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Difficulty: MediumSafe Use of Restraints and Safety Devices

A client admitted to the neurology step-down unit with a traumatic brain injury is agitated and repeatedly attempting to dislodge their external ventricular drain. After alternative interventions have failed, the healthcare provider prescribes bilateral soft wrist restraints. Which of the following nursing actions are appropriate to ensure client safety? Select all that apply.

  1. Remove the restraints one at a time every 2 hours to perform range-of-motion exercises.Answer
  2. Fasten the restraint straps to the movable portion of the bed frame.Answer
  3. Ensure that two fingers can be easily inserted between the restraint and the client's wrist.Answer
  4. D
    Secure the restraint ties using a square knot to prevent accidental removal.
  5. E
    Delegate the assessment of peripheral pulses and capillary refill to the unlicensed assistive personnel (UAP).
  6. F
    Obtain a PRN (as needed) prescription from the healthcare provider to use if the client's agitation worsens.

Answer

The appropriate actions are to remove the restraints one at a time every 2 hours, fasten the straps to the movable portion of the bed frame, and ensure two fingers can fit under the restraint.
For a client in non-violent medical restraints, the nurse must ensure proper circulation and skin integrity by removing the restraints (one at a time) at least every 2 hours to perform range-of-motion exercises. Fastening the straps to the movable portion of the bed frame prevents injury if the bed's position is adjusted. Ensuring that two fingers can slide between the restraint and the client's wrist guarantees that the device is secure without compromising neurovascular status.

Step-by-Step Solution

1
Identify the type of restraint and the legal and safety requirements for its use.
The client requires non-violent medical restraints to prevent the removal of a life-sustaining medical device (external ventricular drain).
Understanding the indication determines the frequency of monitoring and the specific safety protocols that must be followed.
2
Evaluate each nursing action against evidence-based safety standards for physical restraints.
Proper application (two-finger fit), correct attachment points (movable bed frame), and routine release (every 2 hours) are required standards. PRN orders, square knots, and delegating assessments to UAP are unsafe and prohibited.
Adhering strictly to restraint standards prevents patient injury, maintains adequate circulation, and ensures legal compliance.

Key Concept

Safe application, monitoring, and legal documentation of physical restraints.
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Topics

Safe Use of Restraints and Safety Devices

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