A client in a subacute respiratory care unit is experiencing severe confusion and repeatedly attempts to remove their tracheostomy tube. After determining that alternative measures and verbal redirection are ineffective, the healthcare provider prescribes bilateral soft limb restraints. In what order should the practical nurse (PN) perform the following actions to safely apply the devices? (Arrange the actions in the correct sequence, from first to last.)
- 1Provide an explanation of the safety intervention to the client and family.
- 2Wrap the commercially prepared soft limb restraints around the wrists.
- 3Attach the restraint straps to the movable segment of the bed frame with quick-release knots.
- 4Slide two fingers between the restraint and the client's skin to confirm proper fit.
- 5Examine the distal pulses, skin color, and temperature of both hands.
Answer
The correct sequence is: Explain the intervention, wrap the restraints around the wrists, attach the straps to the movable bed frame, check the fit with two fingers, and finally assess the distal neurovascular status.
The correct sequence prioritizes client communication and ethical care first, followed by the safe mechanical application of the devices. Once the devices are wrapped around the wrists and securely anchored to a movable frame with quick-release knots, the nurse must immediately verify the fit (two-finger space) to prevent constriction. Finally, a complete neurovascular assessment (pulses, color, temperature) must be performed and documented to ensure circulation and nerve function are intact.
Step-by-Step Solution
Key Concept
The safe application of physical restraints involves a systematic sequence prioritizing communication, correct mechanical application to a movable bed frame, and immediate neurovascular verification.