A nurse is planning care for a client with sepsis-induced delirium who repeatedly attempts to pull out their central venous catheter. Following unsuccessful attempts at verbal redirection and concealment of the line, the provider prescribes bilateral soft wrist restraints. Which actions should the nurse include in the client's care plan? Select all that apply.
- Anchor the restraint ties to the movable portion of the bed frame.Answer
- BFasten the restraint ties directly to the side rails to prevent sudden pulling.
- CAssign the nursing assistant to evaluate the client's distal pulses and capillary refill.
- Remove the devices at least every 2 hours to provide skin care and assess circulation.Answer
- EObtain a prescription from the provider to use the restraints on an as-needed basis.
- Utilize a quick-release knot when tying the restraint straps.Answer
Answer
The nurse should anchor the ties to the movable portion of the bed frame, remove the devices at least every 2 hours to provide skin care and assess circulation, and utilize a quick-release knot.
Safe physical restraint implementation involves strict protocols to prevent injury. The restraints must be anchored to a movable part of the bed frame so that altering the bed's position does not alter the tension on the client's wrists. A quick-release knot is mandatory to allow immediate removal if the client experiences an emergency, such as seizing or requiring CPR. Furthermore, standard protocol mandates removing the restraints at least every 2 hours to directly assess neurovascular status, verify skin integrity, and perform passive range-of-motion exercises.
Step-by-Step Solution
Key Concept
Safe application, continuous monitoring, and legal requirements for physical restraints.