A client recovering from a bowel resection develops post-operative delirium and continuously attempts to remove their nasogastric tube and surgical dressings. After less restrictive safety measures have proven ineffective, the healthcare provider prescribes bilateral soft wrist restraints. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.
- Attach the restraint straps to the movable portion of the bed frame using a quick-release knot.Answer
- Remove the restraints one at a time every 2 hours to assess skin integrity and perform range-of-motion exercises.Answer
- Ensure that two fingers can be inserted between the client's wrists and the secured restraints.Answer
- DInstruct the unlicensed assistive personnel (UAP) to assess the bilateral radial pulses and capillary refill hourly.
- EFasten the restraint straps securely to the bed's side rails to keep the client's arms away from the nasogastric tube.
- FObtain a PRN (as needed) prescription from the healthcare provider to reapply restraints during episodes of increased agitation.
Answer
The correct interventions are attaching the straps to a movable bed frame with a quick-release knot, removing the restraints one at a time every 2 hours, and ensuring two fingers fit beneath the restraints.
Safe restraint use requires securing straps to a movable part of the bed frame with a quick-release knot to prevent injury and allow emergency removal. Checking for a two-finger gap ensures adequate circulation and prevents nerve damage. Removing the restraints one at a time every 2 hours allows for necessary skin assessment and range-of-motion exercises while preventing the client from removing vital medical devices.
Step-by-Step Solution
Key Concept
Safe application, monitoring, and legal considerations for physical restraints in a medical-surgical setting.