An intubated client in the intensive care unit is awakening from sedation and repeatedly reaches for their endotracheal tube. To ensure client safety and prevent an unplanned extubation, arrange the following nursing interventions in the correct sequence from the least restrictive to the most restrictive.
- 1Provide a calm presence and verbally explain the purpose of the breathing tube to the client.
- 2Assign a trained sitter for continuous one-to-one observation to gently redirect the client's hands.
- 3Apply soft hand mitts that are not tethered to the bed frame.
- 4Secure bilateral soft wrist restraints to the movable portion of the bed frame.
Answer
The correct sequence from least to most restrictive is: providing verbal explanation, assigning a one-to-one sitter, applying unanchored soft mitts, and finally applying anchored wrist restraints.
The standard of care requires nurses to use a stepwise approach, starting with the least restrictive measures. Verbal explanation involves no physical limitation. A sitter provides human supervision without physical devices. Unanchored mitts restrict fine motor grasping but allow arm movement. Anchored wrist restraints severely limit mobility and are the most restrictive.
Step-by-Step Solution
Key Concept
When managing a client at risk for disrupting critical life-sustaining therapies, nurses must exhaust all alternative, less restrictive interventions before applying physical restraints, ensuring the client's safety while preserving autonomy as much as possible.