What should the nurse do here?
A nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to pull out the necessary I.V. lines and an indwelling urinary catheter.
A. Leave the client and get help. B. Obtain a physician s order to restrain the client. C. Read the facility s policy on restraints. D. Order soft restraints from the storeroom.
When a hip is fractured, the injury is always in the femur. The upper end of the femur can fracture in one of three places: the head of the femur, the neck of the femur, or between or below the greater and lesser trochanters. The primary goal is to create a restraint-free environment.
There are many alternatives to the use of restraints are available, and the nurse should try all of them before notifying the patient's health care provider. Restraints should only be used as a last resort.
Obtain a physician\ s order to restrain the client.-rationale: in most settings, the nurse must have a physicians order before restraining a client. a client should never be left alone while the nurse summons assistance. all staff members must receive annual instruction on the use of restraints, and the nurse should be familiar with the facilitys policy.client needs category: safe, effective care environmentclient needs subcategory: safety and infection controlcognitive level: analysisreference: taylor, c., et al. fundamentals of nursing: the art and science of nursing care, 6th ed. philadelphia: lippincott williams & wilkins, 2008, p. 680.