A confused patient who wants to leave
You are a health services assistant on a subacute ward at 9:30 pm. Mr Bryce, 78, was admitted two days ago after a fall at home and has mild cognitive impairment. He is dressed in his coat over pyjamas and is walking toward the exit, saying his wife is waiting for him. His wife died three years ago according to the handover. His gait is unsteady, he has a cannula in his left hand and he has not had his evening medications. The ward has one RN and one assistant on night shift for 18 patients. The door is locked but he is pressing the release button.
1. What is your immediate priority, and how do you balance his autonomy against his safety?
Read the worked answer
Immediate priority is to prevent a fall or an unobserved exit while keeping Mr Bryce calm. Approach from the front, speak slowly, use his name and do not block or grab him, which can provoke resistance or a fall.
Balance autonomy and safety:
- He has mild cognitive impairment, not necessarily a lack of capacity, but his belief that his wife is waiting suggests a delusion or delirium. The new admission, possible infection, pain and missed medications are all reversible causes worth flagging.
- His unsteady gait, cannula and night-time setting make leaving unsafe right now.
- Autonomy is respected by offering choices he can make safely: sit in the lounge with a cup of tea, call his son, or have the RN review him now.
Actions: walk with him, guide him away from the door without confrontation, use the call bell to alert the RN, and stay with him. Do not physically restrain him unless there is an immediate risk of serious harm, and then only with RN direction and minimum force. Document the event and the trigger. Ask the RN to review for delirium, pain, urinary retention and medication needs, and consider a special observation plan.
2. The RN is busy with another patient. Explain what you would do and what you must not do.
Read the worked answer
You must not leave Mr Bryce unsupervised at the door, and you must not sedate, restrain or medicate him - those are outside your scope. You also must not promise that his wife is coming.
Do:
- Stay with him and use redirection and reassurance: 'Let's sit down while I find out about your wife.'
- Press the call bell or use the ward phone to alert the RN with a concise, urgent message: 'Mr Bryce is at the exit door, unsteady, cannula in situ, please come now.'
- Move him to a quieter, safer area away from the door if he will come.
- Check for a reversible cause you can act on within your role: pain, thirst, needing the toilet, being cold.
- Document the time, behaviour, interventions and outcome, and complete an incident report if he reached the door.
Reasoning: your scope covers observation, communication, safety and escalation, not restraint or sedation. Clear, urgent escalation is the correct action even when the RN is busy; a patient at an exit door with a cannula is a higher priority than routine tasks.