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Zorluk: KolayAccident, Error, and Injury Prevention

The healthcare provider has prescribed soft wrist restraints for a client who is severely confused and repeatedly attempting to remove a central venous catheter. All alternative measures have been ineffective. In what order should the nurse perform the following actions to safely apply the restraints? Arrange the steps in the correct chronological sequence.

  1. 1Explain the purpose of the restraints to the client and family.
  2. 2Pad the client's wrists over the bony prominences.
  3. 3Wrap the restraint securely around the client's wrist.
  4. 4Attach the restraint straps to the movable portion of the bed frame.
  5. 5Assess the client's peripheral pulses, skin color, and temperature.

Cevap

The correct sequence is: Explain the purpose, pad the wrists, wrap the restraint, attach straps to the movable bed frame, and assess peripheral pulses.
Safe application of restraints follows a logical nursing process: communication, preparation, application, securing, and evaluation. The nurse first communicates with the client, then protects the skin by padding bony prominences. Next, the restraint is wrapped and safely secured to the movable part of the bed frame using a quick-release knot. Finally, the nurse evaluates the client's neurovascular status to ensure the restraint is not too tight.

Adım Adım Çözüm

1
Explain the purpose of the restraints to the client and family.
The client and family are informed about the intervention.
Ethical practice and standard procedure require explaining interventions prior to starting, which may also help decrease client anxiety.
2
Pad the client's wrists over the bony prominences.
The skin over the wrist bones is protected.
Padding mitigates the risk of skin breakdown and pressure injuries caused by the friction of the restraint.
3
Wrap the restraint securely around the client's wrist.
The restraint is applied to the client.
With the skin protected, the physical restraint can now be safely wrapped around the extremity. The nurse should ensure two fingers can fit under the restraint.
4
Attach the restraint straps to the movable portion of the bed frame.
The restraint is secured to the bed.
Securing straps to the movable part of the bed frame ensures that if the head or foot of the bed is adjusted, the restraint moves with the client, preventing joint dislocation or severe injury. Straps should never be tied to side rails.
5
Assess the client's peripheral pulses, skin color, and temperature.
The client's neurovascular status is evaluated.
Immediately after application, the nurse must verify that the restraint is not occluding blood flow or causing nerve damage.

Anahtar Kavram

Safe Initiation and Application of Physical Restraints
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Konular

Accident, Error, and Injury Prevention

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