An intensive care nurse is managing an intubated client who is severely agitated and attempting to remove the endotracheal tube. After less restrictive measures have failed, the nurse initiates the application of bilateral soft wrist restraints. Arrange the following nursing actions in the correct chronological order from first to last.
- 1Call for assistance from other healthcare personnel.
- 2Secure the restraint straps to the movable part of the bed frame.
- 3Evaluate peripheral pulses, capillary refill, and skin temperature.
- 4Contact the primary healthcare provider to obtain the restraint prescription.
- 5Document the interventions, client behaviors, and neurovascular assessments in the medical record.
Answer
The correct sequence is: obtaining staff assistance, applying the restraints to the movable bed frame, assessing neurovascular status, contacting the healthcare provider for a prescription, and documenting the event.
In a behavioral emergency where a client poses an immediate risk to themselves (such as pulling out an endotracheal tube), the nurse's first priority is securing the client safely with the help of other staff. Once help is present, the restraints are applied correctly to the movable portion of the bed frame to prevent injury during bed adjustments. Immediately following application, the nurse must perform a neurovascular assessment to ensure circulation is not compromised. After the client is physically safe and stable, the nurse contacts the healthcare provider to obtain the required prescription, and finally documents the entire event.
Step-by-Step Solution
Key Concept
Emergency application of physical restraints and priority sequencing