A practical nurse (PN) responds to a continuous bed alarm. Upon entering the room, the PN discovers a client experiencing acute delirium who has firmly grasped their pleural chest tube and is actively trying to remove it. The client is highly combative and cannot be verbally de-escalated. Arrange the following nursing interventions in the correct order of execution from first to last.
- 1Physically hold the client's hands to prevent the immediate dislodgment of the chest tube.
- 2Activate the room's emergency call system to request immediate staff assistance.
- 3Apply temporary bilateral soft wrist restraints with the assistance of other staff members.
- 4Contact the healthcare provider to evaluate the client and issue a physical restraint order.
- 5Document the precipitating behavior, the emergency interventions utilized, and the initial neurovascular assessment.
Answer
The correct priority sequence is to first physically protect the life-sustaining device, activate the call system for staff assistance, apply the emergency restraints with help, notify the healthcare provider for a clinical evaluation and formal prescription, and finally document the incident.
In life-threatening emergencies where a client is actively attempting to remove a critical medical device, the nurse's immediate priority is physiological safety. Physical interventions and restraints may be applied emergently without a prior prescription to prevent severe harm, provided the nurse obtains immediate assistance and the healthcare provider is notified directly afterward for a formal evaluation and order.
Step-by-Step Solution
Key Concept
Emergency Application of Physical Restraints