A client with advanced dementia is at high risk for severe falls and has a new prescription for a belt restraint while sitting in a wheelchair. The practical nurse (PN) is preparing to initiate the use of the restraint. Arrange the following actions the PN should take in the correct chronological order from first to last.
- 1Verify the healthcare provider's current prescription for the restraint.
- 2Explain the purpose of the restraint to the client in a calm and reassuring manner.
- 3Place the belt restraint around the client's waist, over their clothing or gown.
- 4Slide two fingers between the restraint and the client's body to ensure adequate fit.
- 5Attach the restraint ties to the structural frame of the wheelchair using a quick-release knot.
Answer
The correct sequence is to first verify the prescription, explain the procedure to the client, place the restraint over clothing, check the fit with two fingers, and finally secure the ties to the structural wheelchair frame.
The proper sequence for restraint application begins with verifying the provider's prescription to ensure authorization. The nurse then communicates with the client to explain the procedure and reduce anxiety. Next, the restraint is positioned over clothing to protect the skin from breakdown. The nurse subsequently evaluates the fit by sliding two fingers underneath the restraint to prevent constriction of breathing or circulation. Lastly, the restraint is anchored to a stable, structural component of the wheelchair with a quick-release knot, ensuring it can be removed immediately if a safety emergency occurs.
Step-by-Step Solution
Key Concept
The correct procedural steps for applying a restraint prioritize legal verification, client communication, safe physical application, fit assessment, and secure attachment for emergency accessibility.