A nurse is providing care for a client recovering from a traumatic brain injury who is becoming increasingly restless and repeatedly attempting to pull out their enteral feeding tube. To ensure client safety while following the legal and ethical principle of least restrictive interventions, arrange the following nursing actions in the correct sequence from first to last.
- 1Assess the client for physiological causes of agitation, such as pain, hypoxia, or a full bladder.
- 2Implement environmental modifications, such as turning on the bed alarm and decreasing room noise.
- 3Disguise the medical device by covering the enteral feeding tube with a loose abdominal binder.
- 4Arrange for continuous one-to-one observation by a trained staff member to redirect the client.
- 5Contact the primary healthcare provider to obtain a prescription for soft wrist restraints.
Answer
The correct sequence begins with assessment to identify reversible causes, followed by escalating interventions from the least restrictive (environmental modifications and disguising the tube) to continuous observation, and finally ending with the most restrictive intervention (obtaining a prescription for physical restraints).
Safe restraint use requires strict adherence to the nursing process and the legal principle of least restrictive interventions. Assessment always comes first to rule out immediately reversible physiological causes (like a full bladder or hypoxia). Once physiological needs are met, the nurse must exhaust a hierarchy of alternatives: general environmental safety (alarms, quiet room), targeted device protection (binders, sleeves), and direct human supervision (sitter). Only when all these have failed to keep the client safe can the nurse legally request a prescription for physical restraints.
Step-by-Step Solution
Key Concept
The principle of least restrictive interventions and restraint escalation protocols.