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Zorluk: OrtaUse of Restraints and Safety Devices

An 84-year-old client recovering from sepsis is receiving continuous intravenous (IV) fluids. The client suddenly begins thrashing in bed and forcefully grabbing at the IV insertion site. After less restrictive measures fail, the registered nurse (RN) applies bilateral soft wrist restraints as prescribed. Which actions are appropriate for the practical nurse (PN) when caring for this client? Select all that apply.

  1. Fasten the restraint ties to a movable section of the bed frame using a quick-release knot.Cevap
  2. B
    Assume the sudden thrashing and agitation are expected signs of age-related cognitive decline.
  3. Release one restraint at a time every 2 hours to provide skin care and perform range-of-motion exercises.Cevap
  4. D
    Assign the unlicensed assistive personnel (UAP) the task of evaluating whether the client still needs the restraints.
  5. Assess the capillary refill, skin temperature, and radial pulses of both upper extremities every 2 hours.Cevap
  6. F
    In the future, reapply the physical restraints immediately at the first sign of agitation before trialing less restrictive alternatives.

Cevap

The appropriate actions are fastening the ties to a movable section of the bed frame using a quick-release knot, releasing one restraint at a time every 2 hours for skin care and range of motion, and assessing neurovascular status every 2 hours.
When a client is in restraints, the nurse must ensure physical safety and physiological integrity. This includes securing the restraints to a movable part of the bed frame with a quick-release knot to prevent injury when the bed moves and to allow rapid removal in an emergency. The nurse must also release the restraints one at a time every 2 hours to provide skin care and perform range-of-motion exercises, and conduct neurovascular checks every 2 hours to verify adequate perfusion and prevent nerve damage.

Adım Adım Çözüm

1
Analyze the clinical scenario and the nursing intervention.
The client has bilateral soft wrist restraints applied to protect the IV line. The PN must identify safe monitoring, application, and delegation protocols.
Understanding the purpose of the restraint determines the specific safety and monitoring requirements mandated by care standards.
2
Identify correct safety and assessment procedures.
Correct actions include securing ties to the movable bed frame with a quick-release knot, releasing restraints sequentially every 2 hours for care, and performing frequent neurovascular assessments.
These actions prevent nerve damage, ischemia, skin breakdown, and asphyxiation or injury if the bed position is altered.
3
Rule out actions that violate scope of practice or safety standards.
Dismissing sudden confusion as normal aging, delegating clinical evaluation to a UAP, and bypassing less restrictive alternatives in the future are all incorrect and dangerous practices.
Sudden confusion indicates acute illness (delirium), evaluation requires nursing judgment, and restraints must always be a last resort.

Anahtar Kavram

Safe Application and Monitoring of Physical Restraints
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Konular

Use of Restraints and Safety Devices

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