A client hospitalized with a severe urinary tract infection begins exhibiting profound agitation and repeatedly tries to climb out of the hospital bed. After multiple environmental modifications fail to keep the client safe, the healthcare provider prescribes bilateral mitten restraints. Which action is essential for the practical nurse (PN) to implement while managing this client's care?
- Verify the client's radial pulses, capillary refill, and extremity temperature at regular intervals.Answer
- BRequest that the physician write an as-needed (PRN) prescription for the mittens to use only when agitation peaks.
- CDelegate the task of evaluating the client's ongoing psychological response to the devices to the assistive personnel.
- DConclude that the acute combativeness is a normal manifestation of aging and minimize further neurological interactions.
Answer
The practical nurse must verify the client's radial pulses, capillary refill, and extremity temperature at regular intervals.
When physical restraints such as mittens are applied, the nurse is legally and ethically required to frequently monitor the client's neurovascular status. Checking radial pulses, capillary refill, and extremity temperature ensures that the restraint is not applied too tightly and that adequate blood perfusion and nerve function are maintained in the hands.
Step-by-Step Solution
Key Concept
Neurovascular Monitoring and Safety Protocols for Physical Restraints