A critical care nurse is managing a client receiving continuous renal replacement therapy. The client becomes increasingly restless and repeatedly attempts to disconnect the dialysis lines. After unsuccessful alternative interventions, the healthcare provider prescribes bilateral soft wrist restraints. Which actions by the nurse indicate appropriate management of the restraints? Select all that apply.
- Releasing the restraints every 2 hours to perform range-of-motion exercises and evaluate skin integrity.Answer
- BAttaching the restraint straps securely to the bed's adjustable side rails.
- CInstructing the unlicensed assistive personnel to evaluate if the restraints can be permanently discontinued.
- Fastening the restraints to the movable portion of the bed frame using a quick-release tie.Answer
- Recording the less restrictive interventions that were implemented prior to applying the devices.Answer
- FObtaining a standing prescription to reapply the devices whenever the client becomes agitated.
Answer
The appropriate actions include releasing the restraints every 2 hours for assessment, fastening them to the movable bed frame with a quick-release tie, and recording the less restrictive interventions attempted prior to application.
Safe restraint management requires fastening ties to the movable part of the bed frame using quick-release knots, removing the devices every 2 hours for skin assessment and range-of-motion exercises, and thoroughly documenting the behaviors and prior alternative measures that necessitated the restraint.
Step-by-Step Solution
Key Concept
Safe Restraint Application and Maintenance