A nurse is caring for a patient with dementia who is persistently trying to remove their IV line despite attempts at redirection and other interventions. The healthcare provider has ordered soft wrist restraints to prevent self-injury. What action should the nurse take before implementing the provider’s order?
Delay the intervention until there is evidence of worsening attempts at self-harm.
Ensure that permission for this intervention has been obtained from the patient or their legal representative.
Record the patient’s behaviors in detail and inform the family after applying the intervention.
Apply the restraints as ordered to prevent self-injury and perform routine safety checks.
The nurse’s priority is to confirm that permission has been obtained from the patient (if competent) or their legal representative before applying restraints. Obtaining permission demonstrates adherence to legal and ethical standards while respecting the patient's autonomy. While applying the restraints or documenting behaviors may be necessary steps, they do not replace the importance of verifying authorization. Waiting for further escalation is inappropriate, as the provider has already deemed the intervention necessary.
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