A nurse is caring for a client with acute delirium who is repeatedly attempting to pull out a central venous catheter. Arrange the following nursing actions in the correct chronological sequence, progressing from the least restrictive initial intervention to the application and management of restraints.
- 1Assess the client for underlying, reversible causes of agitation, such as pain, hypoxia, or a full bladder.
- 2Implement non-restrictive safety alternatives, such as a bed alarm, frequent rounding, and verbal reorientation.
- 3Contact the healthcare provider to obtain a formal prescription for physical restraints.
- 4Apply the soft wrist restraints and secure them to the movable part of the bed frame using a quick-release knot.
- 5Document the client's behavior, the specific ineffective alternatives trialed, and the details of the restraint application.
Answer
The correct sequence is: assess for underlying causes, implement non-restrictive alternatives, obtain a provider prescription, apply restraints safely to the movable bed frame, and document the intervention comprehensively.
The standard of care for safety devices requires a strict, stepwise approach. The nurse must first attempt to identify and resolve underlying causes of agitation. If this fails, least restrictive alternatives must be trialed. Only when alternatives are ineffective and the client poses an immediate risk to themselves can the nurse seek a provider's prescription for restraints. After applying the restraints safely, thorough documentation is legally and clinically mandated.
Step-by-Step Solution
Key Concept
Prioritization of safety measures progressing from the least restrictive alternatives to the safe application and legal documentation of physical restraints.