Relocate the client to a room directly adjacent to the nursing station for increased visual surveillance.
- 5Obtain a prescription for a continuous 1:1 dedicated safety sitter to remain constantly at the bedside.
Cevap
The interventions must be sequenced progressively from universal, non-restrictive baseline precautions up to continuous, highly restrictive human observation.
The sequence correctly applies the ethical and legal principle of the least restrictive environment to fall prevention. The nurse must start with universal baseline precautions, progress to non-restrictive visual identifiers, introduce technological monitoring when risk increases, escalate to environmental surveillance (room relocation) if alarms are insufficient, and finally resort to constant human observation only when all lesser interventions fail to ensure safety.
Adım Adım Çözüm
Anahtar Kavram
Escalation of fall prevention strategies based on the principle of the least restrictive environment.
Tahmini Süre:1m 30s