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Difficulty: HardSafe Use of Restraints and Safety Devices

A client admitted with acute respiratory distress and severe delirium is persistently attempting to remove their high-flow nasal cannula and peripheral intravenous line. Environmental modifications and having a family member at the bedside have been ineffective in redirecting the client's behavior. The healthcare provider issues a prescription for bilateral soft wrist restraints. Which action by the nurse demonstrates safe and appropriate management of this client?

  1. Release the devices one at a time at least every 2 hours to provide skin care, perform range-of-motion exercises, and reassess the need for restriction.Answer
  2. B
    Secure the straps to the bed's side rails to ensure the devices rise and fall simultaneously when the head of the bed is elevated.
  3. C
    Delegate the ongoing evaluation of capillary refill, skin integrity, and extremity temperature to the unlicensed assistive personnel.
  4. D
    Request that the provider convert the prescription to a PRN (as needed) order to minimize the total hours the client is restricted.

Answer

The safest appropriate action is to release the restraints one at a time at least every 2 hours to perform range-of-motion exercises, assess the skin, and evaluate the ongoing need for the devices.
For a client in non-violent medical-surgical restraints, the nurse must release the restraints at least every 2 hours (one at a time to maintain safety) to perform range-of-motion exercises, assess skin integrity and neurovascular status, provide for basic needs, and determine if the restraints can be safely discontinued. This action minimizes the risk of complications such as skin breakdown, contractures, and impaired circulation.

Step-by-Step Solution

1
Analyze the client scenario and the prescribed intervention.
The client requires non-violent medical restraints for pulling at life-sustaining medical devices, and less restrictive alternatives have already failed.
Determining the type of restraint (violent vs. non-violent) dictates the monitoring frequency and legal requirements for nursing care.
2
Evaluate the nursing responsibilities and boundaries for a client in restraints.
The nurse is responsible for frequent assessment, basic care provision, ensuring safe physical application, and adhering to strict legal and facility guidelines.
Physical restraints pose significant risks to client safety and autonomy, requiring rigorous oversight and preventing inappropriate delegation.
3
Review each option against evidence-based safety standards.
Tying to side rails causes injury, PRN orders are legally prohibited, and assessing circulation cannot be delegated to UAP. The only safe action is releasing them every 2 hours for assessment.
Eliminating unsafe practices identifies the correct, standard-of-care intervention.

Key Concept

Safe maintenance, physical application, and legal parameters of non-violent medical-surgical restraints.
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Topics

Safe Use of Restraints and Safety Devices

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