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Difficulty: MediumUse of Restraints and Safety Devices

A practical nurse (PN) is preparing to apply bilateral soft wrist restraints to a client with severe agitation who is actively disrupting life-saving medical devices. The least restrictive alternatives have been unsuccessful. Arrange the following steps for restraint application in the correct chronological order.

  1. 1Verify the provider's current prescription for the specific type of physical restraint.
  2. 2Inspect the skin integrity and baseline neurovascular status of the extremities.
  3. 3Pad the client's wrists and apply the restraint device.
  4. 4Secure the restraint straps to the movable portion of the bed frame using a quick-release tie.
  5. 5Insert two fingers under the applied restraint to evaluate the fit.
  6. 6Document the client's behavior, the application process, and initial assessment findings.

Answer

The correct sequence is: Verify the prescription, assess baseline skin/neurovascular status, pad and apply the restraints, secure to the movable bed frame, verify the fit using two fingers, and document the procedure.
Applying restraints requires a systematic approach prioritizing legality and safety. The nurse must first ensure an order exists. Next, a baseline assessment is vital before placing the padded device on the client. Securing the device safely to the movable bed frame and verifying the tightness follow to prevent injury. Finally, the entire process must be promptly documented according to legal standards.

Step-by-Step Solution

1
Verify the provider's prescription.
Legal authorization for the specific restraint is confirmed.
Restraints require a valid medical order detailing the specific type and clinical justification.
2
Inspect baseline skin and neurovascular status.
Baseline data is collected for future comparison.
The nurse must know the initial circulatory and integumentary status to detect any impairment caused by the restraints later.
3
Pad the wrists and apply the restraint.
The device is placed on the client safely.
Padding prevents skin breakdown and friction injuries during patient movement.
4
Secure the straps to the movable portion of the bed frame.
The restraints are anchored securely.
Anchoring to the movable frame (not side rails) prevents injury if the bed position is adjusted.
5
Check the fit with two fingers.
Optimal tightness is confirmed.
The two-finger rule ensures the restraint is tight enough to restrict unwanted movement but loose enough to maintain adequate blood flow.
6
Document the procedure.
A legal and clinical record is established.
Thorough documentation immediately after application is required to prove compliance with safety protocols and scope of practice.

Key Concept

Procedural mechanics and safety guidelines for applying physical restraints.
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Topics

Use of Restraints and Safety Devices

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