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Difficulty: HardSafe Use of Restraints and Safety Devices

A registered nurse (RN) is developing a plan of care for a critically ill client who is mechanically ventilated. The client is experiencing acute agitation and has repeatedly attempted to pull at the endotracheal tube despite maximum pharmacological sedation, verbal reorientation, and the continuous presence of a sitter. The healthcare provider has prescribed bilateral soft wrist restraints to prevent self-extubation. Which of the following nursing interventions should the RN include in the care plan? Select all that apply.

  1. Anchor the device ties to the movable portion of the bed frame using a quick-release knot.Answer
  2. B
    Direct the unlicensed assistive personnel (UAP) to perform the neurovascular assessments on the affected extremities every two hours.
  3. Remove one device at a time every two hours to allow for skin inspection and passive range-of-motion exercises.Answer
  4. D
    Apply the wrist devices securely, ensuring that no more than one finger can fit between the material and the client's skin.
  5. E
    Secure the straps firmly to the elevated side rails to restrict the client's upper extremity mobility near the airway.
  6. Reassess the clinical necessity of the devices continuously and obtain a renewed provider prescription every 24 hours if still required.Answer

Answer

The RN should anchor the ties to the movable bed frame with a quick-release knot, discontinue one device at a time every two hours for skin care, and obtain a renewed provider prescription every 24 hours.
Safe management of non-violent medical restraints requires securing the device to the movable portion of the bed frame using a quick-release knot to prevent injury and allow rapid emergency access. Removing one restraint at a time every two hours is essential to assess skin integrity and perform range-of-motion exercises without completely compromising the airway. Furthermore, regulatory standards dictate that non-violent medical restraints require an ongoing assessment of necessity and a new provider prescription every 24 hours.

Step-by-Step Solution

1
Evaluate the restraint prescription and clinical indication.
The client requires non-violent medical restraints to protect a life-sustaining airway after less restrictive alternatives failed.
Determines the specific legal and clinical guidelines that apply, such as the 24-hour prescription limit for non-violent cases.
2
Plan the physical application of the safety devices.
Ensure a two-finger gap under the restraint and tie only to the movable bed frame with a quick-release slip knot.
Prevents neurovascular compromise and accidental musculoskeletal injury if the bed position changes.
3
Establish an ongoing assessment and delegation plan.
The RN retains responsibility for neurovascular checks and plans to remove one restraint every two hours.
Neurovascular assessment requires nursing judgment, and periodic removal prevents joint contractures while maintaining safety.

Key Concept

Evidence-based application, monitoring, and delegation parameters for non-violent medical restraints.
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Topics

Safe Use of Restraints and Safety Devices

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