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Difficulty: HardSafe Use of Restraints and Safety Devices

A client admitted to the medical-surgical unit is severely confused and continuously attempts to pull out a newly placed continuous bladder irrigation (CBI) catheter. After multiple alternative safety measures prove ineffective, the healthcare provider prescribes bilateral soft wrist restraints. Which action by the nurse regarding the management of these restraints is legally and clinically appropriate?

  1. Releasing one restraint at a time every 2 hours to perform passive range-of-motion exercises and evaluate the continued necessity of the intervention.Answer
  2. B
    Securing the restraint ties to the movable portion of the bed frame using secure double square knots to ensure the client cannot escape.
  3. C
    Instructing the unlicensed assistive personnel (UAP) to release the restraints every 2 hours to provide skin care and document bilateral radial pulses.
  4. D
    Discontinuing the restraints temporarily while the client is sleeping and utilizing a PRN (as needed) prescription to reapply them if agitation returns.

Answer

The legally and clinically appropriate action is to release one restraint at a time every 2 hours to perform passive range-of-motion exercises and evaluate the continued necessity of the intervention.
Removing restraints every 2 hours is a mandatory standard of care to prevent neuromuscular damage, skin breakdown, and to evaluate if the client still meets the criteria for restraint use. Releasing them one at a time is a critical safety strategy when a client is actively attempting to pull at life-sustaining or necessary medical equipment, as it maintains partial control while allowing necessary care.

Step-by-Step Solution

1
Analyze the legal and facility protocol requirements for the application of physical medical restraints.
Medical restraints require a specific, time-limited provider order (never PRN), attachment to a movable part of the bed using quick-release knots, and strict ongoing monitoring.
Ensuring legal compliance and patient safety prevents severe injury and respects the client's legal rights.
2
Evaluate the delegation boundaries associated with restraint management.
Basic care (hygiene, feeding) can be delegated to a UAP, but clinical assessments (circulation, skin integrity, continued need) cannot be delegated.
The RN retains accountability for all nursing judgments and assessments.
3
Determine the safest method for performing the required 2-hour restraint care.
Releasing one restraint at a time allows the nurse to assess the limb while preventing the client from using two free hands to dislodge the continuous bladder irrigation catheter.
This balances the physiological need for circulation and skin checks with the immediate safety need to protect the medical device.

Key Concept

Safe Use of Restraints and Safety Devices
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Topics

Safe Use of Restraints and Safety Devices

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