A client with viral encephalitis is experiencing severe delirium and extreme psychomotor agitation. The client abruptly lunges forward and begins forcefully pulling at their femoral arterial sheath. Recognizing an imminent risk for catastrophic hemorrhage, the nurse determines that emergency physical restraints are required. Arrange the following nursing actions in the correct chronological sequence from first to last.
- 1Summon additional unit personnel to assist with safely stabilizing the client's limbs.
- 2Apply padded limb restraints using quick-release knots secured to the movable portion of the bed frame.
- 3Assess the client's distal pulses, skin temperature, and capillary refill in the restrained extremities.
- 4Notify the healthcare provider to conduct an in-person evaluation and provide a restraint prescription.
- 5Document the precipitating combative behavior, failed de-escalation attempts, and the exact time of application.
Cevap
The correct sequence prioritizes immediate physical safety (calling for help and applying restraints), followed by physiological assessment (circulation), legal notification (contacting the provider), and finally, administrative documentation.
In a life-threatening emergency where a client is actively pulling at a critical arterial line, the nurse must prioritize immediate physical safety. Calling for assistance ensures the intervention can be performed safely. Once help is present, applying the restraints prevents catastrophic hemorrhage. Immediately after application, circulation must be assessed to prevent limb ischemia. Finally, administrative duties are completed: the healthcare provider must be notified to evaluate the client and provide a formal prescription, followed by comprehensive documentation of the event.
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Anahtar Kavram
Emergency Application of Physical Restraints