An adult client on an inpatient behavioral health unit exhibits active violent self-harm behavior, attempting to use broken plastic to inflict deep wounds. After verbal de-escalation and pharmacological interventions prove ineffective, the nurse emergently applies four-point mechanical restraints. Which actions must the nurse include in the client's plan of care? Select all that apply.
- ASecure the mechanical restraint straps directly to the bed's movable side rails using quick-release knots.
- Initiate continuous, one-to-one face-to-face observation of the client.Answer
- CDelegate the routine assessment of the client's extremity circulation to the unlicensed assistive personnel (UAP).
- Ensure the healthcare provider performs an in-person evaluation within 1 hour of the restraint application.Answer
- ERequest the healthcare provider to write a PRN (as-needed) prescription for future mechanical restraint applications.
- Document the client's vital signs, skin integrity, and behavioral status at least every 15 minutes.Answer
Answer
The necessary actions are initiating continuous one-to-one observation, ensuring a healthcare provider performs a face-to-face evaluation within 1 hour, and documenting assessments at least every 15 minutes.
When mechanical restraints are applied for violent or self-destructive behavior, strict legal and safety protocols are triggered. The nurse must initiate continuous, face-to-face observation due to the high risk of injury. A healthcare provider is mandated to evaluate the client in person within 1 hour of application to justify the emergent intervention. Furthermore, the RN must assess and document the client's circulation, skin integrity, respiratory status, and behavior at least every 15 minutes.
Step-by-Step Solution
Key Concept
Violent Restraint Protocols and Safety Management