A practical nurse (PN) is assigned to care for a client with a traumatic brain injury who is highly restless and repeatedly attempting to pull out a newly placed gastrostomy tube. The healthcare provider has prescribed bilateral soft wrist restraints. In what order should the PN perform the following steps to safely implement this prescription? Arrange the actions from first to last.
- 1Verify the specific parameters and duration in the provider's prescription.
- 2Explain the safety rationale for using the restraints to the client and family members.
- 3Wrap the padded portion of the soft restraint securely around the client's wrists.
- 4Fasten the restraint straps to the movable portion of the bed frame using a quick-release knot.
- 5Slide two fingers between the restraint and the client's skin to ensure adequate circulation.
Cevap
The correct sequence is to first verify the prescription, then explain the rationale to the client and family, apply the padded restraint to the wrists, fasten the straps to the movable bed frame, and finally check the fit with two fingers.
The sequence of restraint application must prioritize legal authorization, ethical communication, and strict physical safety. The practical nurse must first verify the prescription to ensure legal compliance. Next, educating the client and family promotes understanding. The physical application follows, starting with wrapping the padded portion to protect the skin. The restraint is then secured to the movable part of the bed frame with a quick-release knot to prevent injury during bed adjustments and allow rapid removal if needed. Finally, the nurse checks the fit by sliding two fingers under the restraint to confirm it is not too tight, protecting the client's neurovascular status.
Adım Adım Çözüm
Anahtar Kavram
Safe Implementation and Mechanics of Physical Restraints