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Difficulty: MediumSafe Use of Restraints and Safety Devices

A nurse is managing the care of a client recovering from viral encephalitis. The client exhibits severe confusion and is persistently attempting to dislodge a peripheral intravenous (IV) line and an indwelling urinary catheter. Following the documented failure of less restrictive safety measures, the healthcare provider prescribes bilateral soft wrist restraints. Which of the following nursing interventions must be included in the client's plan of care? Select all that apply.

  1. Evaluate the client's peripheral pulses, skin temperature, and capillary refill at least every 2 hoursAnswer
  2. B
    Anchor the restraint straps directly to the bedside rails to allow for rapid removal during an emergency
  3. Secure the restraint ties to a movable portion of the bed frameAnswer
  4. D
    Assign the unlicensed assistive personnel (UAP) to evaluate whether the client still requires the restraints
  5. E
    Tie the securing straps using a standard square knot to prevent the client from untying them
  6. Temporarily remove the devices sequentially every 2 hours to facilitate range-of-motion exercises and skin careAnswer

Answer

The correct nursing actions include evaluating neurovascular status every 2 hours, securing the ties to a movable portion of the bed frame, and temporarily removing the devices sequentially every 2 hours.
Appropriate and safe care for a client in non-violent medical restraints includes attaching the straps to a movable part of the bed frame so they adjust safely with bed movements. The RN is mandated to perform neurovascular and skin integrity checks at least every two hours. Additionally, the devices should be removed sequentially every two hours to allow for skin care, toileting, and range-of-motion exercises without leaving the confused client completely unrestrained.

Step-by-Step Solution

1
Identify the type of restraint being used and the clinical indication.
The client requires non-violent medical restraints to prevent the removal of life-sustaining medical devices.
Different types of restraints (violent vs. non-violent) have slightly different monitoring timelines and documentation requirements.
2
Determine the correct anatomical placement and securing location for the restraint.
The restraint must be secured to a movable part of the bed frame using a quick-release knot, never to the side rails.
This prevents patient injury when the bed's position is adjusted and ensures rapid removal during emergencies.
3
Establish the required ongoing assessment and delegation boundaries.
The RN must perform neurovascular checks and sequentially release the restraints every 2 hours. Assessment tasks cannot be delegated.
Professional nursing judgment is required to evaluate circulation, skin integrity, and the continued necessity of the restraint.

Key Concept

The safe application, monitoring, and delegation of medical restraints strictly require securing to a movable bed frame with a quick-release knot, RN-led 2-hour assessments, and sequential release for basic care.
Estimated Time:1m 30s
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Topics

Safe Use of Restraints and Safety Devices

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