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Zorluk: Çok zorUse of Restraints and Safety Devices

A practical nurse (PN) is evaluating an older adult client admitted with urosepsis who developed acute delirium. Twelve hours ago, a healthcare provider prescribed bilateral soft wrist restraints because the client was severely agitated and repeatedly disconnecting their intravenous (IV) line. Currently, the PN observes that the client is calm, oriented to person but not to place or time, and asking to use the bathroom.

Which action by the PN demonstrates the most appropriate synthesis of legal guidelines and patient safety principles regarding restraint use?

  1. A
    Release one restraint at a time to assist the client with using a urinal, ensure the IV line is protected, and then re-secure the restraint to the movable portion of the bed frame.
  2. B
    Inform the client's family that due to the client's age and disorientation, the restraints will remain necessary to protect the IV line for the duration of the antibiotic therapy.
  3. Remove the restraints to assist with toileting, observe the client's behavior while unrestrained, and collaborate with the registered nurse (RN) to potentially discontinue the order.Cevap
  4. D
    Independently discontinue the restraint prescription in the electronic health record, document the client's calm demeanor, and initiate a bed alarm.

Cevap

The correct action is to remove the restraints to assist with toileting, observe the client's behavior while unrestrained, and collaborate with the registered nurse (RN) to potentially discontinue the order.
The correct action is to remove the restraints for toileting, observe the client's behavior, and collaborate with the RN. Safety and legal guidelines mandate that physical restraints must be removed at the earliest possible time once the behavior that necessitated them is no longer present. By removing the restraints while the client is calm, the PN adheres to the principle of least restrictive care. Furthermore, collaborating with the RN ensures that the formal discontinuation of the provider's order is handled within the appropriate legal scope of practice.

Adım Adım Çözüm

1
Assess the client's current cognitive and behavioral status.
The client is observed to be calm, cooperative, and asking for assistance with toileting, with no current signs of the previous severe agitation.
To determine if the original indication for the restraints (severe agitation and pulling at IV lines) is still present.
2
Implement a trial of restraint removal.
The restraints are removed to allow the client to use the bathroom while the nurse closely observes their behavior and ability to follow instructions.
Federal guidelines and safety protocols mandate that restraints must be discontinued at the earliest possible time, and a calm state provides a safe opportunity to attempt less restrictive alternatives.
3
Collaborate with the RN and healthcare provider.
The PN reports the client's improved behavior to the RN, who then assesses the client to formally discontinue the restraint prescription.
While the PN can initiate the trial removal and provide direct care, formally discontinuing a medical order and performing the comprehensive discharge assessment of the restraint falls within the RN scope of practice.

Anahtar Kavram

Least Restrictive Environment and Restraint Discontinuation
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Konular

Use of Restraints and Safety Devices

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