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Zorluk: OrtaSafe Use of Restraints and Safety Devices

An older adult with advanced dementia is receiving continuous enteral nutrition through a newly placed gastrostomy tube. The client appears disoriented and repeatedly attempts to grasp and remove the tubing. Which action should the nurse take first to maintain the safety of the medical device?

  1. Camouflage the tubing by routing it under an abdominal binder or the client's clothing.Cevap
  2. B
    Apply soft limb holders to both wrists and immediately notify the healthcare provider for a prescription.
  3. C
    Administer a prescribed as-needed sedative medication to decrease the client's psychomotor agitation.
  4. D
    Direct the unlicensed assistive personnel to assess the client's level of confusion every fifteen minutes.

Cevap

Camouflage the tubing by routing it under an abdominal binder or the client's clothing.
Before applying any form of physical or chemical restraint, the nurse is legally and ethically required to attempt and document less restrictive alternative measures. Camouflaging or hiding the gastrostomy tube under an abdominal binder or clothing removes the visual stimulus for the client with dementia, which often successfully prevents them from pulling at the device without restricting their freedom of movement.

Adım Adım Çözüm

1
Analyze the clinical scenario to identify the primary problem.
A disoriented client with dementia is at risk of accidentally removing an essential medical device (gastrostomy tube).
Understanding the risk helps determine the urgency and appropriate level of intervention.
2
Recall the legal and ethical guidelines regarding the use of restraints.
The standard of care dictates that nurses must systematically attempt and document the least restrictive interventions before considering physical or chemical restraints.
Restraints pose significant physical and psychological risks and are interventions of last resort.
3
Evaluate the provided options against the principle of the least restrictive alternative.
Hiding the tubing removes the visual trigger for the client without restricting their movement, making it the safest and least restrictive first step.
Clients with advanced dementia often pull at devices simply because they see or feel them; camouflaging removes this stimulus.
4
Identify why the remaining options are incorrect.
Limb holders and sedatives bypass less restrictive alternatives. Having a UAP evaluate confusion is an improper delegation of nursing assessment.
Ensuring the chosen action does not violate legal scope of practice or restraint protocols.

Anahtar Kavram

Least Restrictive Alternatives to Restraints
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Konular

Safe Use of Restraints and Safety Devices

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