An acutely agitated adult client is continuously attempting to pull out a life-saving central venous catheter. The nurse determines that all less restrictive measures have failed and emergency bilateral soft wrist restraints are necessary to prevent immediate injury. Arrange the following nursing actions in the correct chronological sequence.
- 1Apply the soft wrist restraints directly to the client's wrists.
- 2Secure the restraint straps to the movable portion of the bed frame using a quick-release tie.
- 3Insert two fingers under the secured restraints to verify appropriate fit.
- 4Contact the healthcare provider to evaluate the client and obtain a formal emergency prescription.
- 5Document the client's behavior, the alternatives attempted, and the exact time of restraint application.
Cevap
The correct sequence prioritizes immediate client safety by applying and securing the restraints, immediately verifying safe application with a two-finger check, obtaining the required provider prescription, and finally documenting the emergency event.
In an emergency behavioral or medical situation where a client poses an immediate threat to themselves (such as pulling out a life-saving device) and all alternative measures have failed, the nurse must intervene first to secure safety. This sequence involves first applying the restraints to stop the behavior, safely securing them to a movable bed part with a quick-release knot, and immediately checking for a safe fit (two-finger method). Once the client is physically safe, the nurse must contact the provider to obtain the required emergency prescription (typically required within 1 hour), followed by comprehensive documentation of the event.
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Anahtar Kavram
Emergency Physical Restraint Implementation Sequence