A client recovering from a complex coronary artery bypass graft (CABG) surgery develops acute postoperative delirium. The client becomes highly agitated and continuously attempts to pull out their epicardial pacing wires and mediastinal chest tubes. After documenting the failure of multiple less restrictive interventions, the healthcare provider prescribes bilateral soft wrist restraints. Which intervention demonstrates correct adherence to restraint safety protocols?
- Removing one restraint at a time every 2 hours to provide skin care, perform passive range of motion, and evaluate the client's behavior.Answer
- BSecuring the restraint straps to the bed's side rails using a quick-release slip knot to facilitate immediate removal during an emergency.
- CDelegating the hourly assessment of the client's peripheral pulses, capillary refill, and skin integrity to the unlicensed assistive personnel (UAP).
- DRequesting that the healthcare provider change the continuous restraint prescription to a PRN (as needed) order to minimize overall usage.
Answer
The nurse should remove one restraint at a time every 2 hours to provide skin care, perform range of motion, and evaluate the client's ongoing need for the restraints.
For non-violent (medical-surgical) restraints, the standard of care requires the nurse to temporarily release the restraints at least every 2 hours. This must be done one extremity at a time to maintain safety. During this release, the nurse must provide skin care, perform passive range-of-motion exercises, assess neurovascular status (pulses, color, temperature, sensation), and evaluate if the client's behavior indicates the restraints can be safely discontinued.
Step-by-Step Solution
Key Concept
Safe Management of Physical Restraints