During the night shift on a medical-surgical step-down unit, a young adult client recovering from a traumatic brain injury becomes increasingly agitated and repeatedly attempts to remove their endotracheal tube. After less restrictive alternatives fail, the healthcare provider orders bilateral soft wrist restraints, which the registered nurse (RN) applies. As the practical nurse (PN) assigned to assist with ongoing care and monitoring, which actions are appropriate to implement? Select all that apply.
- Assess the capillary refill, skin color, and temperature of both hands at least every 2 hours.Answer
- Remove one restraint at a time every 2 hours to provide skin care and perform passive range-of-motion exercises.Answer
- CSecure the restraint straps directly to the raised side rails using quick-release slip knots.
- DRequest a PRN (as needed) prescription for restraints from the provider in case the severe agitation returns tomorrow.
- Verify that two fingers can comfortably slide between the restraint pad and the client's wrist.Answer
- FInstruct the assistive personnel (AP) to evaluate the skin integrity under the restraints during routine rounds.
Answer
The appropriate actions are: assessing capillary refill and temperature every 2 hours, removing one restraint at a time every 2 hours for care, and verifying that two fingers can fit under the restraint.
Safe restraint management requires strict adherence to physical monitoring, correct mechanical application, and continuous evaluation. Checking neurovascular status every 2 hours prevents ischemic injury. Removing one restraint at a time allows the nurse to maintain control over the client's safety (protecting the endotracheal tube) while safely providing necessary skin care and joint mobility. Ensuring a two-finger gap guarantees the restraint does not act as a tourniquet.
Step-by-Step Solution
Key Concept
Use of Restraints and Safety Devices
Estimated Time:2m 0s