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Difficulty: MediumSafe Use of Restraints and Safety Devices

An individual recovering from a severe motor vehicle collision is experiencing intensive care unit (ICU) delirium. The client continuously grasps at their arterial line and endotracheal tube despite family presence, frequent reorientation, and concealment of the tubing. The provider prescribes bilateral soft wrist restraints. Which action represents the safe and appropriate management of these devices by the nurse?

  1. Attach the restraint straps to the movable portion of the bed frame utilizing a quick-release slip knot.Answer
  2. B
    Fasten the restraint ties directly to the elevated side rails to prevent the client from reaching the invasive lines.
  3. C
    Assign the unlicensed assistive personnel the responsibility of evaluating peripheral circulation beneath the devices.
  4. D
    Request that the healthcare provider prescribe the restraints on an as-needed basis for peak periods of agitation.

Answer

Attach the restraint straps to the movable portion of the bed frame utilizing a quick-release slip knot.
The correct answer demonstrates strict adherence to restraint safety protocols. Restraints must always be secured to a movable part of the bed frame (never the side rails) so that the straps move harmoniously with the patient if the bed position is adjusted. Furthermore, using a quick-release knot is a universal safety standard, allowing healthcare personnel to free the patient instantly in the event of an emergency (e.g., cardiopulmonary arrest or fire).

Step-by-Step Solution

1
Recognize that alternative measures have failed and the restraint prescription is valid.
The nurse proceeds with the safe application of the ordered bilateral soft wrist restraints.
Restraints are a last resort, and all less restrictive alternatives must be documented as ineffective first.
2
Identify the correct anatomical and structural anchor points for the restraint ties.
The restraint is secured to the movable portion of the bed frame rather than the side rails.
Securing to a movable frame ensures the restraint moves synchronously with the client when bed height or head elevation is adjusted, preventing limb injury.
3
Select the appropriate method for securing the device.
A quick-release slip knot is utilized.
In the event of an emergency such as a fire or cardiac arrest, the restraints must be easily and immediately removable without cutting or struggling with complex knots.

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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