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Question

Difficulty: MediumAccident, Error, and Injury Prevention

An older adult client with severe delirium is continuously attempting to pull out a nasogastric tube and intravenous lines. After least restrictive measures have failed, the primary health care provider prescribes bilateral soft limb restraints. In what order should the nurse perform the following actions to ensure client safety?

  1. 1Discuss the rationale for the intervention and its temporary nature with the client and family.
  2. 2Inspect the skin over the wrists and apply protective padding to bony prominences.
  3. 3Fasten the restraint cuff around the wrist, verifying fit by slipping two fingers under the device.
  4. 4Tie the straps to the movable part of the bed frame using a quick-release knot.
  5. 5Release the device every 2 hours to provide skin care, toileting, and range-of-motion exercises.

Answer

The correct sequence is to first discuss the rationale with the client and family, then inspect the skin and apply padding, fasten the cuff and verify a two-finger fit, tie the straps to the movable bed frame with a quick-release knot, and finally release the device every 2 hours for care and assessment.
Safe application of restraints follows a logical progression from education and assessment to application and ongoing monitoring. Communication is prioritized to respect client rights and reduce fear. Next, skin assessment and padding prevent integumentary injury. Fastening the cuff and checking the two-finger fit ensures circulation is maintained before the limb is secured. Anchoring the straps to the movable bed frame with a quick-release knot guarantees safety during bed adjustments and emergencies. Finally, establishing a rigid schedule for releasing the restraints prevents long-term complications of immobility.

Step-by-Step Solution

1
Discuss the rationale for the intervention and its temporary nature with the client and family.
The client and family are informed about the safety necessity of the intervention.
Ethical and legal guidelines require informed communication before applying restrictive devices, setting a foundation of trust and understanding.
2
Inspect the skin over the wrists and apply protective padding to bony prominences.
Baseline skin status is noted and the wrists are protected from friction.
Padding prevents mechanical injury and skin breakdown caused by the restraint rubbing against bony areas.
3
Fasten the restraint cuff around the wrist, verifying fit by slipping two fingers under the device.
The restraint is secured on the client with appropriate tightness.
The two-finger check ensures that the restraint is not overly tight, which could compromise neurovascular function and lead to ischemic injury.
4
Tie the straps to the movable part of the bed frame using a quick-release knot.
The restraint is anchored safely to the bed.
Securing to the movable frame ensures the restraint does not tighten if the head of the bed is raised. A quick-release knot allows immediate removal during an emergency.
5
Release the device every 2 hours to provide skin care, toileting, and range-of-motion exercises.
The client receives continuous monitoring and necessary basic care.
Regular removal prevents complications of immobility, such as contractures, pressure injuries, and severe distress, ensuring ongoing safety.

Key Concept

Physical restraint application and safety monitoring sequence
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Topics

Accident, Error, and Injury Prevention

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