The primary care provider has prescribed bilateral soft wrist restraints for a client who is severely disoriented and continuously interfering with a newly inserted chest tube. After gathering the necessary supplies, arrange the nurse's subsequent actions in the correct chronological sequence, from first to last.
- 1Explain the rationale for the safety device to the client and any present family members.
- 2Wrap the restraint device around the client's wrist with the padded portion against the skin.
- 3Insert two fingers between the applied restraint and the client's wrist to verify proper fit.
- 4Fasten the restraint straps to the movable portion of the bed frame using a quick-release knot.
- 5Document the prior alternative interventions attempted and the exact time of restraint application.
Answer
The correct sequence is: Explain the rationale, wrap the restraint with padding against the skin, insert two fingers to verify fit, fasten the straps to the movable bed frame, and document the intervention.
The correct sequence prioritizes client communication and ethical care first, followed by the safe physical application of the device to the wrist. After the wrist cuff is secured and the fit is verified to prevent circulatory impairment, the limb is safely anchored to a movable part of the bed using an emergency release knot. Finally, comprehensive legal documentation is completed to reflect the procedure.
Step-by-Step Solution
Key Concept
Safe application and monitoring of physical restraints requires a standardized, sequential approach to protect the client's rights, maintain skin integrity, prevent neurovascular compromise, and ensure emergency accessibility.