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Zorluk: OrtaAccident, Error, and Injury Prevention

A nurse is caring for an older adult client with dementia who is confused and repeatedly attempting to pull out a peripheral intravenous (IV) catheter. Which interventions should the nurse implement as alternatives to physical restraints? Select all that apply.

  1. Apply a loose stockinette or elastic bandage over the IV site to conceal it.Cevap
  2. Relocate the client to a room closer to the nursing station.Cevap
  3. Provide the client with a safe, repetitive activity such as folding washcloths.Cevap
  4. D
    Elevate all four bed side rails to prevent the client from exiting the bed unassisted.
  5. E
    Administer a prescribed as-needed (PRN) dose of a sedative medication to calm the client.
  6. F
    Instruct the unlicensed assistive personnel (UAP) to assess the client's behavior and orientation every 15 minutes.

Cevap

The nurse should conceal the IV site with a stockinette, relocate the client near the nursing station, and provide a diversionary activity like folding washcloths.
Effective alternative interventions to restraints focus on reducing the client's urge to interfere with medical devices and ensuring close monitoring without restricting their freedom of movement. Concealing the IV site with a loose bandage removes the visual trigger. Relocating the client near the nursing station allows for frequent visual checks by the staff. Providing a safe, repetitive activity distracts the client and channels their restless energy safely.

Adım Adım Çözüm

1
Identify the primary safety concern and the goal of care.
The client is at high risk of dislodging their IV line, and the goal is to prevent this using the least restrictive non-pharmacological measures possible.
Physical and chemical restraints are interventions of last resort due to their associated risks of injury, physiological complications, and loss of dignity.
2
Evaluate each intervention to determine if it is a safe, non-restrictive alternative.
Concealing the site, increasing supervision by moving the room, and providing a diversion are non-restrictive alternatives. Using four side rails and sedatives are actual restraints. Delegating an assessment is outside the UAP's scope of practice.
Nursing interventions must adhere to safety protocols, legal definitions of restraints, and the appropriate scope of practice for delegation.

Anahtar Kavram

Restraint alternatives and maintaining a safe care environment
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