During a night shift, a client recovering from a complicated bowel resection becomes profoundly restless and starts forcefully pulling at their wound vacuum dressing and peripheral intravenous line. Sequence the following nursing actions from the initial priority intervention to the most restrictive emergency measure.
- 1Assess the client's physiological status, including oxygenation and pain levels, to identify reversible causes of agitation.
- 2Implement non-restrictive diversional activities and frequently reorient the client to the environment.
- 3Conceal the intravenous site and wound dressing by covering them with loose, stockinette material.
- 4Apply bilateral soft wrist restraints using a quick-release knot tied to the movable portion of the bed frame.
- 5Notify the healthcare provider immediately to evaluate the client and issue a time-limited restraint prescription.
Answer
The correct sequence of interventions progresses from physiological assessment to the least restrictive behavioral alternatives, followed by device concealment, emergency restraint application, and concluding with provider notification.
The standard of care for restraint application requires a stepwise approach starting with assessing and treating underlying causes (e.g., hypoxia, pain). If agitation persists, the nurse must exhaust least restrictive measures (diversion, device concealment) before initiating physical restraints. When restraints are applied in an emergency to prevent self-harm, the provider must be notified immediately for an evaluation and a time-limited order.
Step-by-Step Solution
Key Concept
Restraint Escalation Protocol and Least Restrictive Alternatives
Estimated Time:1m 30s