A nurse on a medical-surgical unit is caring for a client who is confused and repeatedly attempting to remove a newly placed percutaneous endoscopic gastrostomy (PEG) tube. After multiple alternative safety measures have failed, the healthcare provider prescribes bilateral soft wrist restraints. Which action by the nurse ensures the safe use of these restraints?
- Releasing one restraint at a time every 2 hours to provide skin care and perform range-of-motion exercises.Answer
- BFastening the restraint straps to the side rails of the bed using a quick-release slip knot.
- CObtaining a prescription to use the restraints on an 'as needed' (PRN) basis when the client becomes agitated.
- DDelegating the hourly assessment of the client's radial pulses and capillary refill to the unlicensed assistive personnel (UAP).
Answer
Releasing one restraint at a time every 2 hours to provide skin care and perform range-of-motion exercises.
For clients with non-violent (medical-surgical) physical restraints, the standard of care requires the nurse to remove the restraints at least every 2 hours to assess skin integrity, evaluate neurovascular status, perform range-of-motion exercises, and meet basic needs (e.g., toileting, hydration). Releasing only one restraint at a time is a critical safety measure; it ensures the client's hands are not completely free to pull at medical devices (such as the PEG tube) while care is being provided.
Step-by-Step Solution
Key Concept
Safe application and monitoring of physical restraints