An older adult client with severe metabolic encephalopathy is persistently disrupting a continuous central venous infusion despite multiple documented less restrictive interventions. The healthcare provider has just prescribed bilateral soft wrist restraints. Arrange the nurse's subsequent actions in the correct chronological sequence of implementation.
- 1Verify that the provider's prescription is current, time-limited, and specifies the clinical justification.
- 2Explain the rationale for the safety devices to the client and any present family members.
- 3Perform a baseline assessment of the client's skin integrity and peripheral vascular status in both arms.
- 4Wrap the padded cuffs around the client's wrists, ensuring enough space to insert two fingers underneath.
- 5Tie the restraint straps to the movable portion of the bed frame utilizing a quick-release knot.
Answer
The correct sequence is to first verify the prescription, then educate the client and family, perform a baseline neurovascular assessment, apply the restraints with appropriate clearance, and finally secure the straps to a movable part of the bed.
The correct chronological sequence reflects fundamental nursing principles: validating legal authorization (verifying the order), prioritizing psychosocial needs and ethics (education), utilizing the nursing process (baseline assessment), and finally implementing the intervention safely (application and securing).
Step-by-Step Solution
Key Concept
The application of medical-surgical restraints follows a strict legal and procedural sequence prioritizing order verification, informed care, baseline assessment, and evidence-based safety techniques.