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Difficulty: EasySafe Use of Restraints and Safety Devices

A nurse is caring for a client in the intensive care unit who is agitated and repeatedly attempting to remove their nasogastric (NG) tube. Arrange the following nursing interventions in the order they should be implemented, from least restrictive to most restrictive.

  1. 1Reorient the client to the environment and explain the necessity of the tube.
  2. 2Provide the client with a stress ball to squeeze.
  3. 3Secure the tube out of the client's immediate line of sight.
  4. 4Place bilateral hand mittens that are not tethered to the bed.
  5. 5Apply soft limb restraints attached to the movable part of the bed frame.

Answer

The correct sequence from least to most restrictive is: reorient the client, provide a diversionary activity (stress ball), conceal the tube out of sight, apply non-tethered hand mittens, and finally apply tethered soft limb restraints.
In nursing practice, the principle of the least restrictive environment mandates that non-physical and less restrictive interventions must be attempted and documented before applying mechanical restraints. The sequence correctly progresses from cognitive interventions (reorientation) to behavioral strategies (diversion), environmental modifications (concealing the tube), low-level physical barriers (mittens), and finally high-level physical restraints (tethered limb restraints).

Step-by-Step Solution

1
Identify the least restrictive, non-physical intervention.
Reorient the client to the environment and explain the necessity of the tube.
Verbal communication addresses potential confusion without restricting the client in any way.
2
Identify the next least restrictive behavioral intervention.
Provide the client with a stress ball to squeeze.
Diversionary activities keep the hands safely occupied without applying any physical barriers.
3
Identify an environmental modification that reduces triggers.
Secure the tube out of the client's immediate line of sight.
Removing the visual stimulus can decrease the urge to pull on the equipment.
4
Select the least restrictive physical device.
Place bilateral hand mittens that are not tethered to the bed.
Mittens prevent the fine motor skill of grasping the tube but allow the client to move their arms freely.
5
Identify the most restrictive physical intervention.
Apply soft limb restraints attached to the movable part of the bed frame.
Tethering the client's limbs to the bed severely restricts movement and is only used when all other alternatives fail.

Key Concept

Principle of Least Restrictive Environment
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Topics

Safe Use of Restraints and Safety Devices

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