A practical nurse (PN) discovers a confused client actively pulling at their newly inserted chest tube. After calling for assistance and attempting verbal de-escalation without success, the charge nurse initiates the emergency application of soft wrist restraints. Arrange the following actions in the correct chronological sequence for safe restraint application and management.
- 1Have an assisting staff member manually hold the client's hands to prevent immediate tube dislodgement.
- 2Apply protective padding around the client's wrists before placing the restraint devices.
- 3Secure the restraint ties to the movable portion of the bed frame using quick-release knots.
- 4Assess the client's bilateral radial pulses, skin temperature, and capillary refill.
- 5Verify that the healthcare provider is notified to conduct an evaluation and provide a formal restraint order.
Cevap
The correct sequence is: (1) Implement a manual hold to prevent immediate harm, (2) Apply padding to the wrists, (3) Secure ties to the movable bed frame with a quick-release knot, (4) Assess neurovascular status, and (5) Notify the provider for a formal evaluation and order.
The correct chronological sequence prioritizes the immediate preservation of life (stopping the removal of the chest tube via manual hold), followed by the safe physical application of the restraint (padding, then securing to the movable frame). Once the client is safely secured, immediate clinical assessment (neurovascular check) is required to ensure no physical harm was caused by the application. Finally, the administrative and legal requirement of notifying the provider for a formal order is fulfilled.
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Anahtar Kavram
Emergency Restraint Application Sequence and Safety
Tahmini Süre:1m 30s