for the week of 02.20.06
A 78 year-old client with pneumonia has a productive cough, but is confused. Safety protective devices (restraints) have been ordered for this client. How can the nurse prevent aspiration?
1. Suction the client frequently while restrained
2. Secure all 4 restraints to 1 side of bed
3. Obtain a sitter for the client while restrained
4. Request an order for a cough suppressant
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1 comment:
The correct answer is number: 3
The plan to use safety devices (restraints) should be rethought. Restraints are used to protect the client from harm caused by removing tubes or getting out of bed. In the event that this restricted movement could cause more harm, such as aspiration, then a sitter should be requested. These are to be provided by the facility in the event the family cannot do so. This client needs to cough and be watched rather than restricted. Suctioning will not prevent aspiration in this situation. Cough suppressants should be avoided for this client.
Smeltzer, S.C., & Bare, B.G. (2004)
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Philadelphia, PA. Lippincott Williams & Wilkins.
Altman, G. (2004)
Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.
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