A confused patient with a urinary catheter, nasogastric tube, and intravenous line keeps touching these needed items for care. The nurse has tried to explain to the patient that he should not touch these lines, but the patient continues

Question

What is the best action by the nurse at this time?
a. Apply restraints loosely on the patient's dominant wrist.
b. Try other approaches to prevent the patient from touching these care items.
c. Notify the health care provider that restraints are needed immediately to maintain the patient's safety.
d. Allow the patient to pull out lines to prove that the patient needs to be restrained.

Answer 1

ANS: B
The risks associated with the use of restraints are serious. A restraint-free environment is the first goal of care for all patients. Many alternatives to the use of restraints are available, and the nurse should try all of them before notifying the patient's health care provider. The situation states that the patient is touching the items, not trying to pull them out. At this time, the patient's well-being is not at risk. The nurse will have to check on the patient frequently and then will determine if the health care provider needs to be informed of the situation. Restraints can be used (1) only to ensure the physical safety of the resident or other residents, (2) when less restrictive interventions are not successful, and (3) only on the written order of a health care provider. The health care provider needs to know the situation but also needs to know that all approaches possible have been used before writing an order for restraints. Allowing the patient to pull out any of these items could cause harm to the patient.