A practical nurse is performing scheduled two-hour care for a client who is currently in bilateral soft wrist restraints. Arrange the following steps of restraint care in the correct chronological order.
- 1Untie the quick-release knots and temporarily remove both restraints.
- 2Assess the skin integrity, peripheral pulses, and temperature of both wrists.
- 3Perform active or passive range-of-motion exercises on the client's arms.
- 4Offer the client fluids, a snack, and the opportunity to use the bedpan.
- 5Reapply the restraints securely and document the assessment findings.
Answer
The correct chronological sequence is to first remove the restraints, assess the skin and circulation, perform range-of-motion exercises, address basic physiological needs like hydration and toileting, and finally reapply the restraints and document the care.
Providing scheduled restraint care follows a logical sequence prioritizing physiological safety and basic human needs. The nurse must first remove the restrictive device to gain access to the extremity. The immediate priority is assessing for injury (skin breakdown, poor circulation). Once safety is established, the nurse performs range-of-motion to prevent immobility complications. Next, basic needs such as hydration, nutrition, and toileting are provided while the client is unrestrained. Finally, the restraints are correctly reapplied to maintain safety, and the entire intervention is documented per facility policy.
Step-by-Step Solution
Key Concept
Standard protocol requires that physical restraints be removed at least every 2 hours to conduct thorough neurovascular and skin assessments, perform range-of-motion exercises, and meet the client's basic needs for food, fluids, and elimination.
Estimated Time:1m 0s