A confused patient is restless and continues to try to remove his oxygen and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?

Question

a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail.
b. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.
c. Disturbed body image: Encourage patient to express concerns about body.
d. Caregiver role strain: Identify resources to assist with care.

Answer 1

ANS: A
The priority nursing diagnosis is risk for injury. This patient could cause harm to himself by interrupting the oxygen therapy or by damaging the urethra by pulling the urinary catheter out. Before restraining a patient, it is important to implement and exhaust alternatives to restraint. Alternatives can include distraction and providing companionship or supervision. Patients may be moved to a location closer to the nurses' station; trained sitters or family members may be involved. Nurses need to ensure that patients are provided adequate food, liquid, toileting, and relief from pain. If these and other alternatives fail, this individual may need restraints; in this case, an order would need to be obtained for the restraint. This patient may have deficient knowledge; educating the patient about treatments could be considered as an alternative to restraints; however, the nursing diagnosis of highest priority is risk for injury. This scenario does not indicate that the patient has a disturbed body image or that the patient's caregiver is strained.