A practical nurse (PN) is preparing to implement a new prescription for mechanical wrist restraints for a client who is severely agitated and attempting to remove their central venous catheter. Place the following nursing actions in the correct chronological order.
- 1Confirm the provider's written prescription and specific clinical indications.
- 2Discuss the rationale for the safety device with the client.
- 3Place protective padding around the client's wrists.
- 4Fasten the device straps to the articulating section of the bed using a slip knot.
- 5Evaluate distal perfusion, sensation, and motor function.
Answer
The correct sequence is to first confirm the provider's prescription, then discuss the rationale with the client, apply protective padding to the wrists, fasten the straps to the movable section of the bed frame using a quick-release knot, and finally evaluate the client's neurovascular status distal to the device.
The correct sequence follows the standard of care for restrictive device application. Verification of the legal order ensures authorization; communication respects client rights; padding prevents skin breakdown during application; securing to an articulating frame with a slip knot ensures physical safety; and immediate neurovascular assessment confirms the device is not overly restrictive.
Step-by-Step Solution
Key Concept
Safe application of physical restraints requires a systematic approach beginning with legal order verification, followed by client education, proper physical application techniques to prevent injury, and immediate post-application neurovascular assessment.