A client recovering from an ischemic stroke with expressive aphasia repeatedly attempts to pull out their nasogastric (NG) feeding tube. After documenting the failure of multiple less restrictive interventions, the healthcare provider prescribes bilateral soft wrist restraints. Which actions should the nurse include in the client's plan of care? Select all that apply.
- Remove the restraints to provide skin care and range-of-motion exercises every 2 hours.Answer
- Fasten the restraint ties to the movable portion of the bed frame.Answer
- Verify that two fingers can comfortably fit between the restraint and the client's wrist.Answer
- DDelegate the routine assessment of the restrained extremities' neurovascular status to the unlicensed assistive personnel.
- ETie the restraint devices using a secure square knot to prevent the client from removing them.
- FRequest a renewal of the restraint prescription from the healthcare provider every 48 hours.
Answer
The correct actions include releasing the restraints every 2 hours for skin care and range-of-motion, fastening the ties to the movable part of the bed frame, and verifying a two-finger gap between the restraint and the wrist.
Applying restraints safely requires strict adherence to evidence-based protocols to prevent injury and preserve circulation. Fastening the ties to the movable portion of the bed frame ensures the restraints will not dangerously tighten if the bed's position is adjusted. Verifying that two fingers can slide underneath the restraint prevents localized tissue ischemia and neurovascular compromise. Finally, the nurse is required to release the restraints at least every 2 hours to provide essential skin care, perform range-of-motion exercises, and conduct comprehensive assessments.
Step-by-Step Solution
Key Concept
Safe application, monitoring, and legal requirements for medical-surgical restraints.
Estimated Time:1m 30s