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Difficulty: HardSafe Use of Restraints and Safety Devices

An older adult client with acute hypoxemic respiratory failure is receiving noninvasive positive pressure ventilation (BiPAP) in the step-down unit. The client is confused, agitated, and continuously attempts to remove the facial mask and pull at their continuous intravenous infusion line. After documented failure of alternative measures, including family presence, frequent reorientation, and a bed alarm, the healthcare provider prescribes bilateral soft wrist restraints. When implementing this safety measure, which actions must the registered nurse include in the plan of care? Select all that apply.

  1. Attach the restraint straps to the movable portion of the bed frame using a quick-release slip knot.Answer
  2. B
    Secure the restraint straps to the upper side rails to prevent the client from reaching the facial mask.
  3. C
    Instruct the unlicensed assistive personnel (UAP) to independently evaluate the client's capillary refill and skin integrity distal to the restraints.
  4. Release the restraints one at a time at least every 2 hours to perform range-of-motion exercises.Answer
  5. E
    Obtain a prescription renewal from the healthcare provider every 4 hours while the restraints remain in use.
  6. Verify that the provider's prescription for the restraints is renewed every 24 hours if continuation is clinically necessary.Answer

Answer

The correct actions include attaching the straps to the movable portion of the bed frame with a quick-release knot, releasing the restraints one at a time every 2 hours for range-of-motion exercises, and verifying that the prescription is renewed every 24 hours.
For non-violent (medical-surgical) restraints used to prevent interference with medical treatments, the straps must be secured to the movable portion of the bed frame using a quick-release knot to ensure they move with the client and can be rapidly released in an emergency. The restraints must be removed one at a time at least every 2 hours to perform range-of-motion exercises, provide skin care, and allow the nurse to assess neurovascular status. Furthermore, regulatory guidelines stipulate that non-violent restraint prescriptions must be formally renewed by the healthcare provider every 24 hours if the clinical need persists.

Step-by-Step Solution

1
Identify the classification of the restraint indication based on the client's behavior.
The client is attempting to remove medical devices (BiPAP mask and IV line) but is not exhibiting violent behavior toward staff or self. This categorizes the intervention as a non-violent (medical-surgical) restraint.
Classifying the restraint type is crucial because non-violent and violent restraints have drastically different legal requirements and monitoring timeframes.
2
Determine the required legal timeframe for prescription renewal for this specific restraint type.
Non-violent (medical-surgical) restraint prescriptions must be renewed by the healthcare provider every 24 hours.
Regulatory standards (such as CMS guidelines) mandate a 24-hour renewal limit to ensure the client is continuously evaluated for the necessity of the restraint, promoting least restrictive care.
3
Establish the correct safety standards for physical application of the restraint.
The restraints must be attached to the movable portion of the bed frame using a quick-release (slip) knot.
Tying to a movable frame prevents injury when bed positioning is adjusted. A quick-release knot is mandatory to allow for rapid removal in the event of an emergency, such as a fire or sudden cardiac arrest.
4
Determine appropriate ongoing nursing management and delegation boundaries.
The RN must personally assess circulation and skin integrity; restraints should be released one at a time every 2 hours for care and range-of-motion.
Clinical assessments fall outside the scope of practice for unlicensed assistive personnel (UAP). Alternating release ensures the client's airway and medical devices remain protected while preventing physical complications of immobility.

Key Concept

Management of non-violent (medical-surgical) restraints requires securing straps to a movable bed frame, releasing them every 2 hours for care, retaining clinical assessments for the RN, and ensuring 24-hour prescription renewals.
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Topics

Safe Use of Restraints and Safety Devices

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