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Difficulty: MediumUse of Restraints and Safety Devices

An 82-year-old client receiving treatment for pyelonephritis suddenly exhibits severe combativeness and repeatedly attempts to dislodge their peripheral intravenous (IV) catheter. After less restrictive interventions are unsuccessful, the healthcare provider prescribes bilateral soft wrist restraints. The registered nurse applies the restraints and assigns ongoing monitoring to the practical nurse (PN). Which actions should the PN include in the client's care? Select all that apply.

  1. Evaluate the radial pulses, capillary refill, and skin temperature of both upper extremities at least every 2 hours.Answer
  2. Release the restraints one at a time every 2 hours to inspect the skin and assist with range-of-motion exercises.Answer
  3. Secure the restraint ties directly to the movable portion of the bed frame utilizing a quick-release knot.Answer
  4. D
    Instruct the assistive personnel to independently assess the client's distal circulation and report any abnormalities.
  5. E
    Request that the healthcare provider prescribe the restraints on a PRN (as needed) basis for intermittent episodes of combativeness.
  6. F
    Document the sudden onset of severe combativeness as an expected, normal age-related cognitive change.

Answer

The correct actions include evaluating the client's circulation regularly, releasing the restraints one at a time every 2 hours for skin care and range of motion, and securing the ties to the movable part of the bed frame with a quick-release knot.
Safe restraint management requires the nurse to continuously monitor the client's physiological status and prevent complications. This includes evaluating neurovascular integrity (pulses, capillary refill, temperature) and releasing the restraints one at a time at least every 2 hours to provide essential skin care and range-of-motion exercises. Furthermore, securing the straps to the movable portion of the bed frame with a quick-release knot ensures the restraints will not constrict the client's limbs if the bed is repositioned and allows for immediate removal during an emergency.

Step-by-Step Solution

1
Analyze the clinical scenario to identify the primary nursing responsibility.
The client is an older adult with acute confusion requiring soft wrist restraints, demanding strict adherence to safety, monitoring, and legal guidelines.
Restraints pose significant risks for injury, nerve damage, and reduced circulation, necessitating careful procedural compliance.
2
Evaluate each option against safe restraint application mechanics and monitoring standards.
Assessing pulses, releasing restraints every 2 hours, and using a quick-release knot on the movable bed frame align with evidence-based safety standards.
These actions directly prevent the complications associated with restraint use, such as skin breakdown, joint contractures, and impaired perfusion.
3
Identify contraindicated actions based on the PN scope of practice and legal restraint requirements.
Delegating assessments, obtaining PRN restraint orders, and dismissing acute confusion as normal aging are incorrect.
These actions violate delegation rules, federal restraint regulations, and proper geriatric clinical judgment.

Key Concept

Safe Application and Monitoring of Physical Restraints
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Topics

Use of Restraints and Safety Devices

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