A nurse is caring for a client with acute confusion who is repeatedly attempting to remove a surgical wound drain. Arrange the following nursing interventions in the correct sequence, starting from the least restrictive measure to the most restrictive.
- 1Assess the client for reversible causes of confusion, such as pain, hypoxia, or a full bladder.
- 2Implement non-restraint alternatives, such as concealing the drain under clothing or providing a diversionary activity.
- 3Contact the healthcare provider to obtain a specific, time-limited prescription for physical restraints.
- 4Apply the physical restraints, securing them to the movable portion of the bed frame with a quick-release knot.
- 5Document the alternatives attempted, the restraint application, and initiate regular neurovascular assessments.
Cevap
The correct sequence begins with assessing for reversible causes, followed by implementing non-restraint alternatives. If these fail, the nurse obtains a time-limited provider prescription, applies the restraints safely to the movable bed frame, and then documents and monitors the client.
In accordance with safety and legal standards, nursing care must progress from the least restrictive to the most restrictive interventions. The nurse first assesses for underlying, reversible causes of confusion. If the behavior persists, non-restraint alternatives like diversion or hiding the medical device are implemented. Only when these alternatives fail should the nurse contact the provider for a specific, time-limited restraint prescription. Once ordered, the restraints are applied safely to a movable part of the bed frame using a quick-release knot, followed by rigorous documentation and scheduled neurovascular assessments.
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Anahtar Kavram
When considering restraints, the nurse must strictly follow an escalation protocol from least restrictive (assessment and alternatives) to most restrictive (prescription, safe application, and ongoing monitoring).