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Question

Difficulty: MediumSafe Use of Restraints and Safety Devices

During the night shift on a medical-surgical unit, a nurse is caring for a client with hepatic encephalopathy who is experiencing escalating delirium. Despite the implementation of frequent reorientation, bed alarms, and the continuous presence of a family member, the client persistently attempts to remove a nasogastric tube and a continuous peripheral intravenous infusion. The healthcare provider evaluates the client in person and prescribes bilateral soft wrist restraints. Which of the following nursing actions are appropriate to include in the plan of care? (Select all that apply.)

  1. Release the restraints to assess skin integrity and perform range-of-motion exercises at least every two hours.Answer
  2. Secure the restraint straps directly to the movable portion of the bed frame using a quick-release knot.Answer
  3. Verify that the healthcare provider renews the restraint prescription every 24 hours.Answer
  4. D
    Instruct the unlicensed assistive personnel to perform and document the hourly neurovascular checks of the client's hands.
  5. E
    Fasten the restraint ties securely to the bilateral upper side rails to prevent the client from reaching the medical devices.
  6. F
    Obtain a prescription for the restraints to be applied on an as-needed schedule during periods of severe delirium.

Answer

The appropriate actions are releasing the restraints every two hours for assessment, securing the straps to a movable portion of the bed frame with a quick-release knot, and ensuring the prescription is renewed every 24 hours.
Medical-surgical restraints used to prevent interference with life-sustaining treatments require strict safeguards. They must be secured to the movable portion of the bed frame using a quick-release knot to ensure they can be removed rapidly in an emergency and do not cause injury when the bed's position is altered. Nursing staff must release the restraints at least every 2 hours to perform range-of-motion exercises, offer toileting, and assess skin integrity. Furthermore, federal and accreditation guidelines mandate that prescriptions for non-violent medical-surgical restraints be renewed by a healthcare provider at least every 24 hours.

Step-by-Step Solution

1
Analyze the clinical indication for the restraints in the scenario.
The restraints are indicated for non-violent, medical-surgical reasons (preventing the removal of a nasogastric tube and IV line) after less restrictive alternatives were documented as ineffective.
Identifying the type of restraint dictates the legal time limits and specific monitoring protocols required by regulatory agencies.
2
Evaluate the application and maintenance protocols for medical-surgical restraints.
Safe application requires a quick-release knot on a movable bed frame, and maintenance requires releasing the restraints at least every 2 hours for skin care, motion, and basic needs.
Proper application prevents injury and allows for emergency removal, while regular release prevents skin breakdown and neurovascular compromise.
3
Determine the legal and delegation boundaries for restraint management.
The nurse identifies that PRN orders are illegal, the order must be renewed every 24 hours, and assessments cannot be delegated to UAP.
Maintaining scope of practice and legal compliance is critical for client safety and avoiding professional liability.

Key Concept

Safe application, maintenance, delegation, and legal requirements for medical-surgical physical restraints.
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Topics

Safe Use of Restraints and Safety Devices

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