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Scenario question

Med-Surg   (1,709 Views 4 Comments)
by sv123 sv123 (New Member) New Member

420 Visitors; 3 Posts

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Hey I have a question. If you have a patient who is confused, is pulling out their foley and IV line what should you do? or what steps would you take in this scenario ?

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209 Likes; 1 Follower; 44,050 Visitors; 2,935 Posts

Both your questions sound like homework or maybe you were asked these questions during a job interview? If you give some details, even admit they are homework questions or questions asked during a job interview and you weren't sure how to respond you will receive better responses.

Anyway the pulling out IV's and foley depends on the patient and their situation. If for some reason, they had just had bladder surgery and critically needed the foley to stay in, and their IV was infusing blood or some critical fluids. Then you would need a doctor's order for chemical and or physical restraints. But you can also problem solve, is there some reason the patient is doing this? Is the IV infiltrated, is the foley balloon in the urethra, not the bladder.

If they were elderly, in a skilled nursing facility, of course let the doctor know, but problem solve before you call the doctor. Do they even need the IV, have they been eating or drinking better? Do they even still need the foley (many hospitals and skilled nursing facilities are not using foleys any more). Has their mental or physical status changed so they can get up to a bedside commode or the toilet?

I had a mentally disabled child brought to me in PACU after a minor procedure. He was in wrist restraints. He was agitated, pulling at the restraints, etc. I am so brilliant (ha ha), I removed the wrist restraints, he curled over on his side and went to sleep! He just wanted to lie on his side!!!!

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vintagemother works as a Nurse and Mom.

7 Likes; 44,097 Visitors; 2,687 Posts

I've BTDT. In my facility you get an order for restraints. 😂

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ClaraRedheart has 4 years experience as a BSN, RN and works as a Med-Surg Tele Nurse.

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Cover the IV with an ace wrap. Find something for them to do to distract from the foley. We have these little apron things that would entertain a toddler, but also a demented adult. Bed alarm. If none of this is helping, let the charge nurse know. This patient would likely need a sitter. Let the doc know as well. If we can't get a sitter or keep an IV in, we might need restraints, but that is absolute last result in my facility.

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