The practical nurse (PN) is preparing to apply prescribed bilateral soft wrist restraints to a client who is severely agitated and repeatedly attempting to remove a central venous catheter. All alternative, less restrictive interventions have been unsuccessful. Arrange the following actions in the chronological order the PN should perform them. All options must be used.
- 1Verify the healthcare provider's prescription for the restraints.
- 2Explain the purpose and need for the restraints to the client.
- 3Wrap the padded portion of the restraints around the client's wrists.
- 4Attach the restraint straps to the movable part of the bed frame with a quick-release tie.
- 5Check the fit by inserting two fingers between the restraints and the client's wrists.
- 6Assess the client's peripheral pulses, skin color, and temperature distal to the restraints.
Cevap
The correct sequence is: verify the prescription, explain the procedure to the client, wrap the padded restraints around the wrists, attach the straps to the movable part of the bed frame, check the fit with two fingers, and assess the distal neurovascular status.
Applying physical restraints requires a strict systematic approach to ensure patient safety and legal compliance. Verifying the prescription is always the first step. Communication with the patient follows to provide ethical care. Physical application involves padding the wrists, securing the straps to a movable bed frame using a quick-release knot, and verifying appropriate tightness by inserting two fingers. Finally, an immediate neurovascular assessment ensures the restraints are not compromising distal circulation.
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Anahtar Kavram
Chronological procedure for the safe application and monitoring of physical restraints.