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Difficulty: MediumAccident, Error, and Injury Prevention

A client in the intensive care unit is intubated and continuously attempting to pull out their endotracheal tube. After exhausting all alternative safety measures, the healthcare provider prescribes bilateral soft wrist restraints. Which nursing interventions are appropriate while the restraints are in place? Select all that apply.

  1. Ensure that two fingers can be inserted between the restraint and the client's wrist.Answer
  2. Remove the restraints one at a time every 2 hours to provide skin care and perform range-of-motion exercises.Answer
  3. C
    Secure the restraint straps to the side rails of the bed using a quick-release knot.
  4. D
    Obtain a PRN (as needed) prescription from the healthcare provider for flexible reapplication.
  5. E
    Delegate the assessment of the client's distal pulses and capillary refill to the unlicensed assistive personnel (UAP).
  6. Attach the restraint straps to the movable portion of the bed frame.Answer

Answer

The appropriate interventions are ensuring two fingers fit under the restraint, removing the restraints every 2 hours for skin care and range-of-motion, and tying the straps to the movable portion of the bed frame.
Safe restraint management requires securing the ties to the movable part of the bed frame to accommodate positional changes without causing injury. A two-finger gap prevents restricted blood flow and nerve compression. Additionally, restraints must be temporarily removed every 2 hours to allow for necessary skin assessment, hygiene, and range-of-motion exercises.

Step-by-Step Solution

1
Analyze the legal and physiological requirements for safe restraint use.
Identify that restraints require specific application techniques and regular assessment to prevent harm.
Restraints are high-risk interventions that can cause tissue ischemia, nerve damage, and psychologic trauma if mismanaged.
2
Evaluate the placement and tying of the restraints.
Determine that restraints should be tied to a movable part of the bed frame with two fingers of slack.
Tying to a movable frame prevents tightening during bed adjustments, while the two-finger rule ensures adequate blood flow.
3
Evaluate the ongoing care and delegation requirements.
Identify that regular release (every 2 hours) is mandatory, PRN orders are forbidden, and assessments cannot be delegated.
Regulatory standards mandate continuous RN oversight, prohibit PRN orders for restraints, and restrict UAPs from performing clinical assessments.

Key Concept

Physical Restraint Safety, Application, and Delegation
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Topics

Accident, Error, and Injury Prevention

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