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Difficulty: HardSafe Use of Restraints and Safety Devices

A 45-year-old client in the intensive care unit is receiving continuous renal replacement therapy (CRRT). The client becomes acutely delirious and persistently attempts to dislodge the large-bore hemodialysis catheter. After implementing multiple less restrictive alternatives without success, the healthcare provider prescribes bilateral soft wrist restraints. Which action by the nurse represents the safest and most appropriate management of this client?

  1. A
    Anchoring the restraint devices to the bed's side rails with square knots to ensure they cannot be easily undone by the client during sudden movements.
  2. B
    Assigning the unlicensed assistive personnel (UAP) to temporarily release the restraints and evaluate the client's skin integrity during routine turns.
  3. C
    Obtaining a PRN (as-needed) prescription from the healthcare provider to allow for flexible reapplication of the restraints based on the client's fluctuating agitation levels.
  4. Fastening the restraint ties to the bed frame's movable sections using quick-release slip knots and conducting neurovascular assessments at least every 2 hours.Answer

Answer

The nurse should fasten the restraint ties to the bed frame's movable sections using quick-release slip knots and conduct neurovascular assessments at least every 2 hours.
The standard of care for physical restraints dictates that they must be attached to the movable portion of the bed frame (so they move safely with the client when the head of the bed is raised or lowered) using a quick-release knot (slip knot) to allow for rapid removal in an emergency. Additionally, non-behavioral (medical-surgical) restraints require the RN to temporarily release the restraints and perform a comprehensive neurovascular and skin assessment at least every 2 hours.

Step-by-Step Solution

1
Analyze the legal and physical safety requirements for attaching restraints.
Identify that restraints must be easily removable in emergencies (using quick-release knots) and must not cause injury if the bed position is adjusted (attaching to the movable frame, never the side rails).
Improper application can lead to severe client injury, strangulation, or delayed release during emergencies like fires or sudden clinical deterioration.
2
Evaluate the ongoing monitoring requirements for non-violent medical restraints.
Determine that the RN must assess skin integrity, peripheral pulses, capillary refill, and sensation distal to the restraint at least every 2 hours.
Frequent clinical assessment prevents neurovascular compromise and skin breakdown, which are common and severe complications of restraint use.
3
Assess the delegation boundaries and prescription regulations regarding restraint management.
Recognize that clinical assessments cannot be delegated to a UAP, and PRN prescriptions for restraints are strictly prohibited by CMS and Joint Commission standards.
Only registered nurses possess the clinical judgment required for neurovascular assessment, and strict prescription rules are legally mandated to prevent the overuse and abuse of restraints.

Key Concept

Safe Use of Restraints and Safety Devices
Estimated Time:1m 30s
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Safe Use of Restraints and Safety Devices

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