An older adult client with advanced Alzheimer's disease is admitted for severe dehydration. The client continuously attempts to pull out their peripheral intravenous (IV) line despite the implementation of multiple non-restrictive safety measures. The healthcare provider has prescribed bilateral soft wrist restraints. Arrange the following nursing actions in the correct sequence of execution from first to last.
- 1Review the healthcare provider's prescription to verify the clinical justification and time limits.
- 2Explain the purpose of the safety device and the criteria for its removal to the client.
- 3Wrap the cuffs around the client's wrists and verify that two fingers can slide beneath them.
- 4Secure the restraint ties to the movable part of the bed frame using a quick-release knot.
- 5Assess and document the client's distal pulses, capillary refill, and skin integrity.
Answer
The correct sequence is to first review the prescription, then explain the procedure to the client, apply the cuffs checking for a two-finger clearance, secure the ties to the movable bed frame, and finally assess and document distal circulation.
The application of physical restraints requires a strict, systematic approach to prioritize legal requirements, client rights, and safety. First, a valid healthcare provider's prescription must be verified. Next, the nurse must explain the procedure to the client to reduce anxiety. The restraints are then applied to the wrists, ensuring a two-finger gap remains to maintain adequate circulation. After proper placement, the ties are secured to the movable part of the bed frame using a quick-release knot, which prevents injury when the bed is adjusted. Finally, the nurse must immediately assess and document the client's distal neurovascular status.
Step-by-Step Solution
Key Concept
Safe application and monitoring of physical restraints requires a stepwise approach to ensure legal compliance, client dignity, and physical safety.
Estimated Time:1m 30s